DEN08FA101

The pilot's failure to identify and arrest the helicopter's descent, which resulted in its impact with terrain. Contributing to the accident was the limited outside visual reference due to the dark night conditions.

This report was updated on August 14, 2009. An Emergency Medical Services (EMS) flight dispatch was requested from the accident operator, since a previous EMS operator had "aborted" the same requested mission flight. The EMS operator, who had "aborted" the same mission approximately one hour and 30 minutes prior to the accident flight, reported low clouds in the vicinity of the accident site. No PIREP was reported with the FAA. Official weather reporting stations in the area recorded visional flight rules weather conditions. The pilot contacted his company's operations control center and discussed observed weather and the reasoning for the "turndown" by the other EMS operator. It was agreed that weather observation stations were reporting visual flight rules weather conditions and the flight was accepted. The EMS flight powered up for the accident leg at 0244:11 and departed at 0246:56. The onboard flight tracking system recorded the flight until 0247 to an altitude of 1,016 feet mean sea level (600 feet above the ground), on a flight path of 170 degrees. The wreckage was located 2.5 miles southwest of the last known coordinates in densely forested terrain, the next morning, in the exact location where the other EMS operator had encountered low clouds and lost their reference to surface light sources. Sheared tree tops indicate initial impact occurred with the helicopter's main rotor blade system, in a straight, nose low attitude. The flight path terrain was dark, without surface reference lights, and there was no moon. The accident helicopter was equipped with the Aviation Night Vision Imaging System and radar altimeter; however the settings on the radar altimeter could not be established and the pilot was not utilizing night vision goggles. The helicopter was not equipped with Helicopter Terrain Awareness Warning System (HTAWS). The pilot was appropriately trained and certified to fly the accident flight. An examination of the helicopter airframe, engine, and related systems revealed no anomalies.

This report was updated on August 14, 2009. On June 8, 2008, at 0248 central daylight time, a Bell 407 emergency medical services (EMS) helicopter, N416PH, owned by PHI, Inc., and operated by PHI as Med 12, was destroyed when it impacted a heavily forested area in the Sam Houston National Forest, south of Huntsville, Texas. Dark night visual meteorological conditions prevailed at the time of the accident. The air ambulance flight was being operated under the provisions of Title 14 Code of Federal Regulations Part 135 on a company visual flight rules (VFR) flight plan. The pilot, flight nurse, flight paramedic, and passenger were fatally injured. The flight had departed the Huntsville Memorial Hospital Heliport (KTE03) at 0246, after picking up a patient, and was en route to the John S. Dunn Helistop (K38TE) at the Herman Memorial Hospital, Houston, Texas. The flight to K38TE was 68.7 nautical miles on a magnetic bearing of 168.1 degrees. The accident helicopter was equipped with a Global Positioning System (GPS) flight tracking system referred to as "Outerlink." According to the Outerlink system, the helicopter powered up for flight at 0244:11 and departed the hospital at 0246:56. The last coordinates recorded by the Outerlink system were recorded at 0247 at an altitude of 1,016 feet mean sea level (approximately 600 feet above ground level (agl)), while traveling at a groundspeed of 106 knots. The calculated direction of flight was 170 degrees. Med 12's first position report was due at 0300. According to an emergency room clerk at Memorial Hospital - The Woodlands, the accident flight contacted him over the radio to place his hospital on standby for the patient. A female provided a patient assessment and during the radio call a male voice could be heard. It could not be distinguished what the male voice was saying. The radio call became unreadable and did "not come back." Memorial Hospital - The Woodlands Heliport (K26TS) was located 36.5 miles from KTE03 on a magnetic bearing of 166.8 degrees. He could not recall the exact time. At 0259, one minute prior to Med 12's required position report, the Air Force Rescue Coordination Center contacted the PHI Communications Center in Lafayette, Louisiana, regarding an emergency locator transmitter signal they were receiving, registered to N416PH (Med 12). Search and rescue efforts were initiated immediately and multiple attempts to communicate with the missing helicopter were made. The wreckage was located by aerial search and rescue teams at 0830, about 2.5 miles southwest of the last known coordinates, with the aid of the 406 MHz emergency locator transmitter (ELT). The National Transportation Safety Board (Safety Board) Investigator in Charge (IIC) interviewed several witnesses. These witnesses were located to the north of the impact location. According to one witness, between 0245 and 0300 he heard a helicopter fly over his home with "high pitch" sounds. He stated that helicopters fly over his house all the time; however, this one woke him up, as it was loud. He assumed that the helicopter was flying relatively low, as it was vibrating his house. PERSONNEL INFORMATION The pilot, age 63, held an airline transport pilot certificate with a rotorcraft helicopter rating last issued on November 21, 1991. He was issued a second class airman medical certificate on March 13, 2008. The certificate contained the limitation "holder shall wear corrective lenses." The pilot was hired by PHI Inc, in January 1976. According to PHI's records, the pilot had logged no less than 20,537 hours flight time in rotorcraft; 200 of which was in the make and model of the accident helicopter, and no less than 224 hours at night. The pilot had been flying EMS operations for PHI for 18 months and had accumulated 205.5 hours in EMS operations; 36 hours of which were in the past 90 days and 5.4 hours at night. Their records reflect that the pilot had accepted 36 night flights within the previous 18 months. The pilot's airman competency/proficiency check for CFR 135.293 (Initial and recurrent pilot testing), and 135.299 (Pilot in command: Line checks: Routes and Airports) was completed with a satisfactory rating in all tested areas on November 17, 2007. The flight check was conducted in a Bell 407 helicopter in daylight conditions. Transition training to EMS operations was performed in November of 2006. At this time, night operations training was conducted. According to PHI's records, the pilot had been on the day shift (0700 to 1900) from May 15th through the 28th, 2008. He started duty for the night shift (1900 to 0700) on May 30, 2008, had two days off, and then continued with the night shift until June 8, 2008. Following his rotation to the night shift, the pilot had logged one hour and 27 minutes of flight time on the shift prior to the accident. In addition he logged 25 minutes on the night of the accident, while positioning the helicopter from his base to the hospital. The pilot had not been trained for the use of NVIS. According to PHI's director of safety, there were no safety issues or occurrences that involved the pilot, prior to the accident. AIRCRAFT INFORMATION The accident helicopter, a Bell 407 (serial number 53276), was manufactured in 1998. It was registered with the FAA on a standard airworthiness certificate for normal operations. The helicopter was powered by a Rolls-Royce turbo shaft C-47B engine rated at 650 shaft horsepower. The helicopter was registered to and operated by PHI Inc. of Lafayette, Louisiana, and was maintained under an Approved Inspection Program (AAIP), by PHI out of the Bryan, Texas, base. A review of the maintenance records indicated that an AAIP, event two inspection had been completed on April 16, 2008, at an airframe total time of 6,141 hours and 8 minutes. The helicopter had flown approximately 92 hours and 11 minutes between the last inspection and the accident and had a total airframe time of 6,233 hours and 19 minutes. The helicopter was equipped with the Aviation Night Vision Imaging System (cockpit lighting system that is compatible with night vision goggles) in April 2008 and had a Free Flight radar altimeter installed. The helicopter was not equipped with Helicopter Terrain Awareness Warning System (HTAWS). METEOROLOGICAL INFORMATION The Safety Board IIC interviewed the pilot for Memorial Herman Life Flight that had accepted the same patient transfer flight the morning of the accident. According to this pilot, the weather en route to Huntsville, Texas, was VFR. Prior to his flight, the lowest weather reported for his entire flight was at Huntsville and at the time of the report, the weather was "better than 2,000 [ceiling] and ten [miles visibility]." He departed Memorial Herman at 0106 and flew GPS direct towards Huntsville. There were no traffic or weather concerns at the time of his departure. While en route, approximately 5 miles south of the hospital (KTE03), at 1,400 feet he encountered "wispy clouds." He descended to 1,200 feet and encountered more clouds, continued to descend, to 1,000 feet, encountered more clouds, and finally descended to 800 feet when the visibility decreased rapidly. He stated that he could see to the east but had lost his "surface light reference." He turned immediately to the right, towards the "freeway system" and was immediately back in good weather. He stated that the low clouds and visibility were "pretty sudden and pretty dramatic." The flight was aborted after encountering the weather. Upon his return, he entered this information into a pilot website "weatherturndown.com." The Terminal Aerodrome Forecast (TAF) for KUTS forecasted winds at 140 degrees at seven knots, visibility greater than six miles, and broken clouds at 1,500 feet for the time period just prior to the accident. The area forecast for southern Texas forecasted cloud cover at 2,000 feet above ground level. The outlook w