Aviation Accident Summaries

Aviation Accident Summary ERA13FA014

Coolbaugh Township, PA, USA

Aircraft #1

N108MF

BELL 407

Analysis

The surviving passenger reported that, after taking off, the weather "began to get worse," and the helicopter pilot advised the passengers that they would not be able to make it to their destination airport. The weather worsened, and the pilot decided to divert. When the surviving passenger looked out of the window, it was "misty and dusky." Shortly after, the helicopter struck trees and terrain. A witness reported observing the helicopter flying "very low" along the southbound lane of an interstate with all of its lights on just before the accident. He stated that the visibility was low, that the helicopter was under "low fog," and that it was like "pea soup" around the area. Review of meteorological and GPS information indicated that dark night instrument meteorological conditions (IMC) existed in the accident area. Light rain was present, and low instrument flight rules conditions existed with vertical visibility of 200 feet and variable visibility of 1/2 mile. Before the accident, the helicopter was flying through this area of weather at a low altitude and an airspeed of about 30 knots. Although the pilot could have returned to the departure airport or landed in a suitable area along his route of flight, he chose to enter IMC despite the availability of safer options and was then forced to divert as the weather worsened. Also, once the helicopter had entered the weather, the sun had already set and minimal ground lighting was present in the heavily wooded area surrounding the interstate. Therefore, it is unlikely that a discernable horizon was present, which would have significantly increased the pilot's workload because it would have required him to reference the helicopter's flight instruments to maintain the helicopter's attitude, flightpath, energy state, and altitude. Fuel was found onboard the helicopter, and no evidence of any preimpact failure or malfunction of the helicopter, drivetrain, or engine was found that would have precluded normal operation. Review of data recorded by the engine control unit revealed no hard faults or engine operational issues before the beginning of the accident sequence. Recorded data further indicated that the engine was running during the impact sequence and continued to operate for an additional 21 minutes following the accident while the helicopter was resting on its right side, which resulted in reduced oil flow and lubrication to the engine and the eventual postimpact failure of the turbine main line bearings and rotatable parts. Although the pilot held an airline transport pilot certificate that allowed him to fly under IMC in airplanes, he did not possess an instrument helicopter rating. Review of information provided by the helicopter manufacturer revealed no evidence that the pilot had received any inadvertent IMC or instrument flight rules helicopter training when he was at its training center. Examination of the pilot's flight- and duty-time records also revealed that he was scheduled to fly a round trip for the airline he worked for the day after the accident occurred, which likely resulted in self-imposed pressure to complete the trip he was flying on the day of the accident so that he could return home and make his report time for his assigned trip on the following day.

Factual Information

HISTORY OF FLIGHT On October 9, 2012, about 2003 eastern daylight time, a Bell 407, N108MF, operated by ACS Helicopters LLC., was substantially damaged when it impacted trees and terrain in Coolbaugh Township, Pennsylvania. The airline transport pilot and one passenger were fatally injured, and one passenger was seriously injured. The corporate flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91. Dark night instrument meteorological conditions (IMC) prevailed and no flight plan was filed for the planned flight to Westchester County Airport (HPN), White Plains, New York. The flight last departed Elmira/Corning Regional Airport (ELM), Elmira, New York about 1845. According to recovered cockpit documentation and passenger interviews, on the day of the accident, the helicopter departed Somerset Airport (SMQ), Somerville, New Jersey at 0730 for Morristown Municipal Airport (MMU), Morristown, New Jersey. After arriving at MMU at 0753, the pilot boarded four passengers, and then departed at 0830 for Camden County Airport (19N), Berlin, New Jersey, where it arrived at 0920. After having breakfast, the four passengers then played golf from approximately 1030 to 1500, and then socialized for approximately an hour before returning to the airport, where they once again boarded the helicopter. At 1630, the helicopter then departed for SMQ, landing there at 1710, and deplaned one passenger. At 1720 the helicopter departed once again, this time for ELM with three of the original four passengers onboard. After arriving at ELM at 1830 another passenger deplaned, and at 1845 the helicopter with the pilot and two of the original four passengers departed for HPN. According to the surviving passenger, after taking off from ELM, the weather "began to get worse," and the pilot advised them that they would not make it to HPN. The weather became "even worse" and the pilot decided to divert to Pocono Mountains Municipal Airport (MPO), Mount Pocono, Pennsylvania. The surviving passenger then texted his wife and advised her that they were "3 miles/ 3 minutes" from MPO and that they were going to land there. When he looked out of the window it was "misty and dusky" and he thought it must have been around 1930 or later. He advised that the "crash" happened shortly thereafter. According to a witness, at approximately 1945, she heard a helicopter that sounded "like it was going to land on my house" and that the helicopter was "extremely low" at a "really low altitude" in the area of Interstate 380 (I-380) and the Daleville exit. A truck driver in the vicinity also reported that he saw the helicopter flying "very low" and observed it passing over a Pennsylvania Department of Transportation shed near exit 20 (the Daleville exit) heading southbound along the south bound lane of Interstate 380. All of its lights were on, and at first he thought it was a state trooper 'All lit up" chasing someone down the highway. He described the helicopter as being "at or below, 200 feet off the deck." The visibility was low, and the helicopter was under the "low fog." He also advised that it was like "pea soup" around the area of I-380 and the Daleville exit. According to a limousine driver who was supposed to pick up one of the passengers at HPN, at 1938 he had received a text from the passenger stating that they were "running late". Then at 1953, he received another text instructing him to go back to MMU to pick up the passenger. After arriving at MMU, the driver waited but the helicopter never arrived. A search by Federal, State, and Local authorities was initiated. On October 10, 2012 at approximately 0230 the helicopter was discovered in a heavily wooded area adjacent to the south bound lane of I-380 approximately 1.3 miles northwest of MPO. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA), Bell Training Academy, and American Airlines records, the pilot in addition to flying for ACS Helicopters also flew for American Airlines as a First Officer. He held an airline transport pilot certificate with ratings for airplane multi-engine land, commercial privileges for airplane single-engine land, and rotorcraft-helicopter. He also held Type Ratings for the ATR-42, ATR-72, CE-500, DC-9, and HS-125, in addition to a flight engineer certificate for turbojet powered airplanes. On November 3, 2009, he took his private pilot rotorcraft-helicopter examination in a Robinson R44. On that date, he reported that he had accrued 77 total hours of helicopter flight experience. From November 16th to November 20th, 2009, he attended Bell 407 initial ground and flight training which included ground training, training in a flight training device, and flight training in the Bell 407. On July 14, 2010, he took his commercial pilot rotorcraft-helicopter examination in a Robinson R44. On that date, he reported that he had accrued 202 total hours of helicopter flight experience. On August 9th and 10th 2010, he attended bell 407 refresher training which included ground training, training in a flight training device, and flight training in the Bell 407. On October 28, 2010, the pilot received one additional hour of flight training in the Bell 407. On May 16th and 17th, 2011, he once again attended Bell 407 refresher training which included ground training, training in a flight training device, and flight training in the Bell 407. On May 7th and 8th, 2012, approximately 5 months prior to the accident, he attended Bell 407 refresher training again which included ground training, training in a flight training device, and flight training in the Bell 407. At the time of his refresher training he reported to the Bell Training Academy that that he had approximately 400 total hours of helicopter flight experience, which included, approximately 350 hours in the Bell 407, and approximately 50 hours in the Robinson R44. His most recent application for an FAA first-class medical certificate was dated June 1, 2012. On that date, he reported 19,000 hours of total flight time. Though he held an Airline Transport Pilot Certificate which allowed him to fly under IMC in airplanes, He did not possess an instrument-helicopter rating, and review of information provided by Bell Helicopter revealed no evidence of any inadvertent IMC or Instrument Flight Rules (IFR) helicopter training for the pilot during training at the Bell Training Academy. Examination of the pilot's flight time and duty time provided by American Airlines revealed that on the day before the accident he had reported for duty at 0810 edt at Newark Liberty International Airport (EWR), Newark, New Jersey one hour prior to his scheduled departure to Dallas/Fort Worth International Airport (DFW), Dallas, Texas, then flew 7 hours and 10 minutes arriving back at EWR at 1741 edt. Further examination of his schedule also revealed that he was also scheduled to fly another EWR-DFW-EWR round trip the day after the accident occurred, and was scheduled to sign in at 1155 edt. AIRCRAFT INFORMATION The accident aircraft was a single-engine helicopter of conventional construction. It was equipped with a four-blade, soft-in-plane design, composite hub, main rotor system. A full monococque aluminum skinned tailboom, and conventional two blade tail rotor system. It was powered by a 650 shaft horsepower, Rolls-Royce/Allison 250-C47B turboshaft engine. The original electro-mechanical instrumentation and spinning mass gyroscopes had been replaced with a SAGEM Integrated Cockpit Display System (ICDS) which consisted of electronic attitude & heading sensors and two 10-inch liquid crystal displays. One display functioned as a primary flight display and was vertically oriented on the right side of the instrument panel in front of the pilot, and the second display was horizontally-oriented and functioned as an engine instrument and multi-function display on the left side of the instrument panel. Standby analog instruments (clock, airspeed, attitude, and altimeter) were also provided. The helicopter was certificated for land operation under day or night visual flight rules (VFR) in non-icing conditions. It was not certificated for IFR operations. According to FAA and maintenance records the helicopter was manufactured in 2007. The helicopter's most recent annual inspection was completed on August 3, 2012. At the time of the accident, the helicopter had accrued 837.3 total hours of operation. METEOROLOGICAL INFORMATION Satellite Imagery and Weather Radar Review of satellite imagery of the accident area revealed that cloudy conditions existed over eastern Pennsylvania. Weather radar returned reflectivity values which indicated that light rain was present. Surface temperatures were above freezing indicating that freezing rain and freezing fog were not present. Automated Surface Observing System. Recorded weather obtained from MPO's automated surface observing system located approximately 1.3 miles southeast of the accident site also revealed that low instrument flight rules weather existed around the time of the accident with vertical visibility of 200 feet and variable auto sensor visibility down to 1/2 mile, with a light east wind and light rain as indicated by METARs where: - At 1953, the recorded weather included: wind 120 degrees at 6 knots, visibility 3/4 mile, light rain, mist, vertical visibility 200 feet, temperature 09 degrees C, dew point 09 degrees C, and an altimeter setting of 30.10 inches of mercury. - At 2003, the recorded weather included: wind 100 degrees at 6 knots, visibility 1 1/4 miles, light rain, mist, overcast ceiling of 200 feet, temperature 09 degrees C, dew point 09 degrees C, and an altimeter setting of 30.10 inches of mercury. - At 2017, the recorded weather included: wind 110 degrees at 5 knots, visibility 1/2 mile, light rain, fog, vertical visibility 200 feet, temperature 09 degrees C, dewpoint 09 degrees C, and an altimeter setting of 30.10 inches of mercury. Sun and Moon Data According to the United States Naval Observatory, on the day of the accident sunset occurred at 1829, and the end of civil twilight occurred at 1857. Moon rise did not occur until the following day at 0140. AIRPORT INFORMATION According to the Airport Facility Directory, MPO (the diversion airport), was a publicly owned, uncontrolled airport. It had two runways oriented in a 13/31and 05/23 configuration. Runway 13 was the closest runway to Interstate 380 and was most closely aligned with the helicopters flight path. It was served by two instrument approaches a VOR approach and a GPS approach. The runway was asphalt, in excellent condition, and was equipped with non-precision runway marking in good condition. The total length of the runway was 5,001 feet, and its width was 75 feet. It was equipped with a 2-light precision approach path indicator located on the left side of the runway and runway end identifier lights. The threshold was displaced by 501 feet. An obstruction in the form of a 29 foot tree, located 348 feet from the runway, 235 feet left of centerline was present which took a 5:1 slope to clear. FLIGHT RECORDERS The helicopter was not equipped with a cockpit voice recorder or flight data recorder nor was it required to be equipped with them under the CFRs. The helicopter however was equipped with a Garmin GNS 530 panel-mounted Global Positioning System (GPS) receiver, an Apollo SL40 dual Very High Frequency (VHF) communications transceiver, the ICDS, and the engine control unit (ECU). All of which had some capability of data retention. Additionally, a Garmin Aera 560 portable GPS navigation device was also discovered at the accident site. GNS 530 The Garmin Model GNS 530 GPS receiver featured a 5-inch color liquid crystal (LCD) display and offered navigation and communication data, along with precision and non-precision approach certification in the instrument flight rules (IFR) environment. The unit had a slot for a Jeppesen database (front-loading data card) containing all airports, VHF Omni Directional Radio Range (VOR) sites, Non Directional Beacons, NDBs, intersections, Approach, standard terminal arrival routes (STARs), standard instrument departures (SIDs), and special use airspace (SUA) information. A flight plan composed of multiple waypoints, including user-defined waypoints, could be programmed in to the unit. However, no provision had been made to record and store position information within the unit. Data related to last known frequency settings and last known GPS location was stored in volatile memory and could be read from the front panel display upon power-up. There were no provisions for downloading stored data. An internal button-battery was used to back-up power to the internal memory and real-time clock during those periods when main power was removed. Examination of the unit revealed the unit had sustained minor damage. The unit was able to power on normally by applying external power, however only the active frequency of 120.1 MHz which was the Wilkes-Barre/Scranton International Airport (AVP) control tower frequency and the passive frequency of 121.5 MHz which was the international air distress frequency (emergency frequency) and the helicopter's last known GPS position was captured. SL40 The Apollo SL40 dual VHF communication transceiver featured a 16 character, 5 x 7, LCD dot matrix LED display. The unit had a frequency range from 118-136.75 MHz and could store up to 8 user defined frequencies. The unit's frequency monitor function could listen to the standby frequency while monitoring the active frequency. The Apollo SL40 would also store the last known frequency settings in non-volatile memory. Examination of the unit revealed that it had sustained minor damage. The unit was able to power on normally by applying external power. During power up, the active frequency of 125.47 MHz which was the Elmira / Corning regional Airport (ELM), automatic terminal information service frequency was displayed and the standby frequency of 122.95 MHz which was the AVP and ELM Unicom frequency was displayed. ICDS The ICDS had recording capability and was capable of storing data on two programing/data cards. Examination of the ICDS revealed that the units had received minor damage and were functional. Each unit contained a slot for insertion of a programming/data card. However, examination of the cards contained in the slots revealed that they were dummy cards which were incapable of storing data. Aera 560 The Garmin Aera 560 portable GPS navigation device employed a 4.3 inch touch-screen and color moving map display. The Aera was also capable of storing tracks logs that contained position location information for an unspecified number of points in non-volatile memory internally. Examination revealed the unit had sustained major damage which required a chip level recovery of the data to be performed. The data extracted during the chip level recovery included 103 tracks (24,504 total data points) which started on August 3, 2012. The accident flight was the last track recorded. It started on October 9, 2012 at 19:35:21 and ended at 20:03:24 and was composed of 2,084 total data points. Examination of graphical overlays generated from the Garmin Aera 560 data using Google Earth revealed that a large difference existed between the previous altitudes and airspeeds that were stored during the previous 4 flight legs where for example, at 17:49:04 the helicopter was flying at a GPS altitude of 2,642 feet and a GPS groundspeed of 131 knots but, on the last flight leg the last data points indicated that helicopter was flying in the direction of MPO above and along Interstate 380 at low altitude and airspeed, and where examination of the last data point at 20:02:36 indicated that the helicopter was at GPS altitude of 2,162 feet and a GPS ground speed of 31 knots prior to turning slightly right towards the accident site. WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed that the helicopter had come to rest approximately 200 feet from the right shoulder of the southbound lane of I-380, near a group of approximately 40 foot high trees, in a heavily wooded area,

Probable Cause and Findings

The pilot’s decision to continue visual flight rules flight into instrument meteorological conditions due to self-imposed pressure to complete the trip, which resulted in impact with trees and terrain.

 

Source: NTSB Aviation Accident Database

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