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Cases › CEN13FA096 · Part 135 fatal

MBB BK 117 A-3Air Methods Corporation

Compton, IL, USA · 2012-12-11·N911BK

3
fatal
0
serious
Fatal
highest injury
Substantial
damage

What happened

NTSB summary, verbatim

The medical transport helicopter was on a night flight conducted under visual flight rules (VFR) to pick up a patient for transport. The pilot had computer-based weather information available, but it is unknown what information he reviewed before deciding to accept the flight. Weather observation stations along the route of flight were reporting VFR conditions around the time that the pilot accepted the flight. About 17 minutes into the flight, the pilot reported to the receiving hospital's communications center that he was aborting the mission due to encountering inclement weather and was returning to base. Flight track data indicated that the helicopter initiated a right turn at this time, away from a nearby lighted windmill farm toward an area with sparse ground lighting . The flight track then showed a slight descent before the end of the data. The last recorded position was about 0.75 miles east-southeast of the main wreckage site. The helicopter impacted an agricultural field in an inverted, nose-low attitude. Examination of the wreckage revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Weather data and reports from first responders indicated that the flight likely encountered areas of snow, freezing drizzle, and supercooled liquid water. The lack of ground lighting combined with the precipitation encountered likely reduced the visibility and outside visual references available to the pilot resulting in spatial disorientation and subsequent loss of control.

Photographs

8the aircraft, and what the investigators found
Wreckage and site documentation · 8 photographs from the docket

Photographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.

Probable cause

the Board's determination
The inadvertent encounter with inclement weather, including snow, freezing rain, and reduced visibility conditions,  which led to the pilot’s spatial disorientation and loss of aircraft control.

Occurrence sequence

3 stepsNTSB coding · CICTT taxonomy
  1. 1 · Enroute-cruise
    Structural icing
  2. 2 · Enroute-cruise
    Loss of control in flight
    defining event
  3. 3 · Enroute-cruise
    Loss of visual reference

Findings

5 causal · 0 contributing
  • CAUSE
    Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Freezing rain/sleet — Effect on operation
  • CAUSE
    Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Snow — Effect on operation
  • CAUSE
    Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Low visibility — Effect on operation
  • CAUSE
    Personnel issues › Psychological › Perception/orientation/illusion › Spatial disorientation — Pilot
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Aircraft control — Pilot

Safety recommendations

2 issuedwhat changed because of this accident
  • A-14-002Closed - ReconsideredCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Modify all Federal Aviation Administration-certified automated weather observing system installations with present-weather sensors in the National Airspace System such that they report only snow or “unknown precipitation” when precipitation is detected and the reported air temperature is 32ºF or less.

  • A-14-003Closed - Acceptable ActionCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Revise Advisory Circular 150-5220-16D, “Automated Weather Observing Systems (AWOS) for Non-Federal Applications,” such that future AWOS installations with present-weather sensors in the National Airspace System report only snow or “unknown precipitation” when precipitation is detected and the reported air temperature is 32ºF or less.

NTSB analysis

from the final report

The medical transport helicopter was on a night flight conducted under visual flight rules (VFR) to pick up a patient for transport. The pilot had computer-based weather information available, but it is unknown what information he reviewed before deciding to accept the flight. Weather observation stations along the route of flight were reporting VFR conditions around the time that the pilot accepted the flight. About 17 minutes into the flight, the pilot reported to the receiving hospital's communications center that he was aborting the mission due to encountering inclement weather and was returning to base. Flight track data indicated that the helicopter initiated a right turn at this time, away from a nearby lighted windmill farm toward an area with sparse ground lighting . The flight track then showed a slight descent before the end of the data. The last recorded position was about 0.75 miles east-southeast of the main wreckage site. The helicopter impacted an agricultural field in an inverted, nose-low attitude. Examination of the wreckage revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Weather data and reports from first responders indicated that the flight likely encountered areas of snow, freezing drizzle, and supercooled liquid water. The lack of ground lighting combined with the precipitation encountered likely reduced the visibility and outside visual references available to the pilot resulting in spatial disorientation and subsequent loss of control.