US District Judge Florence-Marie Cooper determined that two tower controllers Edward Weber and Cynthia Issa made a series of negligent decisions that led to the cause of a Robinson R44 Helicopter crash killing pilots Robert Bailey and Brett Boyd and severely injuring Gavin Heyworth, a stident plot. The Federal Aviation Administration (FAA) agreed to pay $4.5 million in damages to Heyworth of the November 6, 2003 helicopter crash at Torrance Municipal Airport (TOA). Gavin Heyworth was taking a solo instructional flight in a Robinson R22 at the time of the accident. Heyworth survived the crash, but suffered severe and life changing injuries.

In the original NTSB report, the Board found the following took place. On November 6, 2003, at 1528 Pacific standard time, a Robinson R22 Beta II, N206TV, and a Robinson R44, N442RH, collided in midair while in the traffic pattern at Zamperini Field, Torrance, California. Pacific Coast Helicopters was operating the R22 under the provisions of 14 CFR Part 91. Robinson Helicopter Company was operating the R44 under the provisions of 14 CFR Part 91. The solo student pilot in the R22 sustained serious injuries. The certified flight instructor (CFI) and the private pilot undergoing instruction (PUI) in the R44 sustained fatal injuries. Both helicopters were destroyed; a post crash fire partially consumed the R44. The R22 departed on a local instructional flight about 1442. The R44 departed on a local instructional flight about 1449. Visual meteorological conditions prevailed, and no flight plans had been filed. The R22 came to rest between runways 29R and 29L; approximate global positioning system (GPS) coordinates of the primary wreckage were 33 degrees 48.275 minutes north latitude and 118 degrees 20.536 minutes west longitude. The R44 came to rest on the departure end of runway 29L; approximate global positioning system (GPS) coordinates of the primary wreckage were 33 degrees 48.277 minutes north latitude and 118 degrees 20.584 minutes west longitude.

The instructor for the solo student had been watching him during his flight. The student flew the R22 from its parking area between taxiways D and E to a helipad north of runway 29R. The student practiced on the helipad, and then completed several touch-and-go landings to the helipad. He requested a return to his parking area. Upon hearing this request, the instructor turned the volume of his radio down, and turned away to talk to a bystander.

One witness reported that the R44 was speeding up and increasing in altitude as it took off straight ahead on runway 29L. He first observed the R22 when it was over runway 29R, or slightly north of it. The R22 was starting to descend as it was transiting across the left runway to the southwest, and appeared to be heading toward its landing area.

Other witnesses pointed out that the R22 was above the R44. The R44 seemed to increase its climb rate just before the collision. The two helicopters collided about 50 feet in the air over runway 29L. The R22 spun left several times before it contacted the ground.

A National Transportation Safety Board specialist interviewed the controllers, and obtained recorded radar data. He prepared a factual report, and pertinent parts follow.

Because of technical difficulties with the recordings of the ATC voice channels, times in this report prior to 1523:02 are based on draft transcripts provided early in the investigation. Times after that are valid times.

The R22 pilot first called the LC1 controller at 1442 requesting to fly from the Pacific Coast Helicopters parking area to the North Pad. He did not indicate that he was a student pilot; the controller did not think that he was a student, because his radio technique was good. He flew to the North Pad, which is a helicopter-only practice landing point that is at midfield on the north side of runway 29R.

Pilots operating at the North Pad typically fly right closed traffic patterns at 600 feet msl. They are required to keep their pattern within the lateral confines of the runway 29R displaced thresholds. They are required to contact the LC1 controller for each circuit around the pattern, or if they wish to extend their pattern beyond the 29R threshold limits.

The R44 pilot contacted the LC1 controller at 1449, and requested a northeast departure from the “antennae site,” which is at the intersection of the ramp area and taxiway G. The LC1 controller cleared him for takeoff from runway 29R, and the pilot departed the airport area to the northeast. The R44 pilot returned at 1505; he reported 6 miles north of the airport, and requested to operate on the North Pad. The controller advised him that the pad was in use (by the R22), and asked the pilot if he wanted to use the runway instead. The pilot accepted, and the controller instructed him to report a 2-mile right base entry. At 1507, the controller provided a traffic advisory of a departing helicopter, cleared him for the option on runway 29R, and told him to enter right closed traffic. The pilot continued routine traffic pattern operations until 1525, including landings on runway 29L.

At 1523:14, the R22 pilot requested a North Pad takeoff and landing at PCH parking. PCH parking referred to the parking area used by Pacific Coast Helicopters. It is west of the tower, on the ramp between taxiways D and E. The controller instructed him to hold, and the pilot acknowledged holding. At 1524:33, the controller advised him that he could proceed in right traffic to the North Pad after a Cessna passed off his left. At 1524:56, the R22 pilot transmitted, ” takeoff and land PCH parking.” At 1524:59, the LC1 controller responded, “Helicopter six tango victor fly westbound.” Between 1525:18 and 1525:52, there was some confusion caused by the pilot of a departing helicopter (29M) who incorrectly used the call sign 2RH when requesting departure from the ramp area. The controller resolved the confusion.

At 1526:01, the controller cleared the pilot of the R44 to, “make your base your discretion two niner left cleared for the option”, and at 1526:15, in the same transmission, continued, “helicopter six tango victor make a right turn to the downwind.” At 1526:19, the R22 pilot acknowledged, but only with his call sign. At 1526:32, the controller again cleared the R44 for the option on runway 29L, and the pilot acknowledged.

At 1526:59, the controller advised the pilot of the R22, “ah you’re gonna cross midfield as soon as I get a chance.” At 1527:17, the controller instructed the R22 pilot to, “turn right,” and the pilot acknowledged with his call sign. At 1527:49, the controller transmitted, “Helicopter six tango victor runway two niner right cleared to land.” At 1527:53, the R22 pilot acknowledged with his call sign. At 1527:54, the controller transmitted, “turn right helicopter six tango victor runway two niner right cleared to land.” There was no communication from the R22 pilot. At 1528:12, the LC1 controller advised the R44 pilot, “robinson two romeo hotel caution for the helo oh.”

A review of recorded radar data showed a target that turned off the right downwind leg, crossed runway 29R, and approached runway 29L in the immediate area of the accident. The last target for this track was at 1528:10, approximately 2 seconds before the collision. A plot of this track on a street map indicated that it was perpendicular to the runways at 1527:49, and the target was between Lomita Boulevard and Skypark Drive. At 1527:54, this target was still approaching Skypark Drive and north of runway 29R. After crossing Skypark about 5 seconds later, the target appeared to turn toward the southwest, and the last two targets were approaching runway 29L at a shallow angle. Another target turned from right downwind to base to final for runway 29L. Its last target appeared at 1527:15; its track lined up with runway 29L, and was westbound abeam the approach end of runway 29R.

PERSONNEL INFORMATION

R22 Pilot

A review of Federal Aviation Administration (FAA) airmen records revealed that the R22 pilot held a student pilot certificate, and a first-class medical certificate issued in September 2003.

An examination of the student pilot’s logbook indicated that his first flight occurred on September 7, 2003. He had an estimated total flight time of 32 hours. He logged 16 hours in the last 30 days. He had solo time on two previous flights that totaled about 1.5 hours.

R44 CFI

A review of FAA airman records revealed that the pilot held a commercial pilot certificate with ratings for rotorcraft helicopter and instrument helicopter. He had a mechanic certificate with ratings for airframe and powerplant. He had a second-class medical certificate issued on October 3, 2003. It had no limitations or waivers.

No personal flight records were located for the CFI. The FAA indicated that the pilot reported that he had a total time of 8,900 hours on his last medical application.

R44 PUI

A review of FAA airman records revealed that the pilot held a private pilot certificate with ratings for airplane single engine land, multiengine land, and instrument airplane; he also had a helicopter rating. He held a second-class medical certificate issued on January 16, 2003. It had the limitation that the pilot must wear corrective lenses.

No personal flight records were located for the PUI. The FAA indicated that the pilot reported that he had a total time of 370 hours on his last medical application. An application for the Robinson safety course indicated that he had 52 hours in rotorcraft; all were in this make and model.

AIRCRAFT INFORMATION

R22

The helicopter was a Robinson R22 Beta II, serial number 2753. A review of the helicopter’s logbooks revealed that it had a total airframe time of 2,974.6 hours. The logbooks contained an entry for an annual inspection dated February 1, 2003. A 100-hour inspection occurred on October 30, 2003, and the helicopter accumulated 23.9 hours since its completion. The Hobbs hour meter read 2,974.6 at the accident site. The time since an airframe overhaul was 783.7 hours.

The engine was a Textron Lycoming O-360-J2A, serial number L-32698-36A. Total time recorded on the engine was 1,976.2 hours, and time since major overhaul was 789.3 hours.

R44

The helicopter was a Robinson R44, serial number 0002. A review of the helicopter’s logbooks revealed that the helicopter had a total airframe time of 1,046.5 hours. The logbooks contained an entry for an annual inspection dated April 3, 2003. It had a 100-hour inspection on July 15, 2003. It accumulated 74.7 hours since that inspection.

The engine was a Textron Lycoming O-540-F1B5, serial number L-25143-40A. Total time on the engine was 2,672.5 hours, and time since major overhaul was 479.1 hours.

COMMUNICATIONS

Both helicopters were in contact with the Torrance airport traffic control tower (ATCT) on frequency 135.6.

AIRPORT INFORMATION

The Airport/ Facility Directory, Southwest U. S., indicated that runway 29L was 3,000 feet long and 75 feet wide. The runway surface was asphalt. Runway 29R was 5,001 feet long and 150 feet wide. The runway surface was asphalt and concrete.

WRECKAGE AND IMPACT INFORMATION

The FAA and Robinson were parties to the investigation. Investigators from the Safety Board and the parties examined the wreckage at the accident scene.

The debris field was on runway 29L, and extended over 500 feet. The first identified debris (FID) pieces were shards of Plexiglass and R44 main rotor blade. A section of one R44 main rotor blade was 135 feet from the FID, and another piece was about 145 feet. The tip cap from this blade was at 174 feet.

A piece of R22 lower frame was 234 feet from the FID. The main wreckage of the R22 was at 270 feet, and about 70 feet north of the runway. About the same distance and another 120 north was a piece of R44 spar. Another piece of R44 spar was on the runway at 412 feet.

The main wreckage of the R44 came to rest inverted at 495 feet and about 25 feet right of the runway centerline. The left skid of the R44 was at 515 feet, and just off the right edge of the runway.

The last piece of debris was the main rotor of the R44 at 525 feet and near the runway centerline. One entire blade was present; it exhibited a wavy appearance, and buckled in several places. It had a scrape mark that was 2 inches wide across half of the blade chord (from the leading edge) and 36 inches from the tip. This scrape was dimensionally similar to the aft right strut of the R22. The second blade fractured and separated about 2.5 feet from the rotor hub; the fracture ran chordwise from the leading edge back to the trailing edge doubler, with the doubler remaining intact. The blade bent aft about 120 degrees at this point. The next 4.5 feet of blade exhibited some buckling. The rest of the honeycomb/skin section of the blade separated, as did the outboard 4.5 feet of spar. Two pieces of this blade, one being about 1.5 feet with the tip weights (3.5 pounds), and the other being the tip cap, were in the R22’s engine compartment behind the left pilots seat.

The R22 exhibited rotational scoring on the fan shroud, on the fan itself, and the tail rotor drive shaft twisted.

MEDICAL AND PATHOLOGICAL INFORMATION

The Los Angeles County Coroner completed autopsies of both pilots in the R44. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilots.

Analysis of the specimens for the CFI contained no findings for tested drugs in the liver. They did not perform tests for carbon monoxide or cyanide. The report contained the following findings for volatiles: no ethanol detected in muscle; 28 (mg/dL, mg/hg) ethanol detected in the brain; 11 (mg/dL, mg/hg) methanol detected in muscle; 212 (mg/dL, mg/hg) methanol detected in the brain; and 30 (mg/dL, mg/hg) of 2-butanol detected in the brain. The report stated that the ethanol found in this case might potentially be from postmortem ethanol formation, and not from the ingestion of ethanol.

Analysis of the specimens for the PUI contained no findings for carbon monoxide, cyanide, volatiles, and tested drugs.

TESTS AND RESEARCH

The aft strut of the right skid of the R22 separated about 1-foot from the bottom of the skid, with the skid placed in its approximate installed orientation. The fracture surface was relatively flat, and the round tubing bent inboard. The right side of the engine exhibited crush damage to the mid portion of the rocker covers and valves that was similar in dimension to an R44 rotor blade. The narrow band of damage continued around to the accessories between the engine and cabin. Tubing in this area and the back of the front seat exhibited fractures across a similar plane. A section of rotor blade from the R44 was imbedded in the lower left side of the R22 near the battery, which was behind the front left seat.

Robinson personnel provided the following information.

The radius of the R44 rotor, from the centerline of the hub to the tip is 198 inches. The distance between the aft strut and forward strut of the R22 is 50.5 inches (centerline to centerline). The distance between the left and right struts on the R22 (at the level of the first contact point) is 55 inches centerline to centerline).

Based on unique impact markings and color transfers, the Robinson air safety investigators opined that first R44 blade hit the center of the aft right strut of the R22, 36 inches from the tip of the blade, cutting through the strut without hitting anything else. The second R44 blade hit the R22 across the valve covers of the engine, 29 inches higher then the first hit. The blade fractured and separated about 48 inches from the tip. This blade also made contact with the engine cooling fan and scroll. The tip of this blade struck the cabin of the R22, 48 inches forward of the aft strut (12 inches of movement from the first blade hit to second blade hit).

This information could not yield a collision angle; however, it placed the R22 above, slightly forward of the R44, and on a similar course.

Visibility Study

The IIC and Robinson investigators examined exemplary helicopters at the Robinson factory. Pilots of the approximate height of the R44 pilots sat in an R44. Looking forward, they could see as high as the outboard 8 feet of the main rotor blade. Looking to the right, they could see eye level and no higher. They could see nothing aft. A pilot of similar height to the R22 pilot sat in the right seat of an R22. He could see about 10 degrees aft with the left door not installed. With it installed, he could only see abeam his seat, and no higher than eye level. The accident R22 had the door installed.

There were several procedures for helicopters to return from the helipad to the parking ramp. One controller stated that helicopters could travel directly across both runways, and land on the ramp if there was no conflicting traffic. The next method was to land on runway 29R; then the controller would clear the pilot to hover taxi across the runways to the ramp. A third method was to have the pilot cross both runways at midfield, land on taxiway A, and then taxi to the ramp.

The student pilot’s flight instructor described the procedures for returning to the ramp from the North Pad. One method was to request a direct air taxi crossing both runways and taxiway A. A second method was to depart west on the up wind. After reaching pattern altitude at the end of runway 29R, the controller would clear the pilot for a left turn to the south. After crossing Airport Drive, the pilot could turn downwind, fly east to the east “tees,” turn left to base, and then turn left to final for taxiway A or runway 29L. A third method was to take off to the west to pattern altitude, make a right crosswind turn, and then turn to a right downwind until abeam the east end of the 29R threshold. Here the pilot would turn right base and right final for either taxiway A or 29L. A fourth method was to take off to the west, make a right crosswind, make a right downwind to midfield, make a right turn to cross both runways at midfield, turn left to a left downwind for 29L, and then left base and final to either taxiway A or 29L.

The LC1 controller stated that he intended to have the R22 pilot depart the pad westbound along runway 29R, turn right to the downwind, and then turn right and land on 29R. He would then clear the pilot to hover taxi along taxiway C to the ramp. As the R22 passed the North Pad area as it traversed eastbound on the downwind leg, he instructed the pilot to turn right. There was no response, and the helicopter did not turn. A few seconds later, he cleared the pilot to turn right and land on 29R. He did not hear an acknowledgement, so he repeated the instruction. The R22 turned at that point. The controller saw the R22 north of the approach end of 29R with the nose pointed roughly at the tower. He then looked away to his radar display as he worked another aircraft. After talking to that aircraft, he decided to advise the R44 that the R22 would be landing on 29R abeam the R44 as it departed. He looked back just as the helicopters collided.

The Safety Board investigator-in-charge (IIC) released the R22 wreckage to the owner’s representative on February 12, 2004. The IIC released the R44 wreckage to the owner’s representative on April 30, 2007.

**This narrative was modified on May 14, 2007.

Contact a Helicopter Lawyer

If you have been injured or a loved one has been killed in a helicopter crash, then call us 24/7 for an immediate consultation to discuss the details of the accident and learn what we can do to help protect your legal rights. Whether the accident was caused by negligence on the part of the helicopter owner, hospital or corporation, the manufacturer or due to lack of training, poor maintenance, pilot or operator error, tail rotor failure, sudden loss of power, defective electronics or engine failure or flying in bad weather conditions, we can investigate the case and provide you the answers you need. Call Toll Free 1-800-883-9858 and talk to a Board Certified Trial Lawyer with over 30 years of legal experience or fill out our online form by clicking below:

Legal Help: Contact a Helicopter Lawyer

On September 20, 2003, about 1238 mountain standard time, an Aerospatiale AS350BA helicopter, N270SH, operated by Sundance Helicopters, Inc., crashed into a canyon wall while maneuvering through Descent Canyon, about 1.5 nautical miles (nm) east of Grand Canyon West Airport (1G4) in Arizona. The pilot and all six passengers on board were killed, and the helicopter was destroyed by impact forces and postcrash fire. The air tour sightseeing flight was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135. Visual meteorological conditions (VMC) prevailed for the flight, which was operated under visual flight rules on a company flight plan. The sightseeing / tourist helicopter was transporting passengers from a helipad at 1G4 (helipad elevation 4,775 feet mean sea level [msl]) near the upper rim of the Grand Canyon to a helipad designated “the Beach” (elevation 1,300 msl) located next to the Colorado River at the floor of the Grand Canyon.

About 0745, the accident pilot flew the accident helicopter on an operational check flight at the company’s base at McCarran International Airport (LAS), Las Vegas, Nevada. After the short local flight, Sundance ground personnel (consisting of loaders and a tour coordinator) boarded the helicopter about 0840 and flew with the accident pilot on a 45-minute flight from LAS to 1G4 to commence the day’s Descent Canyon tour operations. The director of operations estimated that each flight from 1G4 to the Beach helipad lasted about 3.5 minutes (see figure 1).

Figure 1. Topographic chart showing the 1G4 departure site, the accident site, and the prescribed route through Descent Canyon to the Beach helipad.

These tourist flights were part of an advertised tour package in which Sundance pilots flew passengers through Descent Canyon, dropped them off at the Beach helipad for a scenic boat ride on the Colorado River, then picked them up at the Beach helipad later in the day for a return flight to 1G4 through another scenic canyon.

The accident flight was the pilot’s 11th flight through Descent Canyon that day. The tourist / sightseeing helicopter lifted off from 1G4 about 1237 and flew to the rim of Descent Canyon. The tour coordinator stated that she did not hear the pilot make either the first customary radio call stating that he was lifting off from the helipad or the second customary radio call advising that he was entering Descent Canyon en route to the Beach helipad. A pilot for Papillon Grand Canyon Helicopters, who departed in his helicopter from 1G4 and flew through Descent Canyon about 2 minutes before the accident flight, stated that he did not hear any radio calls from the accident pilot and did not know that a helicopter was behind him in the canyon.

The Sundance tour coordinator and a Papillon loader at 1G4 stated that they observed the accident helicopter hover at the rim of Descent Canyon for about 30 to 45 seconds before beginning a level descent. They stated that the helicopters usually flew directly from the loading pads to the top of Descent Canyon and either nosed down into the canyon or hovered for only a few seconds before descending nose-low into the canyon. The Sundance tour coordinator stated that ground personnel assumed that the accident pilot may have been waiting for the Papillon helicopter to clear the canyon before he initiated his descent.

The Papillon pilot who descended his helicopter ahead of the accident flight stated that, while he was approaching the helipad next to the Colorado River, he noticed a fireball rising on the canyon wall behind him in Descent Canyon. There were no known witnesses or air traffic control radar data to provide information on the accident flight’s progress inside the canyon after it descended out of view of the witnesses at 1G4.

The main wreckage was located on a canyon wall ledge about 400 feet beyond a near?vertical canyon wall that showed evidence of gouging consistent with a main rotor blade strike (see figure 2).

Figure 2. Initial main rotor blade impact location and main wreckage location. Note: This photograph was taken by a National Transportation Safety Board investigator on February 4, 2004, during a canyon topography documentation flight. The wreckage was previously removed from the site.

Figure 3. Overview of initial main rotor blade impact location, main wreckage location, and prescribed route of flight. Note: This photograph was taken by a Safety Board investigator on February 4, 2004, during a canyon topography documentation flight. The wreckage was previously removed from the site.

Figure 4. Main wreckage debris field.

SOURCE: NTSB

Contact a Helicopter Lawyer

If you have been injured or a loved one has been killed in a helicopter crash, then call us 24/7 for an immediate consultation to discuss the details of the accident and learn what we can do to help protect your legal rights. Whether the accident was caused by negligence on the part of the helicopter owner, hospital or corporation, the manufacturer or due to lack of training, poor maintenance, pilot or operator error, tail rotor failure, sudden loss of power, defective electronics or engine failure or flying in bad weather conditions, we can investigate the case and provide you the answers you need. Call Toll Free 1-800-883-9858 and talk to a Board Certified Trial Lawyer with over 30 years of legal experience or fill out our online form by clicking below:

Legal Help: Contact a Helicopter Lawyer

Rescue crews completed the dangerous task Saturday of retrieving the bodies of seven people killed Friday in a tour helicopter crash on Maui.

The crash of the Blue Hawaiian Helicopters twin-engine AS355 occurred on a steep mountain hillside in a remote area of Iao Valley. Photos of the crash scene provided by police show the tail section intact but the rest of the helicopter disintegrated into thousands of pieces.

The crash site has a deep slope of about 30 degrees, and is a wet and slick area, making it difficult for crews to gain access, said Lt. John Morioka, a spokesman for the Maui Police Department.

“There’s no place a helicopter can land, so the men are rappelling down,” he said.

A 10-man crew rappelled down from the helicopter to a ridge and then set new lines to rappel to the site at the 2,700-foot level, Morioka said.

Among the recovery team are a master rappeller and crews who take part in eradicating marijuana from remote areas, he said.

George Petterson, an investigator for the National Transportation Safety Board, said Saturday morning that recovery of the bodies would continue during the day, with recovery of the wreckage scheduled for today.

He said he will review pilot and maintenance records, and meet with representatives of the helicopter and engine manufacturers who are en route to the island.

“We really need to look at all the parts and pieces and look at the whole picture,” he said. He expects to issue a preliminary report in about five days.

Dental records were used to identify the pilot as Larry Kirsh, 55, police said.

The names of the other victims were to be released after they are positively identified through their dental records, which are to arrive Monday, said Richard Sword, a Maui psychologist handling disaster stress control for the families of victims.

The Fort Worth (Texas) Star-Telegram identified two of the victims as 14-year-old girlfriends Whitney Wood of Burleson, Texas, and Natalie Prince of Fort Worth, Texas.

A Honolulu television station quoted unidentified sources as identifying the four remaining passengers as a family from New Jersey — William John Jordan, his wife, Jan Hortivick, and their two children, Max Jordan, 17, and Linsey Jordan, 16.

Families of the six passengers have been notified and some are already on the island, Morioka said.

The crash occurred during a 35-minute sightseeing tour of the West Maui mountains.

Kirsh was a Vietnam veteran with more than 11,000 hours of flight time and had been with the company more than a year, said Patti Chevalier, co-owner of the company with her husband, Dave, a former Vietnam scout pilot.

This is the first accident involving a Blue Hawaiian tour helicopter since the company began operations in 1985.

This was Hawaii’s third notable aircraft crash in 11 months. On Sept. 25, a tour plane crashed on the slopes of Mauna Loa on the Big Island, killing all 10 people on board.

On May 10, a private jet slammed into a hillside while approaching an airport on Molokai, killing all six people on board.

Life Flight 6 Crash:
EMS helicopter flights have a greater risk of crashing because they often operate in unfavorable weather conditions that normally ground regular aircraft.

On January 10, 2003, approximately 2050 mountain standard time, an Agusta A-109-K2 twin-engine helicopter, N601RX, operated as Life Flight 6, was destroyed when it impacted terrain while attempting to maneuver in dense fog near the Salt Lake City International Airport (SLC), near Salt Lake City, Utah.

The instrument-rated commercial pilot and the flight paramedic were fatally injured, and the flight nurse was seriously injured. The helicopter was owned and operated by IHC (Intermountain Health Care) Health Services, Inc., of Salt Lake City, and doing business as (d.b.a.) IHC Life Flight. Night instrument meteorological conditions (IMC) prevailed for the 14 Code of Federal Regulations Part 91 flight, for which a company visual flight rules (VFR) flight plan was filed. The flight originated at the LDS Hospital, Salt Lake City, at 2032, and was destined for Wendover, Utah, to pick up a patient who had been injured in an auto accident.

According to Air Methods (another Salt Lake City air ambulance company), dispatch records, and a written statement provided by the Air Methods pilot, at 1949, a call was received from Tooele County, Utah, police dispatch requesting a helicopter to stand by for a possible medical response flight. Approximately 5 minutes later, an Air Methods flight was dispatched from the University of Utah Medical Center, Salt Lake City, for the medical emergency flight to Wendover. After departure, the Air Methods pilot contacted the SLC air traffic control tower (ATCT) and requested an “I-80 transition low-level west bound to Wendover.” SLC ATCT instructed the Air Methods pilot to hold east of SLC due to landing traffic. The pilot held at 700-feet agl from approximately 2010 to 2019 while monitoring the ATCT and the automatic terminal information system (ATIS) frequencies. The pilot stated the weather “drastically changed from 2 miles visibility to 1/16th SM (statute miles) FG (fog).” Approximately 2019, ATCT cleared the pilot to transition over SLC; however, due to the deteriorating weather, the pilot elected to abort the flight and return to the University of Utah Medical Center.

Approximately 2030, the Air Methods flight terminated at the University helipad. After completing the shutdown and post flight procedures, the pilot returned to the Air Methods dispatch facility at the medical center. As the pilot walked into dispatch, he heard dispatch personnel and his crew discussing that Life Flight was attempting the flight. The pilot then contacted the Life Flight 6 pilot on the dispatch radio and reported that he just aborted the same mission because the visibility had reduced to 1/16 mile. The Life Flight 6 pilot stated he was going to try to get over the fog and get to Wendover.

Between 2017 and 2056, the following communications excerpts were recorded by Life Flight dispatch personnel (LFD), Tooele dispatch (TD), and the Life Flight 6 pilot (LF6). It should be noted that recorded times may vary between Air Methods dispatch and Life Flight dispatch due to time disparities between the facilities.

Approximately 2017, Tooele County dispatch and Life Flight Communication Center:

LFD: Life Flight [dispatcher]
TD: Hello this is [dispatcher] from Tooele County
LFD: Hey
TD: Are you guys able to fly
LFD: Auh, I can check, we can sure give it a try
TD: Well, Air Med can’t, so I don’t know if you could
LFD: Oh, well
TD: Is it the same
LFD: Let me check with my pilot…

Approximately 2018, Life Flight 6 pilot and Life Flight Communication Center:

LF6: Life Flight [pilot]
LFD: [Pilot] this is [dispatcher]
LF6: Hi [dispatcher]
LFD: This is [dispatcher], will you check weather for Wendover marker 22, mile marker 22
LF6: You think there is a weather reporting service right at mile marker 22
LFD: Well, yea, that’s what I’m thinking (laughter), well, how about out west, can you fly out west
LF6: I can see out west, all I got really is Wendover itself and it says 10 miles and I’ll look back in Salt Lake again, got Salt Lake and they gotten really bad there right there in the valley 1/16th of a mile
LFD: Ok, so this is a, um, you could probably look at mile marker 22 as closer to Wendover, so
LF6: Is it
LFD: Just yes or no
LF6: Well, it’s one of those things; I can give it a shot.
LFD: Ok
LF6: I can’t make promises
LFD: Alright, I can tell them we will give it a shot and there are no guarantees
LF6: Is this a go
LFD: Yes, let’s plan on going, why don’t you go get ready and I will call the dispatch back, and I will call dispatch back…

Approximately 2022, Tooele County and Life Flight Communication Center:

LFD: Hi, this is [dispatcher] at Life Flight
TD: Dispatch [dispatcher]
LFD: Yea, you know what, we are going to give it a try
TD: Ok
LFD: It looks like Wendover is clear enough to get into it; it’s just going to be between here and there that could be iffy. They’re going to lift to see how far they can get.
TD: Ok
LFD: But I can’t really guarantee anything, so…
TD: That’s ok
LFD: Tell me what you got

Approximately 2044, Life Flight Communications Center and Life Flight 6 pilot:

LF6: We are on the west side of the airport. Air Med got sent out for this same damn thing and then they called us to go out. Air Med turned around for low visibility so they go shopping for another helicopter and we’re turning around at the west side airport. You know it what’s their determination, you know
LFD: I understand, unfortunately that happens all day long a lot of the dispatch center do it, but so I understand that you are turning back twenty
LF6: I mean they need help, I mean when they need help, it’s not you know like they call to just hi themselves anyway, there’s a ton of air traffic out here so we’ll wait to cross back over the airport.
LFD: Alright, were you able to get a hold of anyone the Wendover ambulance on the ground
LF6: We talked with them but we haven’t make contact with them to tell them that we are turning around
LFD: Ok, no problem, I can tell Tooele Dispatch and let them know
LF6: Ok, that would be great

According to the communication transcript provided by the SLC ATCT, at 2031, the Life Flight pilot contacted SLC ATCT for a departure clearance from the LDS Hospital. Approximately 2033, the Life Flight pilot was cleared to proceed toward SLC via the signatory letter of agreement (LOA) and enter the Class B airspace. At 2033, the pilot advised ATCT that he was attempting to “climb out of it” and requested clearance to 7,000 or 8,000 feet. Life Flight 6 was cleared for the ascent and to remain to the east of SLC. At 2035, ATCT inquired how high did Life Flight 6 want to fly to obtain VFR. Life Flight 6 pilot reported that he attempted to climb; however, he would lose VFR and requested not to do that, but to transition through the SLC airspace “to see if it clears up any better for us.” ATCT advised the pilot the visibility was 1/16th of a mile and to proceed inbound via the LOA and remain east of SLC. At 2037, ATCT asked the pilot, “based on [his] flight conditions” if could he continue westbound, and the pilot responded, “I’d like to give it a try if I could.”

At 2039, Life Flight 6 was cleared westbound and to maintain VFR at or below 5,000 feet. At 2041, Life Flight 6 pilot stated he was on the west side of the airfield, and requested to head back to the east; however, he could hold over there. At 2044, the pilot asked ATCT whether he was cleared back to the east. ATCT informed the pilot that she could not let him go east until he could see other aircraft on final approach to runway 34R or have a “hole large enough to get [Life Flight 6] back to the east side.”

At 2049:51, Life Flight 6 pilot reported to ATCT, “I’m basically inadvertent IMC at this time and declaring emergency.” At 2051:03, ATCT asked the pilot whether he had runway 34L in sight, the pilot responded, “that’s negative and I’m currently on a heading one five zero.” ATCT instructed the pilot to turn right to a heading of 340 degrees to vector toward SLC. The accident aircraft did not acknowledge the instruction, the ATCT controller attempted to contact the Life Flight 6 pilot, and no further communications were received by ATCT from the accident aircraft. The SLC airport rescue and firefighting personnel were then notified of a possible crash.

A witness, who was located at a construction site approximately 1/4 mile south of the accident site, reported the accident helicopter was traveling over the job site trailer, and he noted the helicopter was “going north in the fog.” The witness stated it was “very foggy, [and] could see approximately 30 feet with headlights.” The witness added he could see a glimpse of red from the helicopter light, could hear blades turning in a “woshing” sound for about 10 seconds, and then heard a crash. The witness called 911 and then assisted the law enforcement and rescue personnel in locating the aircraft.

Another witness, who was also located at the construction site, reported the helicopter came from the northwest and was low to the ground. The helicopter banked over the construction site with the engine making “high-low variable sounds.” The helicopter then went to the north for approximately 10 seconds with no sound of the motor; however, he could hear the “rotor turning” for approximately 5 seconds before hearing an impact.

The SLC police department dispatch received the 911-phone call from a witness at 2056. The witness reported to the police dispatch “very thick fog…the helicopter barely missed their trailers…fog is very thick can only see 40 feet ahead.” Approximately 2140, local law enforcement personnel and the witness located the helicopter.

According to a statement provided by Air Methods Chief Flight Coordinator, on the day of the accident, several flights were missed due to “extreme fog”.

PERSONNEL INFORMATION

The pilot held a commercial helicopter certificate, issued on September 18, 1985, with an instrument helicopter rating. The pilot was issued a second-class medical certificate on March 15, 2002, with the limitation, “MUST HAVE AVAILABLE LENSES FOR NEAR VISION.”

According to the operator, as of October 15, 2001, the pilot had accumulated 3,671 hours total flight time, 483 hours night flight time, 362 hours night cross-country time, 311 hours simulated instrument time, and 3 hours actual instrument time. The pilot completed his initial Agusta A-109-K2 training on October 27, 2001, which included 10.0 hours total flight time, and 40.0 hours ground training in the A-109-K2. The operator assigned the pilot to the A-109-K2 on October 29, 2001.

A review of the pilot’s flight and duty time records, which were provided to the National Transportation Safety Board Investigator-In-Charge (NTSB IIC) by the operator, revealed that as of December 1, 2001, the pilot had accumulated approximately 114 flight hours as pilot-in-command in the Agusta A-109-K2, with 73.1 hours logged as day flight and 40.6 hours logged as night flight. The pilot had accumulated 34.9 flight hours, 22.6 flight hours, and 11.4 flight hours in the last 90, 60, and 30, days respectively.

On March 21, 2002, the pilot satisfactorily completed his Federal Aviation Regulations (FAR) Part 135 Airman Competency/Proficiency Check in the Bell 206 helicopter. According to the remarks, the pilot completed “inadvertent IMC with ILS (instrument landing system) recovery.” On September 30, 2002, the pilot satisfactorily completed his FAR Part 135 Airman Competency/Proficiency Check in the Agusta A-109-K2 helicopter. According to the remarks, the pilot completed “inadvertent IMC with ILS (instrument landing system) recovery.”

Prior to his employment with IHC, the pilot reported to the operator he had been a helicopter pilot for 17 years and an Emergency Medical Services (EMS) pilot for over 5 years.

The two medical crewmembers, a flight nurse and a paramedic, were based at the LDS Hospital.

AIRCRAFT INFORMATION

The red and white accident helicopter (serial number 10017) was configured for the transport of medical patients with two seats in the cockpit, one rear-facing seat aft of the cockpit, one forward-facing seat, and one medical bed. The helicopter was powered by two 730-horsepower Turbomeca Arriel 1K1 turbo shaft engines (serial numbers 16016 and 16017) and equipped with a four bladed main rotor system, and a two bladed tail rotor. The helicopter was also equipped for IFR operations, and was equipped with a three-channel Stabilization Augmentation System (SAS), which provided the capability of automatically controlling the pitch, roll and yaw axes of the helicopter.

The helicopter was maintained in accordance with the Manufacturer’s Recommended Extended Maintenance Program on a continuous basis. At the time of the accident, the airframe had accumulated 3,545.4 flight hours, the left engine had accumulated 2,801.9 hours and the right engine had accumulated 4,729.2 hours. The 1,200-hour inspection was completed on January 2, 2003, at a total time of 3,544.3 hours, and the 25-hour inspection was completed on January 9, 2003, at a total time of 3,544.3 hours.

METEOROLOGICAL INFORMATION

The Air Methods flight crew stated the visibility was clear from the University of Utah Medical Center to downtown Salt Lake City area. Shortly after departure, one crewmember noted, “there appeared to be almost a wall of clouds or fog to the west.” A Life Flight crewmember, who assisted the accident crew prior to the flight, reported they could “see stars and moon” from the LDS Hospital helipad.

A National Oceanic and Atmospheric Administration (NOAA) representative received a phone call, between 2025 and 2035, from a Life Flight pilot who was located at the SLC airport. The pilot reported to the NOAA representative that he was concerned with the fog, which was “really thick, and the RVR (runway visual range) was zero…” The pilot inquired how long the fog would persist, and the representative stated 2 to 3 hours.

Local law enforcement officials who responded to the accident area stated “it was difficult locating the helicopter due to the fog…the night was very foggy and the crash site was very difficult to find…responding units experienced extreme dense fog.”

At 2011, the SLC Airport reported winds from 340 degrees at 3 knots, 1/16 mile visibility with fog, and a vertical visibility (VV) of 200 feet. The temperature and dew point were both reported at 34 degrees Fahrenheit, and the altimeter setting was 30.10 inches of Mercury.

At 2056, the SLC Airport reported winds from 350 degrees at 6 knots, 1/8 mile visibility with fog, and a vertical visibility (VV) of 200 feet. The temperature, dew point, and altimeter setting remained the same as the 2011 report.

WRECKAGE AND IMPACT INFORMATION

The helicopter wreckage was located by rescue personnel one half mile southwest of the approach end of SLC runway 34L. A ground scar was oriented along a magnetic heading of 150 degrees. A 1/4 mile gap existed between the ground scar and the helicopter, which came to rest upright in a grassy field. The geographic coordinates of the helicopter wreckage were north latitude 40 degrees 46.3 minutes by west longitude 112 degrees 01.1 minutes at an elevation of approximately 4,000 feet msl.

The initial impact area contained three ground scars, which contained white paint transfer, that were consistent with the three landing gear assemblies. There were no additional ground scars noted in the initial impact area. The initial impact area measured approximately 330 feet in length, and contained the two main landing gear assemblies, the nose gear ski, several pieces of broken plexiglass, the outboard 4-inches of the left horizontal stabilizer, and shredded aluminum pieces from the left horizontal stabilizer.

The main wreckage came to rest approximately 90 degrees from the ground scars. Pieces of aluminum, consistent with the tail rotor blades, and pieces of plexiglass were located between the initial impact area and the main wreckage. The distribution path of the debris was consistent with a semi-circular flight path following the initial impact. The main wreckage consisted of the fuselage, the two engines, transmission, main rotor assembly, and the tail boom with the tail rotor gearbox and blade assembly separated. The tail rotor assembly came to rest adjacent to the tail boom. Separated honeycomb core sections of the main rotor blades were located within a 100-foot radius of the main wreckage.

On January 15, 2003, the wreckage was recovered by an aircraft retrieval/salvage firm to a hangar at SLC, and was examined by the NTSB IIC, operations and airworthiness inspectors from the Federal Aviation Administration (FAA), representatives from the airframe and engine manufacturers, and representatives from IHC Life Flight.

The cockpit and cabin fuselage from the avionics bay aft to behind the baggage compartment was crushed and distorted to the right when viewed from the tail. The cockpit and cabin floors were crushed upward. The cabin area roof, aft of the two forward cockpit seats, was crushed downward and to the right by the main rotor transmission and engines. The left side cockpit door and frame were cut and removed by rescue personnel. The damage sustained on the right side of the cockpit was consistent with impact from the main rotor blades. Several flight instruments were separated and displaced from their respective mounting structure. A majority of the cockpit windscreen was shattered and separated from the fuselage.

The tail boom was intact; however the tail boom was crushed upward and displaced to the right. The outboard 1-foot of the right horizontal stabilizer was bent upward and remained intact. The vertical stabilizer was intact and the leading edge displayed a puncture hole. The outboard 1-foot of the leading edge of the left horizontal stabilizer was crushed aft. The outboard 1-foot of the left horizontal stabilizer was bent aft and shredded. The tail boom skid was bent upward and to the left. The tail rotor gearbox separated from the tail boom mounting structure. The tail rotor blades were bent and the outboard 4 to 6 inches of the blade tips were shredded. Continuity was established throughout the tail rotor gearbox to the blades. The tail rotor pitch links were intact. The forward tail rotor drive shaft was separated near the main transmission attach point. The separated drive shaft displayed signatures consistent with torsional overload. Continuity was established throughout the remaining tail rotor drive shafts, from the tail rotor gearbox to the separation near the main transmission attach point.

The engines remained attached to the airframe via the forward engine mounts; however, the aft engine mounts were separated. The left and right engine compressor sections were rotated by hand and continuity was noted to the accessories. Both engine to transmission drive shafts were separated from their respective attach flanges. The engines were removed and transported to the facilities of Turbomeca, near Grand Prairie, Texas, for further examination.

The main transmission was separated from the two forward and one aft attach mounts, and displaced to the right. Continuity was established from the drive shaft inputs to the rotor head. Blade up stops remained intact, and no evidence of blade coning was noted. All four main rotor blades remained attached to the rotor head. Three blades displayed leading edge gouging, scratching, and core separation.

PATHOLOGICAL INFORMATION

The Office of the Medical Examiner, State of Utah, Department of Health, Salt Lake City performed autopsies on the pilot and flight paramedic, on January 11, 2003. Specimens for toxicological tests were taken from the pilot by the medical examiner. According to the autopsy, the cause of death for both persons was blunt force injury of the chest.

The FAA’s Civil Aeromedical Institute’s (CAMI) Forensic and Accident Research Center examined the specimens taken by the medical examiner. The toxicological tests were negative for carbon monoxide, cyanide and alcohol. An unspecified amount of Verapamil (commonly known as Calan or Isoptin) was found in the blood and urine.

TEST AND RESEARCH

The engines were examined and disassembled on April 8, 2003, at the facilities of Turbomeca, under the supervision of the NTSB IIC and representatives from Turbomeca. Examination of the left engine (serial number 16016) revealed foreign object debris (FOD) in the module 03, gas generator combustion chamber. The FOD was consistent with red and white paint chips. Some metal spray deposits were noted on the first and second stage turbine wheels. The axial compressor rotor, free turbine rotor, and turbine reduction gearbox were free to rotate. The powershaft was intact and no evidence of twisting was noted. The fuel control unit was removed and tested according to an FAA approved test procedure. The unit operated according to the manufacturer’s specifications.

Examination of the right engine (serial number 16017) revealed FOD in the module 02, axial compressor section, and the module 03 combustion chamber outer shell and inner chamber. The FOD was consistent with red and white paint chips and Kevlar debris. The axial compressor blades displayed evidence of FOD damage and the compressor rotor was free to rotate. The free turbine rotor was free to rotate and did not display evidence of metal spray deposits. The fuel control unit was removed and tested according to an FAA approved test procedure. The unit operated according to manufacturer’s specifications.

On July 29 and 30, 2003, at the facilities of Honeywell, near Glendale, Arizona, components of the autopilot system were tested under the supervision of the NTSB IIC and representatives of Honeywell. Examination of the gyro horizon revealed internal damage to the roll gimble, and witness marks on the sphere were consistent with a 55-60 degree nose up position. The DH (Decision Height) light bulb filament was stretched and broken, and the GA (Go-Around) light bulb filament was intact. The radio altimeter cockpit instrument DH bug was set at 500 feet agl. The radio altimeter unit was functionally tested and no anomalies were noted. The flight director mode selector was intact and no anomalies were noted. The two helipilot computers, and the flight director computer were not functionally tested due to lack of test equipment.

Contact a Helicopter Lawyer

If you have been injured or a loved one has been killed in a helicopter crash, then call us 24/7 for an immediate consultation to discuss the details of the accident and learn what we can do to help protect your legal rights. Whether the accident was caused by negligence on the part of the helicopter owner, hospital or corporation, the manufacturer or due to lack of training, poor maintenance, pilot or operator error, tail rotor failure, sudden loss of power, defective electronics or engine failure or flying in bad weather conditions, we can investigate the case and provide you the answers you need. Call Toll Free 1-800-883-9858 and talk to a Board Certified Trial Lawyer with over 30 years of legal experience or fill out our online form by clicking below:

Legal Help: Contact a Helicopter Lawyer

On January 8, 2003, about 0847:28 eastern standard time, Air Midwest (doing business as US Airways Express) flight 5481, a Raytheon (Beechcraft) 1900D, N233YV, crashed shortly after takeoff from runway 18R at Charlotte-Douglas International Airport, Charlotte, North Carolina. The 2 flight crewmembers and 19 passengers aboard the airplane were killed, 1 person on the ground received minor injuries, and the airplane was destroyed by impact forces and a postcrash fire. Flight 5481 was a regularly scheduled passenger flight to Greenville-Spartanburg International Airport, Greer, South Carolina, and was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The airplane’s loss of pitch control during take-off. The loss of pitch control resulted from the incorrect rigging of the elevator system compounded by the airplane’s aft center of gravity, which was substaintially aft of the certified aft limit.

Contributing to the cause of the accident were (1) Air Midwest’s lack of oversight of the work being performed at the Huntington, West Virginia, maintenance station; (2) Air Midwest’s maintenance procedures and documentation; (3) Air Midwest’s weight and balance program at the time of the accident; (4) the Raytheon Aerospace quality assurance inspector’s failure to detect the incorrect rigging of the elevator control system; (5) the Federal Aviation Administration’s (FAA) average weight assumptions in its weight and balance program guidance at the time of the accident; and (6) the FAA’s lack of oversight of Air Midwest’s maintenance program and its weight and balance program.

SOURCE: NTSB