Medevac AS 350 B2 Crash Wisconsin

[Airbubba]

3 dead in Hazelhurst medical helicopter crashBy Team Coverage Posted: Fri 8:59 AM, Apr 27, 2018 Updated: Fri 9:22 AM, Apr 27, 2018

HAZELHURST, Wis. (WSAW) -- The FAA confirms a medical helicopter crash Thursday night is fatal. A spokesman for the FAA said a Eurocopter AS350 helicopter departed Madison en route to Woodruff and crashed about 12 miles south of its destination. The helicopter is from Ascension.

A spokesman from Nimsgern Funeral Home said three people have died.

According to the Oneida County Sheriff's Office, the helicopter’s last known contact was at approximately 10:55 p.m. Thursday night. The Oneida County Dispatch Center received a call that the helicopter was missing at 11:22 p.m.

Tom Johnson said he lives close to the crash site, but initially wasn't sure what he had heard.

"Well, I woke up and I heard a loud noise and it sounded like a loud muffler. And I got up and looked outside and there was no lights anywhere and it was just dead quiet so I just went back to sleep. It was a lot of ... rotors hitting trees. Now that I know it was a helicopter, that makes sense. Since that what it sounded like-- that chopping sound. Then it was quiet," he said.Emergency responders searched the area last known, and located the helicopter in the Town of Hazelhurst in a wooded area near S. Blue Lake Road.

The Associated Press reports at least eight agencies were involved in the search.

Hazelhurst is about 5 miles south of Minocqua.

The NTSB will lead the investigation.


3 dead in Hazelhurst medical helicopter crash (http://www.wsaw.com/content/news/Air-Ambulance-Crash-481045181.html)

[Airbubba]

Apparently N127LN registered to Air Methods:

https://twitter.com/AHerreraReports/status/989887386258739205

[SASless]

Take note of what the FAA refused to do following NTSB Recommendations re improving the Safety Record of US EMS Operations.


Medical helicopter crash kills 3 in Wisconsin - ABC News (http://abcnews.go.com/US/medical-helicopter-crash-kills-wisconsin/story?id=54789003)

[JohnDixson]

One more area where the FAA is simply non-responsive. The list would make one wonder whether FAA top echelon pays any attention at all to the vertical lift business.

[heliduck]

My comments assume CFIT based on previous events, the report doesn’t give info on the moonlight so it might not be a factor.
It amazes me that air methods haven’t done anything about the NTSB recommendations, why wait for an FAA directive? I suspect money is the driver, I couldn’t imagine any other reason for not following the recomendations aside from it costing money. As pilots we throw ourselves to the wolves regularly, but I’m surprised air methods can get any medical crews to work for them with the quantity of incidents they have. In a litigious society surely the cost of fitting the equipment recommended by the NTSB would be less than the legal action which surely must follow from family & friends?
103 fatalities in 10 years, 49 of whom were on board. Wow, that’s surprising. I don’t recall hearing about a lot of people being killed when a helicopter fell on them, I’ve obviously been living under a rock.

[malabo]

If every NTSB recommendation was adopted nobody would be flying. They aren’t a deity, and have a responsibility to make a recommendation, any recommendation, when there is an accident. In this case a 1/2 moon, clear night, quality operator, pad to pad - an early jump to conclusions. We flew the old 222UT hard IFR both crew and single for years without an autopilot. Need more info on this one before I start wagging my finger.

[henra]

In this case a 1/2 moon, clear night, quality operator, pad to pad - an early jump to conclusions.

If these assumptions are correct then indeed those are not the standard ingredients for the typical CFIT accident.
That said, the pictures of the wreckage in the woods are really whispering CFIT. The destruction of the cabin indicates massive forward speed. There is no 90° bend between cabin and tail, so the angle of arrival doesn't look like it was vertical or in rotation or any other unusual attitude for that matter. And no Mayday call (at least that I'm aware of).
On top of that the description of the ear witness hearing sounds of Rotorblades hitting trees.
Will be interesting to learn the cause if the cause was really anything but CFIT. I personally would be surprised.

[Non-PC Plod]

The statistics speak for themselves. On average, a fatal accident about every 6 weeks for the last 10 years. I would say the FAA is bordering on negligent in its failure to respond to what is obviously a problem that needs to be addressed.

[Devil 49]

I am interested in the time of day of the accident, after a 170 nautical mile transport. I suspect this crew was well into a shift that started that morning, perhaps the pilot was pushing the maximum duty day of 14 hours.
I don't know if this base was NVG equipped. I believe that all Air Methods are and have been for a few years. The company position that NVGs be on your person or locked away discourages 24 hour carriage. Often only the aft baggage compartment is eligible for cargo carriage and lockable. The med crew does not typically have a key and uses that compartment for supplies.
If this crew's duty day started very early, the handover of sensitive equipment may have not been completed and the NVGs would have been locked away at base, not available to the crew.
If this was, as I guess, a hospital to hospital transport, each transfer could have taken hours. An hour at each hospital is an approximation of a quick transfer of care, but it can take four to six hours at the sending to prepare the patient. This flight could easily have started at or before 1400 hours local time, and NVGs might not have been seen as a priority.
The leg from Madison (receiving hosptal) to the base, Woodruff WI roughly follows a highway, US 51. Being low enough for CFIT over a traffic artery more than an hour from the departure and only a few minutes from the destination, late in the shift, implies some pressure to complete that leg and perhaps a willingness to accept an en route altitude that violates company policy. My memory is that that policy was minimum 500' agl daytime, and 1000' at night. The location and nearby METARS do not eliminate the possibility of local fog....
I believe that altitudes are included in automated pos reps to company flight following, and I believe to Ops Control Center. I hated advisories of obvious issues and queries on my plan and position, but they are/were a part of the job with the company, "Yes, I see the thunderstorm ahead. Your graphic depiction is 10 minutes old, it is moving/dissipipating, no issue".

[Jack Carson]

At this point it is difficult to determine exactly what caused this mishap. D-49 provides a very compelling scenario for a late-night flight with some element of get home itis. Without speculation, does anyone know if this specific AS-350B2 was equipped with a dual hydraulic system. If not so equipped, it could be argued that an instantaneous hydraulic fail could have compromised the control of the aircraft at such an altitude that control was not regained prior to impact with the terrain. Thus, it would not have been a CFIT situation but rather a compromised control issue.

[Airbubba]

Here is the crew of the downed helicopter:

https://twitter.com/SpiritWisconsin/status/990423857663283200

[Tango and Cash]

AS350 B2 would not be dual hydraulic system. That said, an "instantaneous hydraulic failure" scenario is hard for me to get my head around.

[claudia]

T. and C. Failure of the little belt that drives the hydraulic pump would mean instant failure
and that is sadly not uncommon with single system AS350.

[Thomas coupling]

Its not tail rotor, its a hydraulic failure in a 350 - god help.
https://www.youtube.com/watch?v=tXS5St-ak7U (https://www.youtube.com/watch?v=tXS5St-ak7U)

[Devil 49]

At this point it is difficult to determine exactly what caused this mishap. D-49 provides a very compelling scenario for a late-night flight with some element of get home itis. Without speculation, does anyone know if this specific AS-350B2 was equipped with a dual hydraulic system. If not so equipped, it could be argued that an instantaneous hydraulic fail could have compromised the control of the aircraft at such an altitude that control was not regained prior to impact with the terrain. Thus, it would not have been a CFIT situation but rather a compromised control issue.

Single hydraulic system, but the 'grooved' belt, which in my opinion, proved very serviceable.

[LRP]

10:30-11:00PM, doubtful that it was the day pilot.

[Gordy]

T. and C. Failure of the little belt that drives the hydraulic pump would mean instant failure
and that is sadly not uncommon with single system AS350.
Claudia,

The Astar has the hydraulic accumulators that should give you enough hydraulics to get the aircraft slowed down before you lose all your hydraulics.

I am with T and C on this, a hydraulic failure in an astar is not a big deal, I was just giving training in them the other day.

[claudia]

Gordy. All fine and dandy training around an airfield in daylight but try it in the dark, probably close
to IFR conditions, the situation this guy was in and its a very different story. The accumulator
runs out after a few stirs of the cyclic , the horn blows, you have managed to slow to say 70 knots,
big pedal movements needed, but stick and pedals now solid, and you have little or no ground references --- not good.
One of the reasons I personally moved from single to twin squirrels many years ago and also why dual hydraulics is a requirement for
IFR flight here in EASA land.
PS . Note I am in no way saying that was the scenario which caused this tragedy.

[Jack Carson]

I agree with Claudia. I have experienced multiple induced hydraulic failures during training and subsequent check rides in the AS-350B2 and B3. The surprise factor can be quite startling. In most cases I experienced a significant level of airframe gyrations during my attempts to slow to 70Kts. There was also a mishap Apache Junction about ten years ago where I believe that the pilot inadvertently hit the hydraulic test button during approach to landing at night. A crash landing resulted where a medical crew member perished. A sudden hydraulic failure, in an AS-350, is not a trivial event.

[Nubian]

Its not tail rotor, its a hydraulic failure in a 350 - god help.
https://www.youtube.com/watch?v=tXS5St-ak7U (https://www.youtube.com/watch?v=tXS5St-ak7U)

Well, that was misdiagnosed HYD-failure as a t/r failure due to no accumulator on the t/r servo as it was a BA. (cause of the failure was an incorrectly installed pump drive belt) The pedals become hard instantly whereas the m/r servos still getting pressure from the accumulators. He was at about 1000ft in a hover, not in cruise which is a big difference.

BTW, what indications is backing a HYD-failure??? HYD failure is not the first thing that springs to mind when a single pilot medical helicopter is crashing at night!

Air Methods has bought the Appareo Vision1000 FDM years ago so I assume it was fitted, and the helicopter seems not being consumed by fire. Therefore, I think it is a pretty good chance the NTSB will find out what happened.

[SASless]

Is absence of post crash fire a hint to a probable cause by chance?

[Devil 49]

10:30-11:00PM, doubtful that it was the day pilot.

A 168 nautical mile recovery leg implies at least that long in patient transport. Even without the usual time in sending, packaging the patient,, transferring care at the receiving, and no refuel stops, the flight would have had to depart base at 19:53 local. That might be the night pilot. But add a leg tpo sending facility to pick up patient, fuel stop(s) and the usual hospital time and a better estimate would be 1800 local- or earlier, thus the day pilot. Two or three hours at the transferring facility are not unusual. I've waited 6 hours a couple of times in 15 years of HEMS.

With Air Methods standard shift calendar, the day pilots start Thursday or Monday, work 4 day or 3 days and finish their 7-day duty period rotating to nights. It's reasonable to consider that this was the accident pilot's first day of a duty period. If so, the possibility of reporting fatigued starts to add up- AMC doesn't offer sleep facilities for pilots, the PIC may have a had a long commute and minimal rest before the duty day started, I know many pilots who drive 2, 3, 4 hours to report for the duty period- some longer.

I know a pilot who had a unanticipated sudden hydraulic failure (pesky switch!) in a 350B2 at a low level high speed cruise at night. Had the event not occurred with a high level of cultural lighting giving him adequate surface orientation, I don't think he would have survived. But he is a very, very good pilot.... Even so the aircraft was down for a couple of days for thorough examination after exceeding a couple limitations.

I'm illuminating the possible contributing circumstances. This could well be a failure that never occurred before.

[Gordy]

I still have to say, a hydraulic failure in an Astar is not a big deal. If you are getting gyrations slowing it down then you have a bad accumulator period. We train them in the hover, 500' hover, slow speed, fast speed, on final approach and never had a problem. I have had 2 for real, again no big deal, although in full disclosure mine were both day VFR.

I guess it is what you are comfortable with.

[helonorth]

A 168 nautical mile recovery leg implies at least that long in patient transport. Even without the usual time in sending, packaging the patient,, transferring care at the receiving, and no refuel stops, the flight would have had to depart base at 19:53 local. That might be the night pilot. But add a leg tpo sending facility to pick up patient, fuel stop(s) and the usual hospital time and a better estimate would be 1800 local- or earlier, thus the day pilot. Two or three hours at the transferring facility are not unusual. I've waited 6 hours a couple of times in 15 years of HEMS.

With Air Methods standard shift calendar, the day pilots start Thursday or Monday, work 4 day or 3 days and finish their 7-day duty period rotating to nights. It's reasonable to consider that this was the accident pilot's first day of a duty period. If so, the possibility of reporting fatigued starts to add up- AMC doesn't offer sleep facilities for pilots, the PIC may have a had a long commute and minimal rest before the duty day started, I know many pilots who drive 2, 3, 4 hours to report for the duty period- some longer.

I know a pilot who had a unanticipated sudden hydraulic failure (pesky switch!) in a 350B2 at a
low level high speed cruise at night. Had the event not occurred with a high level of cultural lighting giving him adequate surface orientation, I don't think he would have survived. But he is a very, very good pilot.... Even so the aircraft was down for a couple of days for thorough examination after exceeding a couple limitations.

I'm illuminating the possible contributing circumstances. This could well be a failure that never occurred before.

All the good EMS pilots cruise low level at high speed at night!

[Devil 49]

All the good EMS pilots cruise low level at high speed at night!

Leaving the receiving hospital and transitioning out of the busiest Class B in America, one might do so. Otherwise 1500' AGL or better,,company minimum en route altitude.
One might also be much lower than 1500' AGL at 3 minutes from your destination, approximately the situation of the accident aircraft.
I never got to fly as a pax with other pilots, I don't know how they flew. I personally liked to fly as high as I could reasonably get with a strong engine to maximize speed and minimize fuel burn. Not saying that was what was happening with the accident pilot, but 3 minutes out is getting pretty close, within a reasonable transition period from cruise to pre-landing configuration. I know I would be trying to visually acquire landmarks at that stage.

[aecpilot]

Devil49, you are way off base with almost all of your presumptions about AirMethods policy's and procedures you are passing off as facts known to you.
There are only two statements that hold credence put forth so far in this string with facts that are currently known.
SASless and Gordy are spot on with what is known about this accident or the B-2 in general.
This one needs to play out.
I'm afraid there will be a number of contributing factors involved in this tragedy that I suspect will be quite disturbing.

[helonorth]

Leaving the receiving hospital and transitioning out of the busiest Class B in America, one might do so.


One might do so but I'm at a loss as to why.

[SASless]

I'm afraid there will be a number of contributing factors involved in this tragedy that I suspect will be quite disturbing.

In every USA EMS Crash there usually is!

[Mee3]

the pump itself has a lot tolerance... it also has both clog indicator and prescribed SOAP by the OEM... Each servo has a bypass for redundancy... the pump belt has been upgraded then prescribed with a very conservative OTL interval... it has an accumulator to stable out a straight flight... redundancy can only do so much if someone decided to pass all the switch cheese hole consciously.

[LRP]

https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20180427X55413&AKey=1&RType=Prelim&IType=FA

[JimEli]

1 year anniversary and the NTSB website is absent any additional information. Has anyone heard anything?

[mcampbell]

Sad. Hope the required FDR will glean some information. Wonder if they had the camera which records the dash and possibly hear some of the communication that was transpiring in the cockpit.

[JimEli]

Sad. Hope the required FDR will glean some information. Wonder if they had the camera which records the dash and possibly hear some of the communication that was transpiring in the cockpit.

Appareo Vision 1000 installed. Would make one think this shouldn't be that complicated. However preliminary report does state the unit and data card suffered damage.

[wrench1]

Hope the required FDR will glean some information.
FYI: no FDR/CVR required on this type aircraft. Unfortunately, the Appareo mentioned above is not built or required to survive an accident.

[JimEli]

FYI: no FDR/CVR required on this type aircraft. Unfortunately, the Appareo mentioned above is not built or required to survive an accident.

However per FAR 135.607, as of 4/23/2018, an "approved" Flight Data Monitoring System is required.

[LRP]

I'd be looking for the factual in another year/year and a half. We've got our best people on it.

[RVDT]

However per FAR 135.607, as of 4/23/2018, an "approved" Flight Data Monitoring System is required.

Hard to work out whether that will make a difference - possibly knowing "what" went wrong possibly won't change the "why" it went wrong.

[wrench1]

However per FAR 135.607, as of 4/23/2018, an "approved" Flight Data Monitoring System is required.
True. But the only required data to be collected was latitude, longitude, barometric altitude, and the date/time of the reading unless the operator chose to record more. All guidance stated this was not to be confused with an FDR or its crashworthiness.

[JimEli]

True. But the only required data to be collected was latitude, longitude, barometric altitude, and the date/time of the reading unless the operator chose to record more. All guidance stated this was not to be confused with an FDR or its crashworthiness.

The FAA NPRM simply proposed that the flight data monitoring system “would be required to capture data according to a broadly defined set of parameters including information pertaining to the aircraft’s state (such as heading, altitude, and attitude), condition (such as rotors, transmission, engine parameters, and flight controls), and system performance (such as full authority digital engine control, and electronic flight instrumentation system).”

In the final ruling, the FAA does not specify parameters of data or specifically identify a set of performance standards that must be met. It only requires that a flight data monitoring system capable of recording flight performance data be installed. Furthermore, the rule does not establish standards for crashworthiness or environmental testing. Compliance with 135.607 would be met by an FDR-like system installed and recording on the helicopter.

Final ruling: https://www.faa.gov/regulations_policies/rulemaking/recently_published/media/2120-AJ53.pdf

[wrench1]

Compliance with 135.607 would be met by an FDR-like system installed and recording on the helicopter.
Unfortunately, after the date of the final ruling the FAA released it's guidance to enforce that ruling. Here are excerpts from the 2 most referenced. As I've been involved in the install of a number of these units, I can vouch that while most do include additional data, none in my experience reach anything close to "FDR-like" levels as it is at the discretion of the operator.FSIMS 8900.1:
VOLUME 4 AIRCRAFT EQUIPMENT AND OPERATIONAL AUTHORIZATIONS
CHAPTER 5 AIR AMBULANCE OPERATIONS
Section 3 Safety Assurance System: Air Ambulance Service Operational ProceduresE. Flight Data Monitoring.After April 23, 2018, in accordance with § 135.607, all HAAs must be equipped with an FAA-approved Flight Data Monitoring System (FDMS) capable of recording flight performance data. The regulation intentionally does not prescribe retention or use of the FDMS recordings. These decisions are at the discretion of the air ambulance operator. Beyond the minimum flight performance data stated below, the type and frequency of data recorded is at the discretion of the operator. The current edition of AC 27-1 MG 6, Miscellaneous Guidance (MG) for Emergency Medical Service (EMS) Systems Installations, suggests flight data that should be considered for recording; however, this is a recommendation, not a requirement. The minimum requirements are:
· The FDMS must receive electrical power from the bus that provides the maximum reliability for operation without jeopardizing service to essential or emergency loads.
· The FDMS must be operated from the application of electrical power before takeoff until the removal of electrical power after termination of flight.
· FAA approval will be granted to an FDMS which has the capability of recording flight performance data including, at a minimum, altitude (mean sea level (MSL)), time/date of sampling with a minimum sampling rate of one record per second, and sufficient memory to record an entire flight. The FDMS must also be installed securely and must be powered as stated above in the regulation. The installation must be approved under the authority of a Supplemental Type Certificate (STC), an engineering review conducted by the Aircraft Evaluation Group (AEG), or a field approval.

AC No: 135-14B
c. FDMS Capable of Recording Flight Performance Data. To meet the requirements of § 135.607, the operator must install an FAA-approved FDMS in each HAA. In this context, “approved FDMS” means only that the installed FDMS be capable of recording “flight performance data” including at minimum: Latitude, Longitude, Barometric Altitude, and Date/time of recording, once per second and have sufficient memory to retain these data over 4 hours of flight time. The FDMS is approved by Supplemental Type Certificate (STC), design review, or field approval, depending upon the complexity of the installation, the interface between the FDMS and other systems installed aboard the aircraft, and that it poses no hazard to other onboard equipment, nor any hazard to occupants. Beyond the minimum parameters, additional parameters recorded by the FDMS are at the discretion of the operator. Retention and use of recorded data is also at the discretion of the Operator. The FDMS requirement becomes effective on April 23, 2018. The FDMS is not to be confused with a flight data recorder (FDR) certified under § 27.1459, though an FDR would be acceptable to meet the FDMS requirement.

[JimEli]

Thanks for the correction wrench1.

[JimEli]

crickets...

[rottenjohn]

T. and C. Failure of the little belt that drives the hydraulic pump would mean instant failure
and that is sadly not uncommon with single system AS350.

Instant failure or the hydraulic pump yes, the accumulators will provide you with hydraulic assistance for close to a minute.
B2 s I’m pretty sure do not have a dual system option.

[wrench1]

crickets...
FYI: if they are working the investigation from the outside-in, i.e., verify what did not cause the accident, it can take quite some time to do so. There are currently a number of 2017 accidents not complete (probable cause) so considering there is no posted docket or factual for this accident yet, it will probably be a spell more before we see at least a factual. Below is a link for estimated completion dates of pending investigations. Once a factual report is released, you can then check this link periodically to see when the probable cause will be tentatively posted.
https://www.ntsb.gov/_layouts/ntsb.aviation/InvestRel.aspx

[wrench1]

Factual Report............ But there is no public docket posted as of yet.........
https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20180427X55413&AKey=1&RType=HTML&IType=FA