Pilot Debrief

BELL 407 near Sedona, AZ — 2008-10-13

Final reportWPR09TA012
Sign in to save
Date
2008-10-13
Location
Sedona, AZ, USA
Aircraft
BELL 407
Registration
N42AZ
Category
Helicopter
Highest injury
Fatal
Fatalities
1
Phase of flight
Landing

Probable cause

The paramedic's failure to monitor and maintain clearance from the rotating main rotor blades after exiting the helicopter.

NTSB narrative

The flight crew (pilot and paramedic) had been called out on a search and rescue (SAR) mission for two lost hikers. Once the flight arrived on-scene, the crew located the hikers and commenced with the rescue. The pilot reported that he observed a flat rock area near the hikers, and landed at that spot. The skids were on the rock face, with the tail sticking out over the ledge. As the pilot lowered the collective, to place the weight of the helicopter on the skids, he felt a slight fore and aft rocking of the helicopter and decided to maintain main rotor at 100 percent rpm for stability. The paramedic then exited the helicopter, and walked toward the hikers who were forward and slightly uphill of the helicopter. The paramedic assisted the male hiker into the right side of the helicopter, and then returned for the female hiker. The female hiker reported that after the paramedic motioned her toward him, he also pointed out a cactus to her, motioning for her to go around it. The hiker went around the cactus, and then stepped in front of the paramedic who now had his back to the helicopter. She then heard a loud sound and turned back toward the paramedic, and saw him lying on the ground. The paramedic had been struck by the main rotor blades. Reconstruction of the event at the accident site revealed that the helicopter was slightly lower on its right side with the nose slightly elevated. The pilot reported no mechanical anomalies with the helicopter prior to the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Paramedic should have remained aware of rotor blades while assisting hiker.

NTSB coding

Evidence available

  • 2 docket documents
View NTSB final reportView NTSB docket

Docket documents2

Related mishaps