Primary finding
Probable cause
The pilot's failure to maintain control of the helicopter while maneuvering, resulting in the excessive descent rate and impact with terrain. Factors to the accident included the dark night, low ceiling and reduced visibility at the time of the accident.
Investigator assessment
Analysis narrative
The helicopter was destroyed when it impacted terrain about 2.0 nautical miles (nm) south of the departure airport during a positioning flight. Night marginal visual flight rules (MVFR) conditions prevailed with reduced visibilities and low clouds. After refueling the helicopter, the pilot requested to depart to the south in order to "status check a couple pieces of equipment" and then return to the heliplex located on the southeast perimeter of the airport. Aircraft radar track data showed the helicopter traveling south about 1.7 nm before turning to the south-southwest. While traveling to the south, the helicopter climbed to about 500 feet above ground level (agl) while accelerating from 95 knots to about 125 knots airspeed. The helicopter then entered an 18 second period where the climb rate increased from 500 feet/min to 2,000 feet/min and the helicopter reached a maximum altitude of about 1,000 feet agl. The helicopter decelerated from 125 to 100 knots airspeed during this climb. Based on the last two radar returns, the helicopter descended about 200 feet which resulted in a 1,350 feet/min descent rate. Further examination of the data showed the helicopter decelerating from 85 to 35 knots airspeed during the descent. The last radar return was at 800 feet agl and 425 feet east of the initial ground impact. The pilot was appropriately certificated to fly the helicopter and was employed as a pilot for an on-demand air ambulance service. The pilot was working his final shift as an employee with the company when the accident occurred. All primary airframe structural components, flight control systems, rotor systems, transmissions, and powerplant components were recovered at the accident site. Inspection of the recovered components did not exhibit any evidence of pre-impact malfunction. A review of the daily usage logs for the helicopter failed to reveal any unresolved maintenance discrepancies. The pilot who flew the helicopter prior to the accident flight did not report any malfunctions with the helicopter. A fuel sample was obtained from the source used to service the helicopter prior to the accident flight. The fuel sample was tested and met or exceeded the specifications for Aviation Turbine Fuel (Jet-A).
Source record
Factual narrative
HISTORY OF FLIGHT On January 28, 2003, at 2053 central standard time (cst), an Agusta A109C helicopter, N109MX, piloted by an airline transport pilot (ATP), was destroyed during an in-flight collision with terrain about two nautical miles (nm) south of DuPage Airport (DPA), West Chicago, Illinois. Night marginal visual flight rules (MVFR) weather conditions prevailed at the time of the accident. The positioning flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 without a flight plan. The pilot was fatally injured. The flight departed at 2051 and was maneuvering south of the airport at the time of the accident. The helicopter was operated by Air Angels Incorporated, an on-demand air ambulance service. The operator is based at a heliplex located on the southeast perimeter of DPA. According to company personnel, the helicopter was returning from the DPA Flight Center after refueling with 56 gallons of Jet-A fuel. The pilot of N109MX contacted the DuPage Control Tower at 2050:01 (hhmm:ss) and requested to "depart to the east if possible and head out to the south real quick and come back in on two left, and then land at the heliplex." At 2050:05, the tower controller told N109MX to "use caution departure uncontrolled, and ah, you gonna shoot an approach or just come in towards the numbers of two left?" The pilot of N109MX replied "I'm (unintelligible) status check a couple pieces of equipment we got then shoot two left, takeoff and land at the heliplex." The tower controller responded "that's no problem, Angel One you proceed as requested." At 2051:10, a driver of a snow removal vehicle operating on runway 2L asked the tower controller if he needed to be off the runway to allow N109MX to land. The tower controller responded, "I was just debating that, um I would say you would be no problem out there, he's just gonna check some instruments and then break off probably at ah the approach lights and go to the heliplex." At 2051:15, the tower controller asked N109MX if he needed the snow removal vehicle to be off the runway during his approach. The accident pilot replied "That's negative." There were no additional communications with N109MX. According to the tower controller, N109MX departed southbound from the Flight Center and while enroute the pilot "requested to continue south to check equipment." The tower controller stated he "observed a flash of light" to the south of the airport and that he was subsequently unable to communicate with the helicopter. The helicopter operator initially reported that the marker beacon system was inoperative on the accident helicopter. However, at a later date the operator stated that the inoperable marker beacon system was not on the accident helicopter, but on another aircraft at their heliplex. A review of the daily usage logs for the accident helicopter failed to reveal any discrepancies with the maker beacon system within 30 days of the accident. The pilot who flew the helicopter prior to the accident flight did not report any malfunctions with the helicopter, and had successfully flown an instrument landing system (ILS) approach just prior to the accident pilot being dispatched with the helicopter. Aircraft radar track data for the period before and after the reported accident time was obtained from the Chicago Terminal Radar Approach Control (TRACON) facility. The obtained data indicated a single aircraft transmitting a visual flight rules transponder beacon code (1200) maneuvering south of DPA around the time of the accident. The first radar return was at 2051:17, with the helicopter positioned about 0.4 nm east of the DPA control tower at 800 feet pressure altitude or about 200 feet above ground level (agl). The helicopter traveled to the south about 1.7 nm before turning to the south-southwest around 2052:13. The final radar return was at 2052:31, with the helicopter positioned about 2.0 nm south of the control tower at 1,400 feet pressure altitude (~800 feet agl). The last radar return was about 425 feet east of the initial ground impact. While traveling to the south, the helicopter climbed to 1,100 feet pressure altitude (~500 feet agl) while accelerating from 95 knots to about 125 knots airspeed. At 2052:00, the helicopter's climb rate began increasing from 500 feet/min to about 2,000 feet/minute over an 18 second period. During this 18 second period the helicopter decelerated from 125 to 100 knots airspeed. At 2052:22, the helicopter was positioned about 1.9 nm south of the control tower at 1,600 feet pressure altitude (~1,000 feet agl). Based on the last two radar returns, the helicopter descended approximately 200 feet that resulted in a 1,350 feet/min descent rate. Further examination of the data showed the helicopter decelerating from 85 to 35 knots airspeed during the descent. DAMAGE TO AIRCRAFT The helicopter was destroyed by impact forces and a subsequent explosion/fire. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the pilot, age 52, held an ATP certificate with a rotorcraft/helicopter rating. The pilot also had commercial privileges for single and multi-engine land airplanes and instrument airplane operations. He was type-rated for the Bell 212, Eurocopter BK-117, and Sikorsky 58. The pilot also held a certified flight instructor certificate with rotorcraft/helicopter and instrument helicopter ratings. FAA records show the pilot's last medical examination was completed on April 2, 2002, when he was issued a second-class medical certificate with no limitations or restrictions. The pilot began his flying career with the United States Army in October 1968 and remained on active duty until October 1984. Between December 1984 and July 1986, he provided instrument flight instruction for United States Army pilots while working for DWS Incorporated, Daleville, Alabama. The pilot was stationed in Yemen as the Chief of Standardization and Training for Bell Helicopter from September 1986 to April 1989. Beginning in May 1989 and continuing through January 1991, he was a pilot and company check-airman for Omniflight Helicopters, an air-ambulance operator based in Dallas, Texas. The pilot then took a position as a company check-airman for Petroleum Air Services, and was stationed in Egypt from February 1991 to August 1999. From February 2000 to August 2000 he was a pilot for Rocky Mountain Helicopters, an air-ambulance operator. The pilot was the Director of Training of Aris Helicopters Ltd., an air-ambulance operator, between August 2000 and September 2001. The pilot then joined Air Angels Incorporated on July 16, 2002. According to company records, when hired the pilot had a total flight experience of 12,000 flight hours, of which 9,500 hours were in helicopters and 2,500 hours were in airplanes. The pilot reported having 11,200 hours as pilot-in-command (PIC). The pilot had accumulated 250 hours in actual instrument conditions, 310 hours in simulated instrument conditions, and 1,000 hours of night experience. The pilot had flown 79.1 hours during the past year, 22.2 hours during the prior 90 days and 10.4 hours during the previous 30 days. The pilot had flown 1.9 hours during the 24 hours before the accident. The pilot's first flight in an Agusta A109C was on July 18, 2002, and he subsequently accumulated 56.3 hours in the helicopter. The pilot was approved for 14 CFR Part 135 operations after successfully passing a FAA Airman Competency/Proficiency Check on July 25, 2002. The pilot worked 17 twelve-hour shifts during the previous 30 calendar days. The pilot's duty schedule comprised of 7 twelve-hour shifts, followed by 7 days off-duty. The accident occurred during the pilot's last shift for the seven-day work week. The pilot reported for duty on January 28, 2003, at 1900, after being off-duty for 12 hours. According to company personnel rec