ANC16FA023

The pilot's decision to continue visual flight into an area of instrument meteorological conditions, which resulted in the pilot experiencing a loss of visual reference and subsequent controlled flight into terrain. Contributing to the accident were the pilot's self-induced pressure to complete the flight and the operator's failure to maintain operational control over the flight.

The non-instrument-rated commercial pilot was making a visual flight rules internal-cargo company flight in the helicopter. He was returning to base in the helicopter after dropping off 1 employee and 12 dogs at a remote dog camp situated on a glacier surrounded by mountainous terrain. The pilot had previously completed 5 of the day's 7 planned roundtrip flights from the base to the dog camp.  According to the dog camp manager, the weather was deteriorating with snow and wind increasing when the pilot departed on the accident flight. The dog camp manager's observations and radar data indicated that the pilot attempted to depart via the normal route to the south but turned around. He likely encountered low visibility conditions and then attempted several departures by routes to the north of the dog camp. About 8 minutes after departure, the helicopter impacted snow-covered mountainous terrain about 2 miles northeast of the dog camp. Postaccident examination of the helicopter revealed no evidence of preimpact mechanical anomalies that would have precluded normal operation. Given the deteriorating weather conditions when the pilot departed, it is likely that the pilot continued visual flight into an area of instrument meteorological conditions, which resulted in the pilot experiencing a loss of visual reference and subsequent controlled flight into terrain. During the impact sequence, the two cargo straps used to secure two wooden dog boxes to the rear cabin floor failed, and the dog boxes shifted forward, striking the back of the pilot's fiberglass seat. It could not be determined if the forward movement of the dog boxes during the accident sequence contributed to the injuries sustained by the pilot. Immediately before departing from the dog camp on the accident flight, the pilot told the dog camp manager that, due to the degrading weather conditions, he would not be coming back for the last scheduled trip of the day, and the dog camp manager told the pilot that he agreed with him. However, the pilot then told the dog camp manager, "but don't give up on me yet," a statement consistent with self-induced pressure to complete the day's series of flights. On one of the day's previous flights, the pilot reported to the base manager, who was exercising operational control at the time of the accident, that he had encountered icing conditions while in flight. The base manager told the pilot "to do what he thought was best." However, flight operations in icing conditions are prohibited by the helicopter's rotorcraft flight manual and the operator's operations manual, and the pilot's statement should have prompted the base manager to suspend the flights. If flight operations had been cancelled for the day when the pilot reported the icing conditions, the subsequent flights, including the accident flight, would not have occurred. The base manager's failure to appropriately exercise operational control and terminate the flights may have been due to the difference in experience between the base manager, who had been operating these flights for 8 years, and the pilot, who had been operating these flights for 25 years.

The helicopter was not equipped and was not required to be equipped with a cockpit voice recorder, flight data recorder, or image recorder. A Latitude Technologies S200-001 flight tracker, a Garmin GDL 90 datalink transceiver, and an AKV ETM 1000 engine and rotor system monitoring device were recovered from the wreckage. These electronic devices were not designed for crash resistance or survivability. The Latitude Technologies Corporation S200-001 flight tracker, which was used by TEMSCO for flight tracking purposes, was transported to the manufacturer's facility in Victoria, British Columbia, Canada, for an examination of the unit and subsequent data download. According to the manufacturer, the unit had the original firmware installed from when the unit was released in February 2009 with no subsequent firmware updates. The manufacturer additionally reported that this build of firmware had a previously unknown "bug" resulting in the data being captured in the background log being identical to the data that were transmitted while the helicopter was in flight with no additional GPS data in between the transmitted logs being captured. At the time of the accident, the operator had the "ping rate" set to every 120 seconds. The Garmin GDL 90 and the AK ETM 1000 devices were submitted to the NTSB Vehicle Recorder Laboratory in Washington, DC, for examination and download. No track or navigation data was stored on the Garmin GDL 90. Various engine and main rotor system parameters were recorded for the accident flight on the AK ETM 1000. Refer to the Recorder Specialist's Factual Report in the public docket for further information regarding the Garmin GDL 90 and an AKV ETM 1000 devices. TEMSCO Operations The TEMSCO Operations Manual discusses icing conditions and states: Helicopter flights during icing conditions are prohibited. TEMSCO shall not fly into known icing conditions. If icing conditions are encountered, the Pilot-in-Command will deviate from course to avoid and navigate around any encountered icing conditions. The Airbus AS 350 B2 Rotorcraft Flight Manual lists "flight in freezing rain or icing conditions (visible moisture and temperatures likely to produce ice)" as a prohibited maneuver in the limitations section. The TEMSCO Operations Manual discusses operational control and states: Operational control with respect to a flight, means the exercise of authority over initiating, conducting, or terminating a flight. The Director of Operations and the pilot in command are jointly responsible for the initiation, continuation, diversion, and termination of a flight. The Director of Operations may delegate functions to other trained personnel, but retains responsibility for initiation, continuation, diversion, and termination. The final authority over conducting or terminating a flight rests with the pilot in command. The following persons have "operational control" with respect to flight in descending order: director of operations, chief pilot, pilot in command, second in command, director of maintenance, base managers, base lead pilot, and trained flight followers. The FAA's Order 8900.1, Flight Standards Information Management System, identifies one of several failure modes of operational control and states: Loss of operational control within the air carrier – hands-off management results in inadequate controls over its own operations. Management of operations should never be inattentive, distracted, or careless. Hands-off management is not a legitimate excuse for failing to maintain operational control. FAA Operations Specification A008 Operational Control states that non-management personnel exercising operational control shall be specified in the general operations manual (names, titles, duties, responsibilities, and authorities). A review of the TEMSCO Operations Manual showed that, for the operational control chain of command, the base lead pilot positions were listed "as assigned" with no names listed, and the trained flight follower positions had no names listed. A formal flight risk assessment was not conducted by the pilot for the accident flight, nor was it required by the operator at the time of the accident. The TEMSCO Safety Management Systems Manual states that flight risk assessments are to be conducted for emergency medical services and tour operations. The TEMSCO Operations Manual discusses company VFR weather minimums and states that, for the local operating area (within a 30-nautical-mile radius from the base of operations), a 500 ft ceiling or greater and 1 statue mile visibility or greater is required. The manual states that the lowest of the ceiling or visibility shall be the limiting factor for dispatch. A review of the TEMSCO Operations Manual found no operational procedures listed for flight operations in deteriorating VFR weather conditions (such as reduced visibility and ceilings), inadvertent instrument meteorological conditions (IIMC) avoidance procedures, or IIMC recovery procedures. TEMSCO Internal Cargo Operations The TEMSCO Operations Manual discusses internal cargo carried in passenger compartments and states: Will be secured by means approved by the FAA. Will be carried in accordance with each of the following: Will be properly secured by a safety belt or other tie down having enough strength to eliminate the possibility of shifting under normally anticipated flight and ground conditions. Will be packaged or covered to avoid possible injury to passengers. It will not impose any load on seats or on the floor structure that exceeds the load limitations for those requirements. It will not be located in a position that restricts the access to or use of any required emergency or regular exit, or the use of the aisle between the crew and the passenger compartment. It will not be carried directly above seated passengers. This document further discusses the limitations of carriage of cargo in the passenger compartments and states: Each bay or bin will be able to withstand the load factor as applicable to passenger seats of the aircraft. The maximum weight of cargo that each bin or bay is approved to carry will not be exceeded. Each bay will be loaded to insure proper weight distribution when using cargo load schedule. The load will not impose any load on the floor or other structure of the aircraft that exceeds the limitations of that structure. The maximum concentrated load for each compartment will not be exceeded. The bin or netting for loose cargo will be attached to the seat tracks or to the floor structure of the aircraft and its attachment must withstand the load factors applicable to the passenger seats. The cargo will not restrict access to or use of any required exit or aisle in the passenger compartment. It will be the responsibility of the Pilot-In-Command to check and ensure that all cargo and passenger doors are properly secured prior to any flight. The operator reported that before the accident, the company conducted internal cargo load training for contract, charter, and utility pilots at company headquarters in Ketchikan, which was hands-on training that was both mission-specific and aircraft-specific with no training syllabus or published curriculum at the time. The training was not conducted with the tour pilots. After the accident, the operator developed internal cargo loading guidelines for all company Airbus AS 350 pilots. This document covers cargo strap standards (what type to use), the various helicopter floor weight limitations, and the various limitations of the mooring rings. The document also highlights the importance of not exceeding any limitations of seat-belt-based mooring rings when a ring is used to restrain cargo and the seat is occupied. Tour Operators Program of Safety At the time of the accident, the operator was a member of the Tour Operators Program of Safety (TOPS). The most recent TOPS compliance audit o