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NTSB Identification: CHI04FA107.
The docket is stored in the Docket Management System (DMS). Please contact Public Inquiries
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Tuesday, April 20, 2004 in Boonville, IN
Aircraft: Bell 206L-1, registration: N137AE
Injuries: 1 Fatal, 3 Serious.
HISTORY OF FLIGHT
On April 20, 2004, at 2343 central daylight time, a Bell 206L-1, N137AE,
operated by Air Evac Life Team as Air Evac 17, collided with the terrain during
a medivac flight. The patient was fatally injured. The pilot, paramedic, and
nurse, were seriously injured. The helicopter was substantially damaged. The 14
CFR Part 135 flight was operating in visual meteorological conditions and was
receiving company flight following at the time of the accident. The helicopter
last departed the St. Joseph's Hospital Heliport (II47), in Huntingburg,
Indiana, with an intended destination of Deaconess Hospital (16IN) in
Evansville, Indiana.
Air Evac 17 was based at the Davies County Airport (DCY), Washington, Indiana.
At 2151, the crew was notified of a patient who needed to be transported from
II47 to16IN. Air Evac 17 departed DCY about 2204 en route to II47. Air Evac 17
landed in II47 around 2223 and departed around 2325 en route to 16IN with the
patient on board.
The last radio contact that Air Evac dispatch had with the flight was at 2327
when Air Evac 17 reported they had departed II47 with 4 people and 450 pounds of
fuel on board.
The destination helipad, 16IN, is located within the Class C airspace
surrounding the Evansville Regional Airport (EVV), Evansville, Indiana. The
hours of operation of the air traffic control tower at EVV were between 0600 and
2300. The audio recording equipment was inadvertently left on after the tower
closed. A recording of the approach frequency communications revealed the pilot
of N137AE made 12 radio transmissions during the time period 2328 - 2339. The
first four transmissions were attempts to contact the approach control. The
fifth transmission was a partial transmission. This was followed by six more
transmissions attempting to contact approach. The last transmission was
partially unintelligible.
Following the accident, the flight crew paramedic used a cellular phone and
called dispatch to inform them that they had crashed. A recording of the call
was made available to the NTSB. The beginning of the recording is time stamped
2344. The paramedic stated he did not know their location and the last location
he was aware of was being 8 minutes from their destination. He stated they were
in a field and he could see a flashing white light on a tower that was a couple
miles away.
During the cellular call, the paramedic stated he did not know what happened,
but the helicopter was on its side. He later stated they just hit the ground.
The paramedic informed the dispatcher that the pilot was trapped in the
wreckage, the nurse was out of the wreckage by the tail of the helicopter, the
patient was by the nose of the helicopter and that they were all injured.
Despite his injuries which included a broken jaw, the paramedic continued
talking with dispatch, the pilot, and the nurse. The paramedic asked the pilot
what happened and the pilot responded that they lost altitude.
During the time that the paramedic was on the cell phone with the dispatcher,
other Air Evac employees were making telephone calls getting helicopters and
local authorities out to search for N137AE. At 0055, the paramedic informed the
dispatcher that he could see an aircraft light that was heading toward him. At
0112, the paramedic stated that he was able to see flashing lights on an
emergency vehicle in the distance. The paramedic removed a blue pen light from
the shoulder of the nurse and used the light to signal the helicopters that were
flying overhead searching. At 0117, they were located by another Air Evac
helicopter.
One witness, who was at his residence located approximately 300 yards north of
the accident site, reported that around 2330 he heard a helicopter fly overhead.
He reported the helicopter sounded very loud and that the sound gradually faded
away in the distance as if it was flying away. He stated that about a half hour
later he heard another helicopter flying from west to east. He stated this one
was not as loud as the first. He stated that shortly after hearing the second
helicopter, he heard others in the area as if they were searching for something.
He was not aware of the accident when he heard the helicopters.
During an interview, the flight nurse stated he remembered being about 10
minutes away from 16IN and the next thing he remembered is being on the ground
outside the helicopter. He stated he does not recall any problems prior to the
helicopter impacting the ground.
In a post-accident interview, the paramedic stated that he remembered picking up
the patient in Huntingburg and caring for the patient during the flight. He
stated the next thing he remembered is impacting the ground, getting out of the
helicopter, and making the call to dispatch to get help. He stated that he does
not remember the pilot indicating that there were any problems prior to
impacting the ground. He stated that he recalled it being windy at the time of
the accident.
In a post-accident interview, the pilot stated he recalled picking up the
patient in Huntingburg and the next thing he remembered is the helicopter
tumbling on the ground. He stated he remembered being trapped inside the
wreckage.
The emergency medical technicians (EMT) who treated the pilot at the accident
site reported that the pilot stated "Boy I screwed up." An EMT asked him what
happened and the pilot reported, "I started making my turn and we started
tumbling."
PERSONNEL INFORMATION
The pilot held a commercial pilot certificate with airplane single-engine land,
helicopter, instrument airplane, and instrument helicopter ratings. The pilot
held a second-class medical certificate dated January 23, 2004. The medical
certificate contained the limitation: "Must wear corrective lenses."
The pilot reported having a total of 3,846.7 hours of flight time of which
3,592.7 hours were in helicopters. The pilot reported he had a total of 649.6
hours of flight time in Bell 206L-1 helicopters. He reported he flew 63.7 hours
in the last 90 days, 38.1 hours in the last 30 days, and 0.9 hours in the last
24 hours. All of this flight time was in a Bell 206L-1. The pilot's last
biennial flight review was on January 20, 2004, in a Bell 206L-1 helicopter.
The pilot completed his initial training with Air Evac in January 2001, and his
Federal Aviation Regulation (FAR) 135 Airman Competency/Proficiency Check was
satisfactorily completed on January 13, 2001.
In February 2002, the pilot attended a Bell 206L-1 refresher course conducted by
the Bell Helicopter Training Academy. The pilot satisfactorily completed this
Ground and Flight Procedures Training Course. Records were not located to
indicate the date that the pilot passed a FAR 135 Airman Competency/Proficiency
Check in 2002.
In January 2003, the pilot once again attended a Bell 206L-1 refresher course
conducted by the Bell Helicopter Training Academy. The pilot was issued a
completion certificate for the Ground portion of the training. Remarks in the
training record state the pilot "... needs more flight training to achieve Bell
minimum standards." There were no records located which indicated the pilot had
received additional training. Records were not located to indicate the date that
the pilot passed a FAR 135 Airman Competency/Proficiency Check in 2003.
On January 9, 2004, the pilot failed his FAR 135 Airman Competency/Proficiency
Check. Comments in the remarks section of Federal Aviation Administration Form
8410-3 stated, "Company Part 135 check ride unsat." Comments in the pilot's
Flight Training Record dated January 9, 2004 state, "Unsat maneuvers -
hydraulics, hovering autos, t/r malf were not complete. Knowledge of company
ops, weak." Following this check ride, the pilot was placed in an Initial
Training class for requalification. On January 20, 2004, the pilot passed a FAR
135 Airman Competency/Proficiency Check.
During a post accident interview the pilot stated that Air Evac pilots usually
work 7 days on duty followed by 7 days off duty. However, he stated that lately
they have been working 8 days sometimes 9 days on duty. He stated that he
usually worked the 2000 to 0800 shift. The pilot stated that the accident
occurred on the 7th day of his shift. He stated that on April 18th he had little
work to do, so he got plenty of rest. On the 19th he had one flight returning to
DCY where he finished his paperwork around 0200 and he rested after that. He
stated that he rested during the day on the 20th. He had dinner with crewmembers
around 1800, and began his shift at 2000.
AIRCRAFT INFORMATION
The 1979 Bell 206L-1 (Long Ranger) was previously registered as N2758L. The
helicopter was registered to Air Evac Leasing Corporation on October 29, 2003.
The registration number was changed to N137AE on April 9, 2004.
The helicopter was configured with one pilot seat, two aft-cabin forward facing
seats, and one patient litter. The helicopter was equipped with an Allison
250-C28B engine, serial number CAE 860248, 500 horsepower turboshaft engine. The
helicopter was equipped with a high skid type landing gear with float steps.
The helicopter was maintained in accordance with an approved airworthiness
inspection program. The program consisted of 4 phase inspections, one of which
was accomplished every 25 hours of flight time. Phase 1 consisted of a basic
overhaul inspection; Phase 2 was hydraulics; Phase 3 was an engine inspection;
and Phase 4 was the rotor system. In addition to the phase inspections an annual
inspection was accomplished as were daily inspections.
The last annual inspection of the aircraft and engine was accomplished on March
26, 2004, at a total airframe time of 26,871.2 hours and an engine total time of
18,293.2 hours. The last phase inspection accomplished was a Phase 2 check,
which was completed on April 18, 2004, at an aircraft total time of 26,909.0
hours and an engine total time of 18,331.0 hours. The last daily inspection was
accomplished on the day of the accident at a total aircraft time of 26,910.1
hours and a total engine time of 18,332.1 hours.
The pilot who flew the helicopter prior to the accident pilot reported, "...
everything on the aircraft was functioning flawlessly and the aircraft performed
as a new aircraft. There were no vibrations, no unusual flying tendencies, and
the blades were flawlessly true and in balance. It flew very well. There was one
minor problem with the radar altimeter that had caught my attention, it had a
tendency to cycle from 2,500+' to 0' every once in a while, which caught my
attention when it would pass through the place the bug was set and give a short
burst alarm." This pilot stated that he informed the accident pilot of the
problem and that they both checked the minimum equipment list (MEL) and
determined that it was not required equipment for the flights.
The mechanic who was assigned to maintain the helicopter stated that he was
informed of the radar altimeter problem on April 18th. He stated he checked the
system and did not find any obvious problems. He stated that he spoke with the
company avionics specialist the following day and was told that it was probably
an internal problem with the system and that it would need to be replaced. The
mechanic stated that he completed the paperwork to order the replacement
components and informed the accident pilot of the situation. He stated that he
told the accident pilot that he could write up the problem if he so desired. The
mechanic stated that the radar altimeter was a Category C item on the MEL and
that the repair could be deffered for 10 days. He stated he was confident that
the parts would arrive and the replacement would be completed within that time
frame. There were no entries in the aircraft paperwork regarding the radar
altimeter and it was not placarded as being inoperative.
METEOROLOGICAL INFORMATION
The weather observation station located at EVV recorded the weather at 2354 as
being: wind 210 degrees at 12 knots, gusting to 17 knots; visibility 10 Statute
miles (sm); a few clouds at 8,000 feetabove ground level (agl); temperature 21
degrees Celsius; dew point 12 degrees Celsius; altimeter 29.77 inches of
mercury.
The weather observation station located at the Huntingburg Airport (HNB)
recorded the weather at 2135 as being: wind 190 degrees at 14 knots, gusting to
22 knots; visibility 10 sm; a broken cloud layer at 6,500 feet agl; temperature
23 degrees Celsius; dew point 9 degrees Celsius; altimeter 29.97 inches of
mercury.
The weather observation station, located at the Vincennes International Airport
(LWV), Lawrenceville, Illinois, is located about 26 sm west of DCY. This is the
closest weather reporting facility to the departure airport. The altimeter
setting recorded at 2153 was 29.73 inches of mercury.
An Indiana State Police helicopter pilot, who was sent out to search for N137AE,
reported that the surface winds around 0115 were out of the southwest around 15
knots. He stated that when he was returning to EVV at the end of his flight, the
winds at altitude were stronger then the surface winds. He reported that at an
altitude of 1,500 feet mean sea level (msl), 1,000 feet agl his airspeed was
indicating 110 miles per hour and that his ground speed was 70 knots (80 miles
per hour).
WRECKAGE AND IMPACT INFORMATION
The accident site was on the property of an abandoned strip mine approximately
one-half mile southwest of the intersection of Turpin Hill Road and Massey Road
in Boonville, Indiana. The global positioning system (GPS) location of the main
wreckage was 38 degrees 07.771 minutes north latitude, 087 degrees 19.281
minutes west longitude at an elevation of 486 feet msl. This location was
approximately 2 sm outside of the Class C airspace at EVV.
The wreckage path was 187 feet in length along a magnetic heading of 233 degrees
on up-sloping terrain. The initial ground scars consisted of two parallel scars,
which were approximately 3 inches wide and spaced about 7 feet apart. In the
middle of these scars was a wider ground scar which contained the cutter from
the wire strike protection system and the search light assembly. The cutter was
buried in the ground. There was a strong smell of fuel present in this area.
Just beyond this scar was a section of the forward crosstube.
Approximately 19 feet to the right of the center ground scar were three parallel
slash marks in the terrain. These marks ranged from 14 feet 7 inches to 3 feet 3
inches in length. The main wreckage was approximately 93 feet from the last of
these slash marks.
The helicopter came to rest on its right side. The fuselage was fractured just
forward of the tail boom attach point. The lower forward portion of the fuselage
and the nose sustained substantial impact damage. Both the forward and aft fuel
cells were ruptured. The center post was intact and attached at the upper
cockpit area. The lower portion of the center post was detached from the
surrounding structure. The instrument panel was separated from the surrounding
structure. The grass located behind the engine exhaust was burned. A melted
plastic soda bottle that was located on the ground behind the exhaust.
The tailboom remained attached to the aft portion of the fuselage. The vertical
fin was separated from its mount and was found located next to the aft end of
the tailboom. The horizontal stabilizer, although slightly damaged, remained
attached to the tailboom. There was a 2-inch long slice in the leading edge of
the left horizontal stabilizer.
The landing skids, with the exception of a portion of the forward cross tube and
a 7-foot long piece of the skid step, were located alongside the main wreckage.
Both skid tubes, including the tips, were intact. Dirt was present on the bottom
of the skids just aft of the tips. This was more prevalent on the right skid.
The rear crosstube, although flattened, remained intact and attached to the skid
tubes. The forward crosstube was flattened more then the rear tube. A section of
the forward crosstube had separated and was found along the wreckage path.
Both main rotor blades were attached to the hub. Although fractured, the entire
red blade was located at the main wreckage. Maroon (color of the helicopter) and
yellow paint transfers were present along the tip of the blade. The inboard 41
inches of the yellow blade remained attached to the hub. The center section of
the yellow blade was located approximately 87 feet in front of the nose of the
helicopter. The yellow blade tip and a section of the outboard spar were not
located.
Continuity was established between the cyclic and collective control sticks and
their respective servos.
The main rotor hub remained attached to the mast. Both the main transmission
chip detectors did not contain metallic debris. The main driveshaft was
disconnected from the engine, but remained attached at the transmission input.
The mast was bent at the top of the transmission and the right rear transmission
mount was bent.
Several fractures corresponding to airframe damage were observed in the tail
rotor and elevator control systems. Continuity of the tail rotor and elevator
control systems was established both forward and aft of the separation in the
aft fuselage.
The guard on the fuel valve switch was bent and the inner toggle mechanism for
the switch was broken. The hydraulic switch was in the on position.
The emergency locator transmitter did activate during the impact sequence.
MEDICAL AND PATHOLOGICAL INFORMATION
The patient who sustained fatal injuries during the accident was strapped to a
litter which was ejected from the airframe during the accident sequence.
TESTS AND RESEARCH
Washington, Indiana, is in a portion of the state which remains on eastern
standard time throughout the year. Evansville, Indiana, is in a portion of the
state which changes from central standard time to central daylight time which is
the same time as eastern standard time. The time change in Evansville occurred
on April 4, 2004. Prior to the time change the time in Evansville would have
been one hour behind Washington. However, on the day of the accident, the time
in both locations was the same.
Radar Altimeter
The transmitter for the radar altimeter was broken off and damaged during the
accident. The sending unit for the altimeter and the instrument gauge were bench
tested. The needle swung freely throughout its full range. The decision height
(DH) warning light and tone were delayed from 100 feet at the higher end of the
scale to 20 feet at the lower end depending on where the DH bug was set.
During inspection of the wreckage the DH bug was found to be set at about 75
feet. In January 2001, the accident pilot took a written test on which one of
the questions was "The radar altimeter shall be set to." The pilot answered that
is should be set at 300 feet during the day and 500 feet at night. The pilot
scored 100% on the test. Following the accident, the Vice President of
Operations for Air Evac sent an email to all company pilots reiterating the
company policy for setting the radar altimeter to a minimum altitude of 300 feet
for day visual flight rules (VFR) operations and 450 - 500 feet for night VFR
operations. On January 10, 2005, the company operations manual was revised to
include these procedures.
Altimeter
The altimeter setting at EVV recorded 12 minutes after the accident was 29.77
inches of mercury. Inspection of the wreckage revealed the altimeter was set to
30.08 inches of mercury. This setting would have resulted in the altimeter
indicating that the altitude was approximately 310 feet higher then the actual
altitude of the helicopter. It should be noted that the helicopter was flown for
0.4 hours earlier on the day of the accident. The aircraft logs indicate that
the flight previous of that was on April 19th at 1848 when the helicopter was
flown to Poland, Indiana. The closest weather reporting station to Poland is
located at Terre Haute, Indiana. The altimeter setting recorded at Terre Haute
at 1853 on April 19th was 30.08 inches of mercury. In addition, the altimeter
setting recorded at LWV, the weather reporting station closest to the departure
airport, at 1853 was 30.09 inches of mercury.
Engine
The airframe fuel line from the filter to the engine driven pump was
disconnected and fuel was present. Both fuel boost pumps were removed. An
external power supply was attached to the pumps. Both pumps operated.
The engine was tested at Allison Engines on May 4, 2004, under the supervision
of the National Transportation Safety Board and the Federal Aviation
Administration. The engine operated within acceptance test specifications.
Caution/Warning Panel
The caution/warning panel was removed from the helicopter. It was examined at
Bell Helicopter under the supervision of the FAA. The report of that examination
stated, "The bulb filament from the following warning indicator was received
stretched: #18 Transmission Chip right, stretched in the downward direction. The
bulb filaments from the following warning indicators were received broken but
with no signs of stretch: #02 Spare right, #07 Litter Door Open left, #09 Spare
right, #12 Spare left, #16 TR Chip right, #18 Transmission Chip left, #21
Transmission Oil Pressure left, #24 Rotor Low RPM left, #24 Rotor Low RPM right.
The rest of the bulb filaments were neither broken nor stretched."
SkyTrac System
The helicopter was equipped with a SkyTrac flight following system. The unit
transmits flight information via satellite to both SkyTrac and Air Evac once
every minute. The unit was removed from the helicopter and sent to SkyTrac in an
attempt to download data that may have been in the buffer, waiting to be
transmitted. A plot of the data points received by SkyTrac indicates the
helicopter flew a relatively straight course between II47 and the accident site.
The last recorded latitude and longitude position was calculated to be 0.23 sm
from the main wreckage. This data point indicated the helicopter was at 550 feet
msl. At this point the helicopter had a ground speed of 70 knots on heading of
226 degrees. The downloaded information is included in the docket material
associated with this factual report.
Diamond J Instruments
The helicopter was equipped with Diamond J turbine outlet temperature (TOT) and
torque instruments. Both instruments were removed from the helicopter for
inspection by the manufacturer under the supervision of the FAA. Both
instruments were powered up to determine if any exceedences were recorded. The
inspection report stated "The TOT data that was retrieved is consistent with pin
A being shorted to 28Vdc in the aircraft installation. The TOT instrument is
stuck in engine start mode when the start signal (pin A) is shorted to 28Vdc.
The TOT instrument should not switch to flight operation mode and could not
capture and record operational temperatures. The TOT instrument would still be
able to capture start exceedences and record the peak and duration of the most
severe transient start event since the last time the instrument data was
cleared. Shorting pin A to 28Vdc would not affect the instruments ability to
accurately indicate the engine TOT temperature to the pilot." Inspection of the
Torque instrument revealed the instrument did not record any torque exceedences
during the flight mode of the engine.
ADDITIONAL INFORMATION
Parties to the investigation were the FAA, Bell Helicopter, and Rolls
Royce/Allison Engines.
All wreckage was released to the operator's insurance representative. The main
wreckage was released on April 26, 2004. The Garmin GPS was released on May 17,
2004. The Diamond J gauges were released on May 21, 2004, and the radar
altimeter was released on February 4, 2005.
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