Pilot Debrief

BELL 206A near Wenatchee, WA — 2014-07-23

Final reportWPR14FA310
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Date
2014-07-23
Location
Wenatchee, WA, USA
Aircraft
BELL 206A
Registration
N949FM
Category
Helicopter
Highest injury
Fatal
Fatalities
1
Phase of flight
Landing

Probable cause

The pilot's failure to maintain a proper decent rate and path, which resulted in a hard landing and dynamic rollover. Contributing to the accident was the pilot's impairment by a sedating medication.

Contributing factors

Contributing to the accident was the pilot's impairment by a sedating medication.

NTSB narrative

The commercial pilot was drying cherry trees, which called for low-level flying in the helicopter. The landing area was slightly uphill with the ground tilted slightly to the right. Although the pilot had taken off and landed in that location at least once earlier in the day, wreckage documentation and ground scars revealed that, during the accident landing, the helicopter landed hard enough and with sufficient lateral motion to cause a dynamic rollover. No witnesses visually observed the accident; however, one witness heard the helicopter, followed by a thud and then silence. This witness responded to the accident and observed the helicopter on its side and smoking. Postaccident examination of the airframe and engine revealed no evidence of mechanical failures or malfunctions that would have precluded normal operation. Results of toxicology testing for the pilot detected therapeutic levels of tramadol, which is not known to undergo significant postmortem redistribution. Therefore, the identified levels likely represented his antemortem level of tramadol. Although with regular use people can develop a tolerance to the impairing effects of opioids, in this case, the pilot was engaging in a high workload and high risk portion of flight, and even a small level of impairment could have contributed to his inability to safely land the helicopter. The Federal Aviation Administration recommends that pilots using sedating medications on an occasional basis wait five maximum dosing intervals before flight. For tramadol that computes to waiting 40 hours (8 hours x 5) before flying; this pilot's therapeutic level suggests that he did not follow this recommendation. The pilot's impairment by tramadol likely contributed to the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen a different landing area to avoid the slope.

NTSB coding

Evidence available

  • Photos
  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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