Pilot Debrief

BELL 206L-4 near Sabine Pass, TX — 2008-12-11

Final reportCEN09FA086
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Date
2008-12-11
Location
Sabine Pass, TX, USA
Aircraft
BELL 206L-4
Registration
N180AL
Category
Helicopter
Highest injury
Fatal
Fatalities
5
Phase of flight
Climb

Probable cause

The pilot’s failure to maintain clearance from the water. Contributing to the accident was the inadvertent encounter with instrument meteorological conditions.

Contributing factors

Contributing to the accident was the inadvertent encounter with instrument meteorological conditions.

NTSB narrative

The air taxi flight was en route to an offshore drilling platform to drop off passengers. When the helicopter became overdue for its routine position report, the company attempted unsuccessfully to contact the pilot through several means, including radio and telephone. The company conducted an aerial search along the route of flight; however, the helicopter was not located. The company then notified the Coast Guard of the missing helicopter approximately an hour and forty minutes after it became overdue. The wreckage was located 2 miles offshore in 13 to 15 feet of water, along the helicopter's route of flight. An examination of the helicopter airframe, engine, and related systems revealed no anomalies. Damage was consistent with controlled flight into the water. A cold front had just passed through the area several hours prior to the accident. Visible satellite imagery around the time of the accident depicted mid- to high-level cloud layers in the vicinity of the accident location. Breaks in the upper cloud layers depicted low stratus-type clouds within 15 nautical miles of the accident location. AIRMETS for instrument meteorological conditions, turbulence, and icing were valid for the accident area and route of flight. Cloud bases were most likely below 1,000 feet above ground level and visibility was restricted due to mist and possible light snow. The air temperature was recorded at 34 degrees Fahrenheit and the water temperature was recorded at 64 degrees Fahrenheit. There was no record to indicate that the pilot had obtained a formal weather briefing from a recorded source. The pilot held a commercial certificate and an instrument rating; however, he was not approved for instrument flight under Part 135 and was not current. At the time of the accident the company did not have a formal risk assessment program and a formal evaluation of the flight risks was not performed for the accident flight. The pilot normally flew a helicopter in which the flight tracking system engaged when the master switch was turned on; however, the accident helicopter required the system to be activated by a separate switch in the cockpit. This variation was not in the checklist. According to company records, the pilot had been flying the accident helicopter for two or three days prior to the accident. During this time there was no track record for the helicopter, which is consistent with the pilot not activating the helicopter's flight tracking system. The pilot, whose personal flotation device was inflated and secured, suffered severe chest injuries complicated by asphyxia due to drowning. Two passengers were secured within their flotation devices; however, neither flotation device had been inflated. Two passengers were not wearing flotation devices when they were located; however, two personal flotation devices from the accident flight were recovered and showed signatures consistent with use. One had been partially inflated, and the second had been entirely inflated. The 4 passengers suffered asphyxia due to drowning with probable complication of cold water shock and hypothermia. The investigation was unable determine if the company's delay in notifying the Coast Guard contributed to the severity of injuries in the accident.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot did not obtain a weather briefing before the flight.

NTSB coding

Evidence available

  • ATC audio
  • Photos
  • 18 docket documents
View NTSB final reportView NTSB docket

Docket documents18

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