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Cases › WPR16FA037 · Part 135 fatal

BELL 407Rogers Helicopters

McFarland, CA, USA · 2015-12-11·N408FC

4
fatal
0
serious
Fatal
highest injury
Destroyed
damage

What happened

NTSB summary, verbatim

The commercial pilot of the helicopter air ambulance flight, which was operating under visual flight rules, departed in night visual meteorological conditions (VMC) to transport a patient from Porterville, California, to a hospital in Bakersfield, California; a flight nurse and a paramedic were also aboard the helicopter. GPS data indicated that, after takeoff, the helicopter proceeded on a southerly course paralleling a highway and ascended to a maximum GPS altitude of 1,554 ft with groundspeeds varying between 124 and 144 mph. About 13 minutes after takeoff, the helicopter began to descend; 20 seconds later, the helicopter entered a left descending turn with groundspeeds that initially increased and then decreased. According to the last 6 seconds of GPS data, the descent rate of the helicopter was about 2,210 ft per minute. Although both the departure airport and an airport near the helicopter's intended destination reported VMC shortly after the accident flight began, no recorded weather observation stations were located along the route of flight. Meteorologists at the National Weather Service field office nearest to the accident site indicated that the conditions at the time and the location of the accident were conducive to fog. They also referenced a Twitter post from an individual that observed fog in the area of McFarland, however the Twitter post was unavailable. The pilot of the helicopter that located the wreckage about 1 hour, 51 minutes after the accident reported ground fog in the area. In addition, that pilot stated that he encountered heavy rainfall in the general search area. Thus, it is likely that the accident pilot encountered an area of reduced visibility due to rain or fog. Examination of the accident site indicated that the helicopter impacted open, sparsely populated, unlit, and hilly terrain in a descending left turn. Postaccident examination of the helicopter structure, systems, and engine revealed no evidence of any anomalies that would have precluded normal operation. The operator used two Bell 407 helicopters for helicopter air ambulance operations; one was equipped with an advanced (glass cockpit) instrument display system (the accident helicopter), and one was equipped with analog instruments. A review of the pilot's logbook and company records revealed that the pilot had primarily flown the Bell 407 helicopter that was equipped with analog instruments. The pilot's commercial pilot certificate included an instrument helicopter rating, so he most likely had the operational skills necessary to safely conduct a flight in a familiar helicopter. However, during the almost 7 months preceding the accident, the pilot had 11.2 hours of total flight experience in the accident helicopter that included 2.3 hours of night flight time, of which 2 hours comprised of night flight training and night vision goggles (NVG) training about 4 months before the accident. The pilot had logged .3 hours of night time in the accident helicopter 48 hours prior to the accident.  Thus, the pilot lacked recent nighttime experience with the accident helicopter's advanced avionics, which may have increased his susceptibility to spatial disorientation or loss of control during maneuvering flight.

Photographs

15the aircraft, and what the investigators found
Wreckage and site documentation · 15 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 pilot's loss of control and collision with terrain while attempting a course reversal after inadvertently entering an area of reduced visibility weather conditions. Contributing to the accident was the pilot's lack of recent experience with night time operations.

Occurrence sequence

2 stepsNTSB coding · CICTT taxonomy
  1. 1 · Enroute
    Loss of control in flight
    defining event
  2. 2 · Enroute
    Collision with terr/obj (non-CFIT)

Findings

5 causal · 2 contributing
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Aircraft control — Pilot
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Use of equip/system — Pilot
  • CAUSE
    Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Low visibility — Effect on operation
  • CAUSE
    Personnel issues › Experience/knowledge › Experience/qualifications › Recent experience — Pilot
  • CAUSE
    Personnel issues › Experience/knowledge › Experience/qualifications › Recent instrument experience — Pilot
  • FACTOR
    Personnel issues › Experience/knowledge › Experience/qualifications › Total experience w/ equipment — Pilot
  • FACTOR
    Environmental issues › Conditions/weather/phenomena › Light condition › Dark — Effect on operation

NTSB analysis

from the final report

The commercial pilot of the helicopter air ambulance flight, which was operating under visual flight rules, departed in night visual meteorological conditions (VMC) to transport a patient from Porterville, California, to a hospital in Bakersfield, California; a flight nurse and a paramedic were also aboard the helicopter. GPS data indicated that, after takeoff, the helicopter proceeded on a southerly course paralleling a highway and ascended to a maximum GPS altitude of 1,554 ft with groundspeeds varying between 124 and 144 mph. About 13 minutes after takeoff, the helicopter began to descend; 20 seconds later, the helicopter entered a left descending turn with groundspeeds that initially increased and then decreased. According to the last 6 seconds of GPS data, the descent rate of the helicopter was about 2,210 ft per minute. Although both the departure airport and an airport near the helicopter's intended destination reported VMC shortly after the accident flight began, no recorded weather observation stations were located along the route of flight. Meteorologists at the National Weather Service field office nearest to the accident site indicated that the conditions at the time and the location of the accident were conducive to fog. They also referenced a Twitter post from an individual that observed fog in the area of McFarland, however the Twitter post was unavailable. The pilot of the helicopter that located the wreckage about 1 hour, 51 minutes after the accident reported ground fog in the area. In addition, that pilot stated that he encountered heavy rainfall in the general search area. Thus, it is likely that the accident pilot encountered an area of reduced visibility due to rain or fog. Examination of the accident site indicated that the helicopter impacted open, sparsely populated, unlit, and hilly terrain in a descending left turn. Postaccident examination of the helicopter structure, systems, and engine revealed no evidence of any anomalies that would have precluded normal operation. The operator used two Bell 407 helicopters for helicopter air ambulance operations; one was equipped with an advanced (glass cockpit) instrument display system (the accident helicopter), and one was equipped with analog instruments. A review of the pilot's logbook and company records revealed that the pilot had primarily flown the Bell 407 helicopter that was equipped with analog instruments. The pilot's commercial pilot certificate included an instrument helicopter rating, so he most likely had the operational skills necessary to safely conduct a flight in a familiar helicopter. However, during the almost 7 months preceding the accident, the pilot had 11.2 hours of total flight experience in the accident helicopter that included 2.3 hours of night flight time, of which 2 hours comprised of night flight training and night vision goggles (NVG) training about 4 months before the accident. The pilot had logged .3 hours of night time in the accident helicopter 48 hours prior to the accident.  Thus, the pilot lacked recent nighttime experience with the accident helicopter's advanced avionics, which may have increased his susceptibility to spatial disorientation or loss of control during maneuvering flight.