Three Dead....Another Night Bad Weather Flight Over Dark Terrain
The NTSB report on the AirHeart One crash near Santa Rosa Beach, Florida has been published.
Some excerpts from the report.....
History of the Flight
On October 20, 2004, about 0043 central daylight time, a Eurocopter Deutschland BO-105 CBS5, N916SH, call sign Airheart One, registered to and operated by Metro Aviation, Inc., as a Title 14 CFR Part 91 emergency medical services (EMS) positioning flight, from Santa Rosa Beach, Florida, to DeFuniak Springs, Florida, crashed in Choctawhatchee Bay, near Santa Rosa Beach. Instrument meteorological conditions prevailed in the accident area at the time and a company visual flight rules flight plan was filed. The helicopter was destroyed and the commercial-rated pilot, paramedic, and flight nurse were fatally injured. The flight originated from Santa Rosa Beach at 0041.
Personnel from the Walton County, Florida, Emergency Operations Center, stated that at 0021 they received a call from Healthmark Hospital in DeFuniak Springs, requesting the Airheart One helicopter to transport a patient to West Florida Hospital in Pensacola, Florida. The dispatcher then contacted the pilot of Airheart One and advised him of the request. The pilot stated he would have to check the weather and get back to him. At 0035, the pilot called back and stated they would take the flight. At 0041, the paramedic on Airheart One called via radio and reported they were airborne with three persons on board, 2 hours 20 minutes of fuel, and an estimated time en route to Healthmark Hospital of 10 minutes. At 0043, the paramedic reported that due to weather they were returning to base. The dispatcher did not talk with the flight after this. At 0050, the dispatcher cleared the Airheart One call, believing that they were back at base due to the short flight time. At 0610, the relief pilot that was coming on duty called the Emergency Operations Center and advised that Airheart One was not at base. Search and rescue operations were initiated and the wreckage of the helicopter was located in Choctawhatchee Bay about 0820.
A witness, who was fishing on the northwest side of the Highway 331 bridge reported that between 0030 and 0100, he observed a helicopter flying from south to north parallel to the bridge on the east side. The weather was lightning and thunder and it was just starting to drizzle and rain. He observed the helicopter either fly into a big cloud or fly behind the big cloud. He then saw lightning. He then saw the helicopter making a "U Turn" toward the east and then descend at a 45-degree angle to the water. He observed the helicopter by the red light on the belly. He left shortly after this because of the rain.
Recorded radar data from Eglin Air Force Base showed that the flight departed the Walton County Sheriff's Department heliport and was first observed on radar at 0040:37 while at 300 feet, 1/10 of a mile east-southeast of the heliport. The flight climbed to 900 feet, while proceeding north bound, across the bay, flying parallel to Highway 331 Bridge. The flight then descended to between 700 and 800 feet. At 0042:18, the flight initiated a turn to the east and at 0042:49, the last radar contact was recorded when the flight was at 700 feet, flying on an east-southeast heading. This position was about 3/4 mile to the east-northeast of the crash site.
Meteorological Information
A meteorological study was performed by the NTSB Operational Factors Division. The study showed that at 2353 the Destin-Ft. Walton Beach Airport (KDTS), Destin, Florida, automated surface weather observation was winds 220 degrees at 7 knots, 200 degrees to 280 degrees variable, visibility 7 statute miles, ceiling 800 feet broken, temperature 79 degrees F., dew point temperature 75 degrees F., altimeter setting 29.94 inches of Hg., lightning distant north, ceiling 700 variable 1300. The airport is located 16.2 nautical miles west of the accident site. At 0053 the KDTS automated surface weather observation was winds variable at 6 knots, visibility 7 statute miles, ceiling 600 feet broken, 1,500 feet overcast, temperature 79 degrees F., dew point temperature 75 degrees F., altimeter setting 29.93 inches of Hg., lightning distant southeast.
The 2355 surface weather observation taken at the Valparaiso/Okaloosa-Eglin AFB (KVPS) was winds 210 at 5 knots, visibility 7 statute, clouds 800 feet scattered, ceiling 2,000 feet overcast with thunderstorm, temperature 77 degrees F., dew point temperature 77 degrees F., altimeter setting 29.94 inches Hg., thunderstorm northeast and east moving southeast. The airport is located 20 nautical miles west-northwest of the accident site. The 0055 surface weather at KVPS was winds 230 at 5 knots, visibility 7 statute, clouds at 800 feet scattered, ceiling 1,700 feet broken with thunderstorm, overcast at 4,000 feet, temperature 77 degrees F., dew point temperature 77 degrees F., altimeter setting 29.93 inches Hg., thunderstorm northwest and north moving southeast.
Weather radar data obtained from the Eglin AFB Doppler Weather Radar System show that weak weather echoes were present in the area of the accident at the time of the accident. Additionally, an intense to extreme weather echo was present about 10 nautical miles north of the accident site.
At the time of the accident Airmet IFR MIAS WA 200145 was in effect for the accident area. The Airmet called for occasional ceiling below 1,000 feet, visibility below 3 miles, precipitation, mist, and fog. The Airmet was issued at 2045 on October 19, 2004, and was valid until 0300 on October 20, 2004.
The General Operations Manual establishes weather minimums for night visual flight rules EMS helicopter operations. The minimums are visual ground light reference, enough to properly control the helicopter, and existing or forecast weather for the duration of the flight should be obtained from a flight service station, weather bureau, automated weather observing system, ect., or the pilot's own observations. For local flights within 30 nautical miles of base the cloud ceiling should be a minimum of 800 feet agl and visibility greater than 2 miles. For preflight planning the cloud ceiling should be 1,000 feet agl and visibility should be 3 miles.
Metro Aviation, Inc. pilots reported to NTSB that on occasion the Sacred Heart Health System, Flight Program Coordinator would question a pilot's decision to not perform a flight because of poor weather conditions. An NTSB Human Performance Investigator and the NTSB Investigator-In-Charge conducted interviews with the Metro Aviation, Inc., Lead Pilot and the 7 pilots based at the Sacred Heart Health Systems operation, the Sacred Heart Health Systems Flight Program Coordinator and Chief Flight Nurse, the Metro Aviation, Inc. Owner, the General Manager, and the Director of Operations, and the accident pilot's wife. The purpose of the interviews was to gather information for evaluating whether the Sacred Heart Health Systems, Flight Program Coordinator's questioning of pilot's decisions might have influenced the accident pilot's decisions on the day of the accident. Most of the pilots interviewed stated that the flight program coordinator had a history of inappropriately involving himself in the weather-related decision making of pilots, and encouraging them to accept and complete more flights. However, the coordinator was not working and on the night of the accident and there is no evidence that he communicated with the accident pilot. Moreover, the lead pilot and most of the other pilots interviewed believed that the accident pilot was experienced, mature, confident in his decisions, and unlikely to have been swayed by the flight program coordinator's actions.
Note: All underlining and bold print is mine and not the NTSB's.
The intense or extreme radar echo would have been pretty much on the track the aircraft would have had to make to get to DeFuniak Springs from Santa Rosa Beach. Could the weather check have missed the large thunderstorm on the proposed route? Could the crew not see the lightning ahead of them? Why would the pilot turn to the East when flying on the East side of the only highway that runs north-south over the bay?
Any wonder why the US EMS fatal accident rate is as high as it is?
75% of the fatalities occur at night....usually from VFR flight into IMC conditions.
Anyone care to begin an "accident chain" on this one....or perhaps do a safety case review and comment on factors that "pressured" a pilot to make the decision he did?
Three people died in this one....we ought to mitigate that loss by learning from it.
Last edited by SASless; 2nd Jan 2006 at 04:04.