Newkirk, NM, USA
N507CF
AGUSTA SPA A109E
After the commercial pilot received an emergency medical services helicopter flight request, he quickly (in about 20 seconds) assessed the weather conditions and accepted the flight. No records were found indicating that the pilot obtained an official weather briefing before departing on the flight, and the investigation could not determine which weather resources the pilot used to assess the weather. About 8 minutes later, the pilot called the company's operations center to report that the flight was departing; this was the last communication received from the pilot. The helicopter was operating in an area that was known by company pilots, including the accident pilot, to have the potential for low visibility, even though there were no airport weather reporting facilities or Doppler radar coverage in the area. A review of GPS data showed that, while en route to pick up the patient, the helicopter performed a slight descending 360° turn before continuing toward the hospital. Weather overlays with the GPS track indicated that the helicopter made the 360° turn about the same time that an outflow boundary wave, which could have increased the potential for windshear and strong updrafts and downdrafts and reduced ceilings and visibility. Following the 360° turn, the helicopter proceeded toward the destination. About 14 minutes later, the helicopter turned right and began flying toward a major highway. It is likely that, due to the reduced visibility in the area, the pilot was flying toward the highway to follow the lights toward the city. The helicopter then turned further right and began to climb. As the helicopter entered another outflow boundary wave, it turned left. The left turn tightened, and the helicopter began to rapidly descend into terrain. The helicopter impacted a mesa in a near-level attitude. A review of a company communication recording showed that, about 17 minutes after the estimated accident time, the operations center attempted to contact the flight crew and was unsuccessful. The company sent three company helicopters to the accident helicopter's last known position; one helicopter pilot flew near the helicopter's site but was unable to see anything, and the two other pilots could not proceed close to the accident site due to clouds and low visibility. The wreckage was subsequently located by local law enforcement. A postaccident examination of the helicopter and engine did not reveal any anomalies that would have prevented normal operation. Due to mid- and low-level cloud cover, it is likely that no lunar or celestial lighting was available for amplification by the pilot's night vision goggles (NVG). Since the helicopter was not equipped with an infrared spotlight, only cultural light would have been available for NVG amplification. However, the helicopter was operating in a remote, sparsely populated area with minimal cultural light. Although the pilot's recurrent training included recovery procedures from inadvertent entry into instrument meteorological conditions (IMC), and his training records showed that he satisfactorily completed this item on his most recent training flight about 8 months before the accident, the circumstances of the accident are consistent with the pilot's inadvertent visual flight into IMC, which resulted in a loss of helicopter control.
HISTORY OF FLIGHTOn July 17, 2014, at 0142 mountain daylight time, an Agusta A109E helicopter, N507CF, collided with a mesa near Newkirk, New Mexico. The commercial pilot, flight nurse, and paramedic were fatally injured. A postimpact fire ensued and the helicopter was destroyed. The helicopter was registered to and operated by TriState CareFlight LLC under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Night visual meteorological conditions existed for the helicopter's departure and a company visual flight rules flight plan was filed. The flight originated from the Santa Fe Municipal Airport (SAF), Santa Fe, New Mexico, at 0051 and was en route to a hospital in Tucumcari, New Mexico. The helicopter was the subject of an alert notice and was found by a local resident. The helicopter wreckage came to rest on the north side of a mesa about 150 ft above the surrounding terrain. A postimpact fire consumed a majority of the fuselage. All main airframe and engine components were accounted for at the accident site. PERSONNEL INFORMATIONThe pilot, age 46, held a commercial pilot certificate for helicopter and instrument helicopter. He also held a flight instructor certificate for helicopter and instrument helicopter. On September 17, 2013, the pilot was issued a second class medical certificate with the limitation that he must wear corrective lenses. The pilot was hired by TriState CareFlight (TSCF) on September 10, 2009. During his employment with TSFC, he began flying Agusta 119 helicopters, before being transferred to Eurocopter AS350 helicopters. On December 13, 2012, he was assigned the duties of pilot in command of Agusta A109 helicopters. Using data from TSCF and the pilot's annual resume, it was estimated that he accumulated about 6,167 total hours, with 208 hours in Agusta A109 helicopters, over 410 hours of night time, 75 hours of simulated instrument conditions, and 0 hours of actual instrument conditions. The pilot had been operating out the of the Santa Fe base for over a year and a half and had been flying in the mountainous desert environment of Arizona, Nevada, and New Mexico since his hire in 2009. He had flown numerous flights in the Santa Fe and Tucumcari areas prior to the accident. The most recent check flight for the pilot was accomplished on December 16, 2013. It was a combined 14 CFR Part 135.293 and 135.299 check flight. The flight lasted 1.2 hours, was flown completely under night vision goggle (NVG) use, and some of the maneuvers flown and evaluated included: normal operations, emergency operations, unusual attitude recovery, inadvertent instrument flight rules (IFR) procedures, and NVG failure in flight. Astrological conditions for that training flight would have included clear skies with a bright moon at 100% disk illumination. The pilot was qualified to fly using NVGs. At the time of the accident he had accrued at least 162 hours of flight assisted by NVGs. His last recurrent NVG training flight was on December 16, 2013, with ground training accomplished that day. The pilot inspected and tested his NVGs on July 16 and reported no discrepancies on the company's NVG Sign-Off Sheet. In the 90 days prior to the accident, he had flown 8.3 hours of NVG time: Date Hours April 23, 2014 0.4 April 25 2.4 April 27 1 May 22 2.6 May 26 1 May 27 0.2 June 18 1.1 June 19 0.6 July 16 0.8 The pilot normally worked a schedule that consisted of 7 days on-call and 7 days off-call. Prior to the accident, the pilot had been on-call for 15 days. From July 2 to July 8, the pilot was on-call between 0700 until 1900. The pilot was then given 24 hours off and then on July 9, was on-call between 1900 until 0700. The accident occurred on the pilot's eighth consecutive shift. Prior to the accident flight he had previously flown 0.6 hours on that same shift. AIRCRAFT INFORMATIONThe Agusta A109E helicopter was manufactured in 2000 and had been modified for helicopter air ambulance (HAA) flight operations. It was powered by twin Pratt & Whitney Canada PW206C turbo shaft engines each rated at 549 horsepower. The helicopter was certified for instrument flight rules operations. The last inspection, completed on July 4, 2014, was an approved aircraft inspection program which combined the 25 hour, 50 hour, and 150 hour inspections. After that date, the helicopter flew 17.3 hours with 2 discrepancies. On July 7, the accident pilot reported weak wheel brakes which were replaced that day. On July 11, the accident pilot reported a transmission oil chip light illumination. After the flight, maintenance cleaned "slight fuzz" from the chip detectors and returned the helicopter to service. The helicopter was equipped with a Garmin GNS-530 GPS/NAV/COM, a SkyConnect Transceiver, and a panel mounted Garmin GPSmap 396. The cockpit was modified for NVG use via a supplemental type certificate. In addition, the helicopter was equipped with an enhanced ground proximity warning system, auto flight system, and radar altimeter. METEOROLOGICAL INFORMATIONA weather study was conducted for the accident flight by an NTSB Senior Meteorologist. A review of the National Weather Service Surface Analysis Chart for 0000 mountain daylight time (MDT) found a fairly active surface environment with a surface trough located over the accident site at 0000 MDT. In addition, a stationary front was located south of the accident site and three areas of low pressure were located to the distant northwest, south, and southeast of the accident site. Potential existed for clouds and precipitation due to numerous lifting mechanisms around the accident site to include combined surface, low-level, and mid-level troughs. At 1845 on July 16, the Storm Prediction Center predicted a 15% chance of damaging thunderstorm wind or gusts of 50 knots within the vicinity of the accident site until 0600 on July 17. A review of aviation weather reporting facilities in the vicinity of the accident flight, revealed that the helicopter likely had a southerly wind component until flying south to southeast of Las Vegas, New Mexico at which point the wind would have shifted to out of the northeast. In addition, cloud ceiling would have lowered as the flight proceeded towards Tucumcari. An upper air sounding indicated the potential for cloud formations between 5,000 and 8,000 ft mean sea level (msl), with the possibility of rain showers and thunderstorms. Additionally, the sounding indicated the strongest wind speeds possible with a microburst or outflow boundary would have been between 45 to 53 mph. A potential for low-level wind shear was identified between 5,000 and 6,000 ft msl with clear air turbulence from the surface to 10,000 ft msl. The closest Doppler radar site was located at Cannon Air Force Base (FDX), located 43 miles southeast of the accident site. Scans initiated between 2124 MDT on July 16 through 0235 MDT on July 17, revealed two distinct features before, during, and after the accident time. First, an outflow boundary moved from east to west across New Mexico from 2124 MDT to 0030 MDT. As the outflow boundary moved from east to west, the surface wind direction switched from southerly to northeasterly, concurrent with the aviation weather reporting facilities. Next, another outflow boundary and wave pattern was detected on the 0235 scan but due to Doppler beam angle and distance to the accident site was likely masked on the earlier scan. Backwards trajectory analysis was completed to map the progression of the outflow boundaries. Mapping estimated that the first outflow boundary and associated convective activity would have been over the accident site at the accident time. This would have increased the potential for increased wind shear, strong updrafts and downdrafts, reduced ceilings, and reduced visibility. Airmen's Meteorological Information (AIRMET) Sierra, issued at 2045 MDT on July 16 and valid at the accident time for the accident site and route of flight, forecasted instrument meteorological conditions for the accident site with ceilings below 1,000 ft and visibility below 3 miles with precipitation and mist. The terminal aerodrome forecast (TAF) for Tucumcari, located 32 miles east of the accident site, issued at 2334 MDT on July 16 forecasted wind from 030 degrees at 11 knots, prevailing visibility 6 miles, rain showers in the vicinity, few clouds at 2,000 ft agl and a broken ceiling at 8,000 ft agl. The phase of the Moon was waning gibbous with 65% of the Moon's visible disk illuminated. At the time of the accident there would have been no moon visible due to the mid- and low-level cloud cover that the accident flight was likely flying beneath. AIRPORT INFORMATIONThe Agusta A109E helicopter was manufactured in 2000 and had been modified for helicopter air ambulance (HAA) flight operations. It was powered by twin Pratt & Whitney Canada PW206C turbo shaft engines each rated at 549 horsepower. The helicopter was certified for instrument flight rules operations. The last inspection, completed on July 4, 2014, was an approved aircraft inspection program which combined the 25 hour, 50 hour, and 150 hour inspections. After that date, the helicopter flew 17.3 hours with 2 discrepancies. On July 7, the accident pilot reported weak wheel brakes which were replaced that day. On July 11, the accident pilot reported a transmission oil chip light illumination. After the flight, maintenance cleaned "slight fuzz" from the chip detectors and returned the helicopter to service. The helicopter was equipped with a Garmin GNS-530 GPS/NAV/COM, a SkyConnect Transceiver, and a panel mounted Garmin GPSmap 396. The cockpit was modified for NVG use via a supplemental type certificate. In addition, the helicopter was equipped with an enhanced ground proximity warning system, auto flight system, and radar altimeter. WRECKAGE AND IMPACT INFORMATIONThe helicopter came to rest midway between the peak and the surrounding terrain of a 300-foot high mesa, at a measured elevation of 4,654 ft msl. The wreckage was generally located in one area with fragments of main rotor blades and light debris scattered nearby. A postimpact fire consumed a majority of the wreckage. The main wreckage consisted of the main rotors, fuselage, tail boom, and tail rotors. Some of the exterior panels and medical equipment were found strewn in the area surrounding the wreckage. All linkages between the swash plate and pitch change horns were found intact and cotter pinned. The tail rotor blades rotated when the tail rotor drive shaft was turned by hand. All linkages to the tail rotor blades were found intact and cotter pinned. On the boulder where the tail rotor had come to rest, machining was visible on the rock's surface consistent with tail rotor blade strikes. In addition, the top of a boulder closest to the nose of the helicopter wreckage displayed circular scuffing with a portion of a main rotor blade tip wedged into the rock. The helicopter's airspeed indicator needle pointed at 190 knots. Of note, the helicopter's never exceed speed (Vne) is listed as 168 knots. The left side vertical speed indicator needle pointed between 2,500 and 3,000 ft per minute descent. All other gauges were destroyed or unreadable. The lower portion of the helicopter was partially buried in the dirt and gear positioning was consistent with the landing gear in the retracted position. The emergency locator beacon was impact and thermally damaged. A Garmin GPSmap 396 was found buried in the dirt and was sent to the NTSB laboratories in Washington, D.C. for a data download. Due to the mesa's slope and thermal damaging of the surrounding rocks, the wreckage could not be fully examined on-site. A postaccident examination was conducted after the wreckage was transported to a storage facility. The examination revealed that portions of the flight controls displayed fracture signatures consistent with overload and/or thermal damage. No preimpact anomalies were detected with the flight controls. The engines were examined and did not display any preimpact anomalies. ADDITIONAL INFORMATIONLow Visibility Area The helicopter was operating in an area that was known by company pilots to have the potential for low visibility. This area extended from Moriarty, New Mexico, to Amarillo, Texas, and from Wagon Mound, New Mexico, to Fort Sumner, New Mexico. TSCF personnel reported that this area could develop low visibility even when the surrounding aviation weather stations reported clear weather. A photo of the map at the Santa Fe base is provided in the docket associated with this report. ITT Night Vision & Imaging Aviator Night Vision Imaging System (ANVIS) 9 F4949 The operator utilized a Generation III ANVIS 9 system for their aircrews. According to company personnel, the pilot and one additional crew member were to utilize the ANVIS 9 during NVG operations. Marketing documents stated that the ANVIS 9 had a 40 degree nominal field of view. The F4949 intensified light 2,000 to 3,500 times. Meteorological modelling of the accident area estimated that due to mid and low-level cloud cover, the helicopter likely operated without the aid of lunar or celestial light sources. The helicopter was not equipped with infrared spotlight, nor was it required to be. The helicopter was equipped with a regular spotlight which would not have been compatible with the NVGs and was likely not used. The pilot and one of the crew members would have utilized the NVGs during the flight. Damage to the NVGs precluded the determination of whether the NVGs were in the down position during the accident. United States Army Field Manual (FM) 3-04.203, Fundamentals of Flight, May 2007 The Army has incorporated NVGs into their flying programs for decades, making their knowledge base larger than most organizations. While not required reading for civilian pilots, FM 3-04.203 was constructed to educate pilots of the principles surrounding aviation for them to be better prepared to react to unexpected conditions. Chapter three titled "Rotor-Wing Environmental Flight," section 62 states "…when moon illumination is low or during the new-moon cycle, the desert presents a formidable challenge to night flying. It is probably the most difficult environment in which to interpret terrain relief and elevation, especially while using [night vision devices]. Unaided night flight and operations are far more difficult and not recommended." In chapter four, titled "Rotary-Wing Night Flight," several passages described the hazards and risks of night flight with night vision systems. Key points were that the NVGs had a tendency to distort depth perception and distance estimation with the quality of depth perception being dependent on ambient light, terrain surface conditions, the ability of the NVG device, and the pilot's experience flying in those conditions. "…adverse weather is difficult to detect at night. Often the decrease in visual acuity and a gradual loss of horizon are very subtle. As meteorological conditions deteriorate, aviators must decrease airspeed to reduce risk of flying into inadvertent [instrument meteorological conditions]." The "NVG's field of view significantly reduces peripheral vision as compared with unaided flight. Crewmembers must use a continual scanning pattern to compensate for the loss." "Maneuvers requiring large bank angles or rapid attitude changes tend to induce spatial disorientation. An aviator should avoid making drastic changes in attitude/bank angles and use proper scanning and viewing techniques." COMMUNICATIONSTSCF used the SkyConnect satellite communication system to communicate between their California based operations center and the accident helicopter. At 0050:48, the pilot called the operations center to report that he had departed for Tucumcari. No further communications were made from the helicopter. The helicopter was operating under a company visual flight rules flight plan and was not in communication with air traffic control. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy was authorized and conducted on the pilot by the New Mexico Office of the Medical Investigator. The cause of death was the result of multiple injuries and the manner of death was ruled an accident. Forensic toxicology was perform
The pilot's inadvertent visual flight into instrument meteorological conditions, which resulted in a loss of helicopter control.
Source: NTSB Aviation Accident Database
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