# NTSB WPR19LA071: Bell 206, N8227J, Ashland, OR, January 23, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: January 23, 2019, 11:43 local (19:43 UTC) - Place: Ashland, OR - Coordinates: 42.066665, -122.596389 - Nearby events: https://openairdocs.org/map.md?lat=42.0667&lon=-122.5964&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Rolls Royce, Federal Aviation Administration, Bell Helicopters, Erickson Helicopters Inc - NTSB case key (mKey): 98851 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA071 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98851/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98851 - Page: https://openairdocs.org/ntsb/WPR19LA071 ## Probable cause The pilot's decision to continue visual flight into deteriorating weather, which resulted in an encounter with instrument meteorological conditions and spatial disorientation leading to a loss of control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Ceiling/visibility/precip: clouds](https://openairdocs.org/ntsb-findings/03035025): Environmental issues › Conditions/weather/phenomena · Effect on personnel (probable cause); cases with it: [Bell 206L-3, 1 case](https://openairdocs.org/ntsb-findings/03035025/cases.md?model=1182108), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/03035025/cases.md) - [Ceiling/visibility/precip: fog](https://openairdocs.org/ntsb-findings/03035055): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Bell 206L-3, 1 case](https://openairdocs.org/ntsb-findings/03035055/cases.md?model=1182108), [All aircraft, 78 cases](https://openairdocs.org/ntsb-findings/03035055/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Bell 206L-3, 3 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1182108), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Bell 206L-3, 8 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1182108), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Bell 206L-3, 1 case](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=1182108), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Bell 206L-3, 14 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1182108), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) (defining event); cases with it: [Bell 206L-3, 5 cases](https://openairdocs.org/ntsb-events/220/sequence.md?model=1182108), [All aircraft, 780 cases](https://openairdocs.org/ntsb-events/220/sequence.md) ## Analysis The purpose of the flight was for the pilot to accrue flight-time to fulfill annual flight-time insurance requirements. Radar data indicate that, after departure, the pilot flew the helicopter generally to the south of the departure airport, where the helicopter made various low-level maneuvers and then began to follow a highway northward. The helicopter made several turns during the final two minutes of recorded radar data before the last recorded data point, which was near to the accident site. Examination of the wreckage found no evidence of any engine or airframe anomalies that may have contributed to the accident. At the time of the accident, weather forecasts and advisories for the accident area predicted areas of instrument meteorological conditions (IMC) and mountain obscuration and various cameras in the area captured images of low ceilings, fog, and obscuration. There was no record the pilot obtained a preflight weather briefing on the day of the accident. Had he obtained such a briefing, he likely would have been aware of the possibility of encountering below minimum weather conditions for helicopter operations. The circumstances of the accident are consistent with the pilot encountering IMC, subsequently becoming spatially disoriented, and losing control of the helicopter. ## Factual narrative On January 23, 2019, at 1143 Pacific standard time, a Bell 206L-3, N8227J, was substantially damaged when it was involved in an accident near Ashland, Oregon. The pilot was fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 flight. The pilot was operating out of Medford Airport (MFR), Medford, Oregon, with the purpose of amassing flight-time to fulfill the operator’s annual flight-time requirements. On the day prior, he had flown the accident helicopter on two different flights totaling five hours of flight time. A review of the preliminary radar data provided by the Federal Aviation Administration disclosed that in the 1.5 hours following departure, the helicopter maneuvered in the local area west of Ashland making numerous turns. Thereafter the helicopter continued south over the Siskiyou Summit and after making various low-level maneuvers, followed Interstate 5 (I-5) toward Hilt, Oregon. Around 1120 the helicopter began to head north and made several turns and slow maneuvers. At 1141, the helicopter continued north and adjoined the I-5 for about 1.5 minutes. At 1142:50 the radar track showed that the helicopter then made several turns until heading east. The last radar return at 1143:30 was located in the immediate vicinity of the accident site and oriented about 600 ft east of the interstate at an elevation of about 4,100 ft. Toxicology testing performed at the FAA Forensic Sciences Laboratory identified Acetaminophen, Salicylate and Pramoxine in urine samples. An autopsy of the pilot was performed by the Jackson County Office of the State Medical Examiner, Central Point, Oregon. The cause of death was listed as severe blunt trauma due to a helicopter crash. The pilot completed a risk assessment form prior to the flight and determined it to be “low risk.” He marked the following on the form: visibility greater than 1 mile during the day, which was in the “low risk” category; icing was forecast but that the current weather indicates that conditions changed, which was a “medium risk” category; and that the ceiling was forecast and currently greater than 500 ft, which was the “low risk” category. Investigation found no evidence that the pilot obtained a weather briefing. The pilot’s papers on his kneeboard contained written notes consistent with the Medford Meteorological Terminal Air Report (METAR) issued at 0853. It was consistent with noting the freezing level at 7,000 to 11,000 ft, and broken cloud layers at 1,200 and 2,100 ft with an overcast layer at 5,000 ft. An employee of the operator who responded to the accident, stated that at 1400 he drove south on I-5 toward the accident (between mile marker #5 and #6). He reported that the fog was dense starting at mile marker #2 with less than 50 yards visibility. He additionally observed that the clouds/fog were coming over the summit at what seemed to be a very fast pace with the summit completely obscured. A ski resort located approximately5.5 nm west of the accident site had several webcams installed that captured the weather conditions immediately surrounding the time of the accident. The webcam images depicted snow covering the surface with obscured sky conditions with fog. The accident site was located south of the cold front in the warm air side of the front and immediately north of the high-pressure ridge in an area with a weak pressure gradient. The surrounding station models on the surface analysis chart depicted calm to light southwesterly winds of 10 knots or less, overcast cloud cover, with temperatures in the upper 30’s to low 40’s degrees Fahrenheit (F), with temperature-dew point spreads of 4º F or less. Several stations northwest of the accident site over the western Cascades reported light continuous snow and rain. The 12-hour Low-Level Significant Weather Prognostic Chart that depicted the expected general flight categories: cloud conditions, freezing level, and turbulence that was current at the time of the accident and valid until 1600. The chart depicted an area of instrument flight rule (IFR) conditions over northern California, western Oregon and Washington. The freezing level was depicted at approximately 8,000 ft over the Ashland area and implied the potential for icing in-clouds above that level. Graphic Forecast for Aviation (GFA) and AIRMETs forecasts indicated that mountain obscuration and IFR conditions were expected over the area. The GFA “aviation surface forecast” image depicted visibility restrictions less than a mile during the period with AIRMET Sierra for IFR conditions over the area from 1000 and expanding at 1300 over the accident area. The GFA “cloud cover forecast” also expected overcast clouds with bases at 3,500 ft lowering to 3,000 ft msl during the period with tops from 12,000 ft to 8,000 ft over the area, with AIRMET Sierra current for mountain obscuration conditions. According to the operator, the pilot had amassed about 84 hours in the year proceeding the accident during 39 flights. During that time, 55.6 hours were in the accident helicopter (20 flights). The accident site was located in the dense trees about 9 nautical miles (nm) southeast of Ashland, Oregon. In character, the terrain was composed of mature Douglas-Fir and Ponderosa Pines trees between 100-150 feet in height. The wreckage was found distributed over a 100 ft distance with no discernable flight path direction. The main rotor blades were both attached to the hub and the hub was attached to the mast. Both blades were severed chordwise approximately 5-7 feet outboard of the hub. Both tail rotor blades exhibited chordwise bending consistent with impact forces. Postaccident engine and airframe examinations revealed no mechanical failures or malfunctions that would have precluded normal operation. ## Aircraft - Registration: [N8227J](https://openairdocs.org/deregistered/N8227J-2019-04-29), registration cancelled 2019-04-29, S/N 51313, built 1989 (OpenAirDocs) - Reported make and model: Bell 206 (L3) - Registry model: [Bell 206L-3](https://openairdocs.org/model/bell-206l-3) (registry code 1182108) (OpenAirDocs) - Registry engine: [Allison 250-C30 series](https://openairdocs.org/engine/allison-250-c30-series) (registry code 03015, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 51313 - Year built: 1989 - Airframe hours: 5088 - Engines: Rolls Royce M250-C30P 650 horsepower turbo shaft - Damage: Substantial damage - Flight: Other work use, Part 91 - Operator: Erickson Helicopters Inc - Registered owner: HeliFleet LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, July 14, 2018, 6 hours before - Departed: OR99, Medford, OR - Destination: OR99, Medford, OR - Flight plan: Company VFR - Airport: OR99, Rogue Valley Medical Center - Equipment: Satellite tracking device, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: fatal; airline transport; instrument ratings: helicopter; medical: class 2, with waivers/limitations; seat: right; restraint: 4-point; toxicology performed; flight hours: 18,011 total, 4,458 in this make and model, 13,897 as pilot in command, 29 in the last 90 days, 15 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: calm - Visibility: 4 statute miles - Lowest ceiling: 900 ft overcast - Temperature: 45 °F, dew point 39 °F - Altimeter: 30.50 inHg - Observed at: KMFR, 23 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20190123000339A](https://openairdocs.org/incident/20190123000339A), Jan 23, 2019: Bell 206L-3, Ashland, OR, Destroyed, 1 fatal. On 01/23/2019, a pilot was operating aircraft from mfr, home base, under part 91, building hours. While flying at approximately 62DEG heading, at low airspeed,… ## Docket (7 files) The files NTSB released with the investigation on May 12, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98851. 12.2 MB in all. - Meteorology factual report (item 1, PDF, 35 pages, 24 photos, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11367500&FileExtension=pdf&FileName=WPR19LA071%20-%20Ashland,%20OR%20Factual-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 2, PDF, 9 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11367626&FileExtension=pdf&FileName=Z%20-%20Attachment%20B%20-6120_Redacted-Rel.pdf - Radar data (item 3, KMZ, 263 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11367249&FileExtension=kmz&FileName=20190123_AB3B9F_68984153_Eval-Rel.kmz - Record of conversations (item 4, PDF, 3 pages, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13814483&FileExtension=pdf&FileName=Z%20-%20Record%20of%20Conversations-Rel.pdf - Investigation supplemental documents (item 5, PDF, 20 pages, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13814527&FileExtension=pdf&FileName=ZZ%20-%20Investigation%20SUmmary-Rel.pdf - Statement of party representatives to NTSB investigation (item 6, PDF, 2 pages, 981 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13847173&FileExtension=pdf&FileName=Z%20-%20Attachment%20O%20-%20All%20Party%20Forms_redacted-Rel.pdf - Toxicological report (item 7, PDF, 1 page, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11366836&FileExtension=pdf&FileName=Z%20-%20Attachment%20J%20-%20Toxicology_Redacted-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.