Pilot Debrief

BELL 206B near Green Cove Springs, FL — 2011-12-26

Final reportERA12MA122
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Date
2011-12-26
Location
Green Cove Springs, FL, USA
Aircraft
BELL 206B
Registration
N5016M
Category
Helicopter
Highest injury
Fatal
Fatalities
3
Phase of flight
Climb

Probable cause

The pilot’s improper decision to continue visual flight into night instrument meteorological conditions, which resulted in controlled flight into terrain. Contributing to the pilot’s improper decision was his self-induced pressure to complete the trip.

Contributing factors

Contributing to the pilot’s improper decision was his self-induced pressure to complete the trip.

NTSB narrative

The pilot, who was SK Jets’ president, owner, and director of operations, received a call from one of his company schedulers about 0335, notifying him about a trip for his largest customer to transport a doctor and a medical technician from Mayo Clinic Heliport, Jacksonville, Florida, to Shands Cair Heliport, Gainesville, Florida, to procure an organ for transplant. To prepare for this flight, the pilot reviewed aviation routine weather reports (METARs) and terminal area forecasts (TAFs) on the Internet; however, he did not obtain a standard weather briefing from a Federal Aviation Administration-approved source. At the time of his review of the METARs and TAFs, weather conditions near the departure heliport were visual meteorological conditions (VMC), with visibility of 10 miles and a broken cloud ceiling at 7,000 feet. Weather conditions were also VMC near Shands Cair Heliport, with visibility of 6 miles and a broken cloud ceiling at 1,600 feet. A TAF included a temporary condition during the estimated time of arrival near Shands Cair Heliport of instrument meteorological conditions (IMC) with visibility of 4 miles in mist and an overcast cloud ceiling at 400 feet. Just before the accident flight, the helicopter completed a short, uneventful repositioning flight from the operator’s home base at a nearby airport to Mayo Clinic Heliport. During that flight, although the helicopter initially climbed to about 1,000 feet above ground level (agl), it then flew between 700 and 900 feet agl, possibly due to a low cloud ceiling. About 0537, the helicopter picked up the doctor and medical technician at Mayo Clinic Heliport, departed, and proceeded southwest, flying a track slightly south and east of a direct course to Shands Cair Heliport. The pilot likely selected this route of flight so that he could navigate by landmarks and fly low in order to stay out of clouds. The pilot contacted an air traffic controller 4 minutes before the accident to ask about the status of restricted airspace, which he learned was inactive at the time. The transmissions were routine, and there was no evidence that the pilot or helicopter were experiencing any problems. During the en route portion of the 17 minute accident flight, the helicopter’s altitude varied between about 450 and 950 feet agl. The helicopter’s airspeed was about 100 to 110 knots. The last three radar returns were consistent with a right turn of about 45 degrees and a 300-foot descent, which placed the helicopter on a near-direct west course to Shands Cair Heliport at an altitude about 450 feet agl. The accident site was located about 1/2 mile south of the last radar return, with a southerly debris path, consistent with a significant change in course and left turn with a continued descent. The 320-foot-long straight debris field, with descending cuts into trees, was indicative of substantial forward speed at the time of impact. Examination of the wreckage revealed no evidence of any preimpact failures or malfunctions of the engine, drive train, main rotor, tail rotor, or structure of the helicopter. Additionally, there was no indication of an in-flight fire. The accident helicopter was not certified for instrument flight rules (IFR) flight and did not have an autopilot or radar altimeter. Further, the helicopter’s global positioning system did not have an optional modification that would have included a terrain and obstacle warning feature. The operator’s general operating manual (GOM) noted that unless otherwise approved by the director of operations or chief pilot, the weather minimums for visual flight rules (VFR) flight in a helicopter at night were a 1,000 foot cloud ceiling and 3-mile visibility. The GOM did not address whether the pilot, as director of operations, could approve himself to deviate from the night VFR minimums in a helicopter. All weather information suggests that there were areas of both VMC and IMC along the route of flight. The recorded weather near Mayo Clinic Heliport about 16 minutes after departure, when the helicopter was nearly halfway between Mayo Clinic Heliport and Shands Cair Heliport, included a broken cloud ceiling at 700 feet. Further, airmen’s meteorological information (AIRMET) Sierra was in effect at the time of the accident and indicated the potential for IFR conditions with mist and fog covering the route of flight and accident site. Although the pilot likely did not receive this AIRMET, the pilot did receive the information about the TAF indicating possible IMC. A former company helicopter pilot familiar with the flight route described the accident area as susceptible to fog due to swampy terrain and indicated that once fog develops (which would obscure the ground and surface features), the area was a “black hole” at altitudes of 200 to 400 feet agl, and a flight was effectively in IMC in these circumstances. During postaccident interviews, other company pilots stated that they would have accepted the trip based on weather reports presented but would have arranged a backup plan, such as ground transportation or transportation by fixed-wing aircraft, if the flight could not be completed. There was no evidence the pilot had arranged such a backup plan in the event that the trip could not be completed as scheduled due to the potential for IMC. (Although SK Jets used a flight risk analysis tool [FRAT] to assess risk of both helicopter and fixed-wing flights, a FRAT form was not recovered for the accident flight. However, had the FRAT form been filled out, it would have shown that the flight was low risk.) The pilot’s financial pressure as the owner of the company likely influenced his decision to continue flight into deteriorating weather conditions. The operator’s business had declined several years before the accident as a result of economic recession. The accident helicopter had been leased days before the accident. The operator’s only IFR certified helicopter, which was the largest customer’s preferred helicopter, had been down for maintenance for 4 months while the operator attempted to secure loans for engine maintenance. The pilot was scheduled to meet with this customer in the coming weeks to obtain clarification about the customer’s requirements. The pilot was also aware that his largest customer had begun identifying other aviation companies that might better fulfill its needs. Thus, the pilot would have been highly motivated to complete trips as requested so that he could demonstrate the reliability of his service. Additionally, due to the economic downturn, the pilot’s company had lost millions of dollars during the 3 years before the accident. Therefore, the pilot likely wanted to make the most of every revenue generating opportunity. Review of the pilot’s medical history revealed a 30-year history of hypertension and several other conditions, including insomnia, all of which were well controlled with medication. A postmortem analysis indicated that the levels of medication for insomnia that were in the pilot’s system at the time of the accident were below the therapeutic range and did not imply impairment. His routine conversation with a controller just minutes before the accident suggests that he was not incapacitated. Regarding the pilot’s work, rest, and sleep history, review of company records revealed that the pilot had not flown in the 7 days before the accident and had spent the previous 2 days with family, celebrating his anniversary and a holiday, indicating that he was not overworked during the days before the accident. The pilot experienced some circadian disruption during the 2 nights preceding the accident. Although he normally awoke about 0630, he awoke about 0800 the day before the accident and about 0330 the morning of the accident, and the accident occurred before his normal waking time. In addition, the pilot had experienced some sleep restriction for 2 nights preceding the accident. He obtained about 5 hours of sleep during each of those nights. However, according to the pilot’s wife, the pilot had been a 6 hour a night sleeper for the past 50 years and felt well rested on 6 hours of sleep. In addition, he supplemented his nighttime sleep with a 1- to 1 1/2-hour nap during the afternoon the day before the flight. Therefore, the reduction in his recent sleep, compared with his reported sleep need, was very small. Although the pilot likely experienced some fatigue on the morning of the accident because of circadian disruption and reduced sleep, the pilot’s reduction in total sleep was quite low compared to his reported sleep need, and the National Transportation Safety Board was unable to determine the extent to which fatigue might have affected the pilot’s preflight decision-making and performance during the accident flight.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot should have canceled the flight due to night IMC conditions.

NTSB coding

Evidence available

  • ATC audio
  • Video
  • ADS-B / radar
  • Photos
  • 67 docket documents
View NTSB final reportView NTSB docket

Docket documentsshowing 50 of 67

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