Aircraft Was Not Certified For Flight In IFR Conditions

The FAA has released a factual report stemming from an accident which happened the day after Christmas in 2011. The accident resulted in the fatal injury of the pilot and two passengers. According to the report, instrument conditions prevailed at the time of the accident, but the helicopter was not equipped for IFR operations.

According to the report, the aircraft, the Bell 206B helicopter, N5016M, collided with terrain while maneuvering near Green Cove Springs, Florida. The airline transport pilot and two passengers were fatally injured. The helicopter was substantially damaged. The helicopter was registered to Abraham Holdings, LLC, and operated by SK Logistics, doing business as SK Jets, as a 14 Code of Federal Regulations (CFR) Part 135 on-demand air taxi flight. Night instrument meteorological conditions (IMC) prevailed along the flight route, and no flight plan was filed. The flight originated from Mayo Clinic Heliport (6FL1), Jacksonville, Florida, about 0537 and was destined for Shands Cair Heliport (63FL), Gainesville, Florida.

Review of the pilot's portable electronic devices revealed that he received a call from a company scheduler about 0335 notifying him about the accident trip. About 0357, he reviewed weather reports for airports near the flight route on his computer. About 0423, he opened a card-activated entrance gate to the SK Jets hangars at Northeast Florida Regional Airport (SGJ), St. Augustine, Florida.

According to Federal Aviation Administration (FAA) radar data, the helicopter conducted an uneventful repositioning flight from SGJ to 6FL1. It departed SGJ about 0517 and arrived at 6FL1 about 0530. Although the helicopter initially climbed to 1,000 feet above ground level (agl) during the repositioning flight, it then flew between 700 and 900 feet.

After picking up the two passengers, the helicopter departed 6FL1 to the southwest, flying a track slightly south and east of a direct course to 63FL. The pilot contacted Jacksonville Approach about 0549 to inquire about the status of restricted airspace. About 0550, the controller replied that the restricted areas were inactive; the pilot acknowledged the transmission. No further communications were received from the pilot. During the enroute portion of the flight, the helicopter's altitude varied between approximately 450 and 950 feet agl. The helicopter's calibrated airspeed was about 100 to 110 knots. (For more information about the helicopter’s airspeed, see the National Transportation Safety Board’s [NTSB] Radar Study in the public docket for this accident.) 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 course to 63FL about 450 feet agl. The last radar target was recorded at 0553:23, indicating a calibrated airspeed of 81 knots. The accident site was located about 1/2 mile south of the last radar return, with a southerly debris path.

According to representatives of the Mayo Clinic Hospital, Jacksonville, Florida, the accident flight was contracted by the hospital to carry a doctor and a medical technician to Shands Hospital, Gainesville, Florida, for the purpose of procuring an organ for transplant. The flight was then to return to the Mayo Clinic Hospital with the procured organ. The flight did not arrive at Shands Hospital and was reported overdue by a Mayo Clinic Hospital representative; the hospital activated local search and rescue operations. The wreckage was located about 1000 in a remote wooded area by the Jacksonville Sheriff's Department Aviation Unit.

PILOT INFORMATION

The pilot, age 68, was the founder, president, owner, and director of operations of SK Jets. He held an airline transport pilot certificate with ratings for airplane single engine and multiengine land. He also held a commercial pilot certificate and a flight instructor certificate, both with ratings for rotorcraft and instrument helicopter. Additionally, he held type ratings in the Learjet and Learjet 60. His most recent FAA first-class medical certificate was issued on October 5, 2011, with a restriction that he must wear corrective lenses. The pilot learned to fly at age 16 and later flew for the US Army, which included one-and-a-half tours of duty in Vietnam where he earned a Bronze Star, Purple Heart, and Distinguished Flying Cross with Three Oak Leaf Clusters.

Review of company records revealed that the pilot had accumulated 11,343 total flight hours, 3,646 hours of which were in helicopters with 1,648 hours in the Bell 206. He had accrued a total of 3,288 hours of night experience and 3,259 hours of instrument experience. The pilot had flown 10.7 hours and 2.5 hours during the 90-day and 30-day periods preceding the accident, respectively, of which 3.1 hours and 1 hour were at night, respectively. None of the flight time during the 90 days preceding the accident was instrument time. The pilot had not flown during the 7-day period preceding the accident.

The pilot was involved in a previous accident on December 22, 2007 (NTSB case number MIA08CA040). The accident pilot attempted the flight with three passengers onboard; however, a few minutes into the flight, he turned back and returned to the departure airport due to poor weather. (The ceiling was 400 feet, and the visibility was 2.5 miles.) While returning to the fuel pump area, the helicopter's tail rotor struck trees, resulting in substantial damage to the helicopter. There were conflicting reports about whether the collision happened during approach or taxi. According to current and former employees at SK Jets, a different helicopter pilot had turned down the flight due to the poor weather. Following that accident, the pilot successfully completed an FAA reexamination.

Work/Rest/Sleep History

According to the pilot's wife, he normally awoke about 0630 every day and went to sleep around 2330 or 0000, whether it was a workday or not. He had been a 6-hour-a-night sleeper for at least 50 years. On Friday, December 23, 2011, the pilot awoke about 0630 and went to the office about 0730. He came home early that day because it was his 50th wedding anniversary. He and his wife went to a nearby resort, arriving about 1500. They had a quiet evening at the resort, ate dinner, and stayed the night. The pilot's wife estimated that he might have fallen asleep about 2330.

On Saturday, December 24, 2011, the pilot awoke about 0630, then went back to bed and slept an extra hour. He ate breakfast with his wife at the resort, and they ran an errand. They returned home and then visited the residence of a relative, where they ate lunch. They returned home again about 1620. The pilot engaged in routine activities and took a nap between 1800 and 1900. The pilot and his wife left the house about 2230 and attended midnight services at their church.

On Sunday, December 25, 2011, the pilot and his wife returned home from church about 0115, and the pilot went to sleep about 0300. He awoke about 0800 and celebrated Christmas morning. The pilot went for a bike ride in the early afternoon and stopped by the office. He returned home and ate lunch about 1330. The pilot then told his wife he was going to take a nap (beginning about 1600) in case he had to fly that night because another SK Jets helicopter pilot was not going to be available. The pilot's wife was not sure how long he napped, perhaps 1 hour to 1 1/2 hours. After his nap, he got up and engaged in routine activities around the house. He ate dinner and went to sleep between 2230 and 2300 before being awakened by the telephone call about 0335.

AIRCRAFT INFORMATION

The five-seat, single-engine, two-bladed helicopter was manufactured in 1979 and maintained under an FAA-approved manufacturer's maintenance program. The helicopter's most recent inspection was a conformity inspection, completed on December 1, 2011. At the time of the inspection, the helicopter had accumulated 11,172.5 total hours of operation. The helicopter had flown about 3.5 hours since that inspection until the time of the accident.

The helicopter was equipped with a Rolls Royce (Allison) model 250-C20B, 420-shaft horsepower turbine engine. Review of the maintenance records revealed that the engine was overhauled and installed on the helicopter in 2005 at 11,053.5 total engine hours. The engine had accumulated 167.1 hours since the overhaul until the time of the accident.

The helicopter was not certified for instrument flight rules (IFR) flight and was not equipped with a radar altimeter or autopilot. The helicopter was equipped with a Garmin GNS 430 global positioning system receiver and a very high frequency omnidirectional range unit with localizer and glideslope indications. However, the Garmin GNS 430 unit installed on the helicopter only had modifications 1 through 5, which do not provide a terrain or obstacle warning function. An upgrade (modification 7) was available for the unit, which would have provided terrain/obstacle warning capabilities.

Before the accident flight, the helicopter was fueled with 35 gallons of Jet A aviation fuel, which brought its total fuel load to approximately 58 gallons.

METEOROLOGICAL INFORMATION

There was no record of the pilot contacting flight service for the accident flight. However, the pilot's laptop computer was located at his residence, and its Internet browser was open to www.aviationweather.gov, with weather data displayed from the Aviation Digital Data Service (ADDS). The data included aviation routine weather reports (METARs) for SGJ; Craig Municipal Airport (CRG), Jacksonville, Florida; and Gainesville Regional Airport (GNV), Gainesville, Florida. The data also included terminal area forecasts (TAFs) for CRG and GNV. The ADDS service was not one of the weather sources approved in the SK Jets operations specifications; however, some company pilots stated during interviews that they used weather sources that were not approved in the general operations manual (GOM) or operations specifications as a supplement to the approved weather. (The GOM indicates to use an FAA-approved weather source.)

Review of the laptop computer data revealed that the METAR for the initial departure airport, SGJ, about 0327 reported 10 miles visibility, scattered clouds at 1,700 feet, and a broken cloud ceiling at 7,000 feet. About 0509, about the time of initial departure, the recorded weather at SGJ included 10 miles visibility, a broken ceiling at 900 feet, and an overcast ceiling at 8,000 feet.

CRG was located about 7 miles northwest of 6FL1. Review of the laptop computer data revealed that the METAR for CRG about 0353 reported 10 miles visibility and a broken ceiling at 7,000 feet. The recorded weather at CRG about 0553 was wind from 010 degrees at 6 knots, visibility 10 miles, overcast ceiling at 700 feet, temperature 14 degrees C, dew point 13 degrees C, and altimeter 30.22 inches Hg.

The METAR for GNV, located about 5 miles northeast of the destination heliport, about 0353 reported 6 miles visibility, mist, and a broken cloud ceiling at 1,600 feet. The TAF at GNV for the accident flight’s estimated time of arrival at 63FL called for wind from 030 degrees at 6 knots, visibility better than 6 miles, and an overcast ceiling at 800 feet. The TAF also included a temporary condition during the estimated arrival time of IMC with visibility 4 miles, mist, and an overcast ceiling at 400 feet. Additionally, data downloaded from the pilot's cell phone revealed that he called the GNV automated surface observing system about 0419. The recorded weather at GNV about 0424 was wind calm, visibility 7 miles, broken ceiling at 1,400 feet, temperature 16 degrees C, dew point 14 degrees C, and altimeter 30.19 inches Hg. The recorded weather at GNV about 0553 was wind 020 degrees at 3 knots, visibility 7 miles, sky clear, temperature 16 degrees C, dew point 14 degrees C, and altimeter 30.21 inches Hg.

The accident site was located about 12 miles northeast of Palatka Municipal Airport (28J), Palatka, Florida. The recorded weather at 28J about 0554 was wind 010 degrees at 3 knots, visibility 10 miles, few clouds at 3,800 feet, broken ceiling at 7,000 feet, temperature 15 degrees C, dew point 14 degrees C, and altimeter 30.21 inches Hg.

A former SK Jets helicopter pilot described the area near the accident site as susceptible to fog due to swampy terrain. He added that once fog developed, the area was a "black hole" at altitudes of 200 to 400 feet agl, and a flight in these circumstances was effectively in IMC.

During postaccident interviews, other pilots from SK Jets 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 fixed-wing transportation, if the flight could not be completed. There was no record of the accident pilot arranging any other transportation relating to the accident flight.  The SK Jets GOM, section V, page V-10, paragraph V.14, “VFR [visual flight rules] Helicopter Minimums,” stated, in part, "Unless otherwise approved by the Director of Operations or Chief Pilot, the following weather minimums will be used for VFR flight in the helicopter…Night – 1000 Foot Ceiling and 3 miles visibility." Further review of the GOM did not reveal any restrictions for the accident pilot, as director of operations, to approve himself to deviate from night VFR helicopter minimums.

WRECKAGE INFORMATION

A debris field originated with several pine trees that were severed by breaks at descending altitudes. The debris field was approximately 320 feet long and 70 feet wide, extending on a magnetic course of 172 degrees. The initial tree strike was at an estimated height of 30 feet above the ground, which severed an approximately 50-foot-tall tree.

Pieces from the helicopter's chin bubble were located near the initial tree strike. A large section of tailboom, a piece of right skid, both rear cabin doors, the main rotor hub with half of the red main rotor blade remaining, and one tailrotor blade were located approximately 110 to 130 feet along the debris path, respectively. The main wreckage and engine were located about 175 feet along the debris path, and approximately 80 percent of the wreckage was consumed in the postcrash fire. The instrument panel, seats, and a section of the white main rotor blade were located beyond the main wreckage.

The collective pitch jack shaft was wrapped around a tree with the engine, transmission, and oil cooler. The cyclic and collective controls were separated from the system along with the antitorque pedals, which were located forward past the first piece of the tailboom and the copilot's tail rotor controls. All control tubes exhibited evidence consistent with overload failure, and some tubes were also crushed. The pitch change links were broken off at the clevis, and the swash plates were fused together. Due to impact and fire damage, flight control continuity could not be confirmed.

All tail rotor drive shaft segments with Thomas couplings extended rearward from the short shaft to where the 90-degree gear box separated. Some segments were not located and were likely consumed by the postcrash fire. The remaining drive shaft segments exhibited evidence of overload signatures. Both tail rotor blades separated from the 90 degree gear box. The red main rotor blade spar was separated into three sections, and the leading edge exhibited bending. Yellow paint transfer marks were present near the tip of the rotor blade. The white main rotor blade was damaged and exhibited yellow paint transfer about 4 feet from the rotor blade tip. The outboard 10 to 15 inches of the afterbody from the red and white main rotor blades separated from their blade spars, leaving a 45-degree tear where the sections attached.

Postaccident examination of the engine revealed that the compressor rotor exhibited evidence of tip rub to the first stage compressor blades. The accessory gear box had been consumed by fire, exposing the internal gearing. The outer combustion case displayed crush damage from the dome area extending across the top, with a puncture on the top just aft of the air tube flange. Visual examination of the inside of the liner revealed no evidence of unusual burn patterns or streaking. Both the power turbine and gas producer supports were visually normal and only exhibited external thermal exposure. Removal of the harness and examination of probe tips revealed no evidence of over-temperature operation. The suction side of the power turbine rotor showed circumferential rubbing around both the inner and outer rim faces, consistent with rotational contact with corresponding areas of the No. 3 wheel. Rotational signatures within the compressor and turbine modules were observed. No preimpact mechanical malfunction or failures were found that would have precluded normal operation.

The main rotor mast (upper end) was submitted to the NTSB materials laboratory for examination. The mast was heavily deformed and bent above the fracture. Magnified examination of the fracture revealed large overstress shear lips around the mast. The orientation of the shear lips and the overall pattern of deformation were consistent with a bending overstress separation.

The annunciator panel was submitted to the NTSB materials laboratory for examination of the light bulb filaments. The annunciator panel was x-rayed to determine the condition of the filaments inside each individual indicator light. Radiographs of the filaments in all of the indicators showed that several of the bulb filaments were fractured; however, all of the filament material was present and exhibited no signs of stretching. The bulbs with intact (unbroken) filaments also showed no signs of filament stretching.

Most of the cockpit instrumentation was destroyed. The altimeter was recovered, and 30.22 was displayed in the Kollsman window. The altimeter needles were destroyed.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot on December 27, 2011, by the state of Florida, District 4 Medical Examiner's Office, Jacksonville, Florida. The cause of death was listed as "multiple injuries."

Toxicological testing on the pilot was performed by the FAA's Civil Aerospace Medical Institute, Oklahoma City, Oklahoma. Review of the toxicology report revealed that Pravastatin and Zolpidem were detected in the liver and blood.

The pilot's wife stated that the pilot was very physically fit and in excellent health. He wore eyeglasses with trifocal lenses. He did not have a history of chronic medical conditions. He had high blood pressure since he was 30 but was on three medications for it, and it was under control. He had not experienced any illnesses in the days before the accident. He did not snore or exhibit any signs of sleep disorders. He visited a flight surgeon regularly and had been seeing a personal physician for 30 years. She said that he rarely drank alcohol, and when he did, it was perhaps a glass of wine with dinner. His most recent consumption of alcohol was a glass of champagne on Friday evening, December 23, 2011. He did not use tobacco products.

(Bell 206 image from file. Not accident aircraft)

FMI: www.ntsb.gov