Aviation Accident Summaries

Aviation Accident Summary NYC07FA048

Dagsboro, DE, USA

Aircraft #1

N407JJ

Bell 407

Analysis

While en route to pick up a passenger for a revenue VFR flight, the helicopter pilot encountered fog. She subsequently diverted from her intended destination and landed in a field. By the time her passenger arrived at the helicopter, darkness had fallen, and dense fog had formed. The pilot and passenger then boarded the helicopter. A witness watched as the helicopter climbed vertically to a height just above the trees to its left and the utility lines to its front, and hovered for a few seconds. While hovering, the landing light of the helicopter cycled on and off two times. The helicopter then pitched nose down and accelerated forward. Instead of climbing, the helicopter accelerated forward in a shallow descent until it impacted the ground. The witness described that the conditions of darkness and fog prevented him from making his way to the accident scene without the aid of a light. Several other witnesses described similar conditions around the time of the accident. Forecasted and actual recorded weather conditions in the area around the time of the accident were consistent with the observations of the witnesses. The ceiling and visibility conditions were significantly worse than the minimum values required by the company's operations specifications. Further review of the operations specifications revealed that the pilot was required to report any changes in her itinerary to the operator. No evidence was found to indicate that the pilot had notified the operator of her initial deviation and subsequent landing in the field, or of her intent to depart from that field after sunset. Additionally, during postaccident interviews the operator could not clearly articulate its actual method for determining whether an aircraft was overdue, since no one individual was charged with that specific duty for operations after normal business hours. Examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions.

Factual Information

HISTORY OF FLIGHT On December 14, 2006, about 1815 eastern standard time, a Bell 407, N407JJ, operated by HeloAir Inc., was destroyed when it impacted terrain during takeoff from a private farm field near Dagsboro, Delaware. The certificated commercial pilot and the passenger were fatally injured. Instrument meteorological conditions prevailed, and a visual flight rules (VFR) Air Defense Identification Zone (ADIZ) flight plan was filed for the flight, destined for Washington Dulles International Airport (IAD), Dulles, Virginia. The non-scheduled passenger flight was conducted under 14 Code of Federal Regulations (CFR) Part 135. According to the operator, the pilot began her work day at 1115, and departed from the helicopter's base in Manassas, Virginia, at 1215. The pilot picked up the passenger at his private residence at 1230, and dropped him off at a golf club in Ocean View, Delaware, at 1330. She then proceeded to Sussex County Airport (GED), Georgetown, Delaware, and refueled the helicopter. The pilot departed Georgetown about 1650, and was scheduled to pick up the passenger at the golf club, about 1730, and return him to Washington Dulles Airport. Another pilot saw and spoke with the accident pilot while at the airport in Georgetown. The pilot observed the accident pilot as she used the weather computer in the pilot lounge to obtain weather information. He then discussed some of this information with the accident pilot including the weather radar, surface observations, and forecasts, as well as general weather patterns in the area. He described that the accident pilot was "nervous" about the weather, and that she expressed this concern to him. The accident pilot checked the weather several times before she departed Georgetown. About 1700, two witnesses observed the helicopter flying at an altitude about 75 feet above the trees, in the vicinity of the accident site. One witness observed the helicopter disappear into fog, and then reappear traveling in the opposite direction. When asked to describe the lighting and the weather in the area at the time, the other witness stated that it was dusk, and that fog was beginning to form. She added that by the time it was dark, around 1730, the fog had worsened and "you couldn't see." About 1715, the accident helicopter landed in a farm field. The property owner did not recognize the helicopter, became concerned, and contacted the Delaware State Police. A state trooper arrived at the helicopter around 1730, and spoke with the pilot. The pilot advised the trooper that she was scheduled to pick up a passenger at a nearby golf club, but was unable to land there due to fog. She diverted from the intended destination and landed in the field to await the passenger's arrival. When he was asked about the light and weather conditions at the time that he talked to the pilot, the trooper noted that it was "dark and foggy." According to the automobile driver of the helicopter passenger, the passenger informed him about 1745 that the helicopter had landed in a farm field about 5 to 7 miles from their location. The driver and passenger departed the golf club, and after the pilot gave him a description of her location, the driver was able to find the helicopter. The driver stopped his vehicle in front of the helicopter, and greeted the pilot. He then asked the pilot if she felt comfortable with the conditions. He specifically pointed out the power lines, irrigation equipment, and the tree line adjacent to the helicopter. The pilot replied that it was a "piece of cake," and pointed to the sky above. The driver recalled that at that time, the stars could clearly be seen. The pilot stated that her only worry was getting across the Chesapeake Bay and to Dulles on time. The driver then asked the pilot if she needed or wanted to use the headlights of his vehicle in any way, to which the pilot responded that it was not necessary. The driver then pulled the vehicle away, and briefly stopped to watch the helicopter take off. Due to the dark lighting conditions and the foggy weather, the driver was unable to see the helicopter or its lights. He drove away shortly thereafter. A witness was working about 800 feet from the accident site at the time of the accident. According to the witness, about 1815, he heard the helicopter's engine start, and proceeded outside to watch the takeoff. The helicopter climbed vertically to a height just above the trees that were to its left and above the utility lines that were to its front, and hovered for a moment. While hovering, the landing light of the helicopter turned on, off, on, and off again. The helicopter then pitched nose down and began to accelerate forward. The witness expected to see the helicopter climb, as he had seen other helicopters do in the past; however, the accident helicopter just accelerated forward in a shallow descent until it impacted the ground. When asked about the sound of the helicopter or its engine during the takeoff, he stated that the sound was smooth and continuous, and that nothing sounded abnormal. The witness additionally described that at the time of the accident it was dark, the fog was dense, and that it thickened throughout the evening. The witness attempted to respond to the accident site, but could not find his way in the darkness and thick fog, and subsequently returned to where he was working to retrieve a video camera with a light attached. A review of the video taken by the witness following the accident revealed weather and lighting conditions consistent with those he reported. An off-duty firefighter reported that he heard, but did not see, the helicopter during the takeoff. After he heard the sounds of impact he contacted local authorities and responded to the scene. At the time that he was making his way to the accident site, he estimated that the visibility was 1/8 mile or less in fog. The accident occurred during the hours of night at 38 degrees 32.913 minutes north latitude, 75 degrees 12.832 minutes west longitude. METEOROLOGICAL INFORMATION An AIRMET for instrument metrological conditions encompassing the route of flight between the departure point and the eastern shore of Northern Virginia was issued at 1545. It warned of ceilings below 1,000 feet, and visibilities less than 3 statute miles due to mist and fog, with the conditions continuing beyond 2200. At 1801, the weather conditions reported at Sussex County Airport, located about 11 nautical miles northwest of the accident site, included winds from 100 degrees at 3 knots, 3 statute miles visibility in mist, clear skies, temperature 46 degrees Fahrenheit, dewpoint 45 degrees Fahrenheit, and an altimeter setting of 29.99 inches of mercury. At 1840, the visibility at Sussex County Airport was reported as 1 1/4 statute miles in mist. According to the United States Naval Observatory, on December 14, 2006, the official sunset in Dagsboro, Delaware occurred at 1641, and the end of civil twilight occurred at 1710. Moonrise occurred at 0221 on the following day. At 1002 the pilot contacted the Leesburg, Virginia, Flight Service Station (FSS) in order to file three VFR ADIZ flight plans. She planned to depart Manassas, Virginia, at 1200, then depart the passenger's residence around 1230, and to reenter the ADIZ at 1800. During the telephone call the pilot did not request any weather information from the briefer. The pilot again contacted the Leesburg FSS at 1548, and filed a fourth VFR ADIZ flight plan, for a flight from Dulles Airport to Manassas Airport. The pilot did not request any weather information from the briefer during the telephone call. Examination of telephone records revealed that between 1629 and 1805 the pilot placed 24 telephone calls from her personal mobile phone. Of those telephone calls, two were placed to the Leesburg FSS. The first was placed at 1659 and lasted 9 seconds. The second was placed at 1723, and lasted 171 seconds. Neither telephone call could be correlated with a recorded conversation. Within that same time period, the pilot placed 19 other telephone calls to several automated weather stations. These included, and were located in, Cambridge, Maryland; Manassas, Virginia; Baltimore, Maryland; Arlington, Virginia; Reston, Virginia; Stafford, Virginia; and Leonardtown, Maryland. The calls were of various durations. The shortest was 3 seconds, and the longest was 78 seconds. About 2056, the chief pilot for the operator contacted the Leesburg FSS inquiring about the status of the helicopter. The chief pilot also inquired about the weather conditions in the departure area. The briefer informed the chief pilot that the weather conditions at Easton /Newnam Field (ESN), Easton Maryland included overcast clouds at 100 feet, and a visibility of 1 mile in mist, and that the weather had been "low" there for the previous 3 to 4 hours. The briefer further advised the chief pilot that there had been no recent air traffic control contact with the helicopter. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with a rating for rotorcraft-helicopter. She also held a flight instructor certificate with a rating for rotorcraft helicopter. She did not hold an instrument rating. Her most recent Federal Aviation Administration (FAA) second class medical certificate was issued on April 28, 2006, and on that date, she reported 2,800 total hours of flight experience. The pilot's most recent FAR Part 135 recurrent check was conducted on February 8, 2006. According to documentation provided by the operator, as of October 19, 2006 the pilot had logged 3,300 hours of experience acting as pilot-in-command of a helicopter, 500 hours of which were at night. WRECKAGE AND IMPACT INFORMATION The wreckage was examined at the site on December 15, 2006. There was a strong odor of fuel, and all major components of the helicopter were accounted for at the scene. The takeoff point of the helicopter was identified by the Delaware State Trooper. Examination of the site revealed two depressions in the ground consistent in size and shape with the helicopter's landing gear skids. No damage was noted in the tree line located about 50 feet south of the takeoff point, nor was any damage noted to the utility lines located about 300 feet west of the takeoff point. The beginning of the wreckage path was located 1,090 feet, bearing 297 degrees magnetic, from the takeoff point. The wreckage path was on flat terrain, oriented in a direction of 288 degrees magnetic, and was 116 feet long. The initial ground scar was about 2 feet long, 8 inches deep. Another ground scar, located directly beyond the initial impact point, was 4 feet long, and about 2 feet deep. The right skid was lodged in the ground at an approximate 40-degree angle to the surface, oriented roughly parallel to the initial ground scar. The cockpit and cabin area were destroyed, and fragmented along the wreckage path. The tailboom was separated into two 5-foot sections, and was lying adjacent to the main wreckage. The fractured ends of the tailboom and fuselage exhibited impact damage consistent with the size and curvature of the leading edge of the main rotor blades. One of the tail rotor blades exhibited impact damage about 8 inches from the blade tip. The engine, transmission, and main rotor system remained attached to the fuselage. All four main rotor blades remained attached to the rotor hub, and the main spar of each blade was intact to its respective tip. Approximately half of the honeycomb afterbody from each main rotor blade was separated and scattered along the wreckage path. All four main rotor blades exhibited s-bending and chord-wise scratching consistent with ground contact. Three of the rotor blades exhibited paint transfer consistent in color with the tailboom and fuselage. All four yoke flextures exhibited delamination and spar fiber fractures, and all four blade down stops exhibited signatures consistent with contact with the pitch horn. Two of the four pitch change links were fractured near their respective bottoms, and the other two were bent. When moved, the swashplate rotated freely. Single pilot controls were installed, and the unused collective and cyclic controls were found in the aft baggage compartment. The installed cyclic and collective controls were separated at their bases. The flight control vertical tunnel was separated at the top and bottom from the fuselage. All three control tubes, two cyclic and one collective, were fractured at various points throughout the system, and all breaks were consistent with overload. Pre-impact continuity of the controls was confirmed to the main and tail rotors. Continuity of the drivetrain was confirmed. The main driveshaft was separated forward of the rotor brake and exhibited rotational scoring. Examination of the engine revealed that the N1 and N2 sections were free to rotate. The engine control unit was removed from the engine, and all electrical connections were snug, and were absent of moisture, corrosion, or debris. The aft main fuel tank was ruptured, but did contain a significant amount of residual fuel, and the ground adjacent to the tank was saturated with fuel. The forward main fuel tank remained intact, and the ground near the separated fuel lines was saturated with fuel. The engine was removed and shipped to the manufacturer for further examination. On February 6, 2007, the engine was mounted in a test stand and run. The engine developed takeoff power and no abnormalities were noted. Examination and download of the engine's Full Authority Digital Engine Control revealed no evidence of any preimpact mechanical malfunction or failure. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the Office of the Chief Medical Examiner, Wilmington, Delaware. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. ORGANIZATIONAL AND MANAGEMENT INFORMATION According to the operator's Operations Manual (OM), section 2.19, Basic Company VFR Weather Minimums, "The PIC [pilot-in-command] will not operate a VFR helicopter without visual surface reference." The manual also listed weather minimums required for a night cross country flight, which included a ceiling of 1,000 feet above the ground, and a visibility of at least 3 miles. According to section 2.27, Flight Destination Minimum Requirements, of the Operations Manual, "The PIC will compile all available information regarding the intended route or airport prior to departure. Prior to the initiation of a flight, the PIC will ensure that his destination is suitable for landing. It is the sole responsibility of the PIC to decide the suitability of any landing zone where he may conduct a flight. Prior to takeoff, the PIC will check the following to ensure the safety of his destination." Several guidelines for the PIC were listed including: a. If the destination is not an approved FAA landing area that the permission of the land owner has been received. b. If the landing is to occur at night that the proper ground lighting or reflective material is in place for the landing. c. Familiarize [yourself] with the terrain and obstruction hazard. d. If the destination is unfamiliar, that an appropriate landing area check has been completed prior to the initiation of the flight. e. Prior coordination to ensure public safety at the landing site. f. Prior to landing the PIC will determine wind direction from an illuminated wind direction indicator, local ground communications, or the PIC's personal observation. According to section 2.30 of the OM, Flight Following/Locating, it was the PIC's responsibility to ensure that they could remain in radio contact with the principal operations base, maintain positive flight following, file a VFR flight plan, or to leave all flight plan information with the principal operations base. Any deviations or alterations to the route of flight, itinerary, or number of passengers would need to be updated with the chief pilot or flight service as soon as possible. In the event that the pilot operated to or from an area or facility where no communications were available, or where communication difficulties

Probable Cause and Findings

The pilot's improper decision to depart under visual flight rules into night instrument meteorological conditions. Contributing to the accident was the fog and the dark night conditions.

 

Source: NTSB Aviation Accident Database

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