DEN08MA116

Both helicopter pilots’ failure to see and avoid the other helicopter on approach to the helipad. Contributing to the accident were the failure of N407GA’s pilot to follow flight arrival route guidelines, and the failure of N407MJ’s pilot to follow communications guidelines requiring him to report his position within a minimum of 5 miles from the helipad.

Both Emergency Medical Services (EMS) helicopters were on approach to the Flagstaff Medical Center (FMC) helipad to drop off patients. During the flights, the N407MJ pilot had established two-way communications with his communications center and provided position reports, and the N407GA pilot had established two-way communications with FMC's communications center (which was his company's communication center and which also monitored and advised all traffic at the helipad) and provided position reports. The FMC communications center transportation coordinator advised the N407GA pilot that N407MJ would also be dropping off a patient at FMC. The coordinator also advised N407MJ's communication center that N407GA would be landing at FMC, but the N407MJ's communication center did not inform the N407MJ pilot nor was it required to do so. Established arrival and departure procedures for the FMC helipad required pilots to contact the FMC communications center at the earliest opportunity or at a minimum of 5 miles from the helipad. According to the FMC communications center's staff, N407MJ's pilot did not make the required contact with the communications center at any time during the flight. About 3 minutes before the collision, N407GA dropped off a medical crewmember at the local airport (about 5 miles south of the medical center) to reduce the weight on the aircraft and to improve aircraft performance during landing at the medical center. According to witness information, flight-track data, and a hospital surveillance video, N407GA approached the helipad from the south, flying past or slightly inside the southeast tip of the noise abatement area on a direct line toward a final approach position just east of the helipad. However, according to helipad arrival guidelines and company procedures, N407GA should have approached the helipad from farther to the east. (After the on-scene accident site investigation, the Air Methods regional chief pilot, accompanied by NTSB investigators, flew the accident route in another Air Methods Bell 407 using GPS data retrieved from N407GA. According to the regional chief pilot, the “trained route” was much farther to the east and not in a direct line to the hospital.) N407MJ approached the helipad from the northeast, and it is likely that the pilot would have been visually scanning the typical flight paths, as described in the noise abatement and helipad arrival guidelines, that other aircraft approaching the medical center would have used. Thus, if N407GA had approached from a more typical direction, the pilot of N407MJ may have been more likely to see and avoid it. At the time of the collision, both pilots were at a point in the approach where their visual attention typically would have been more focused on the helipad in preparation for landing, rather than on scanning the surrounding area for other traffic. The helicopters collided approximately 1/4 mile east of the helipad. There were no communications from either helicopter just prior to or after the collision. Neither helicopter was equipped with a traffic collision avoidance system, nor was such a system required. Had such a system been on board, it likely would have alerted the pilots to the traffic conflict so they could take evasive action before collision. No radar or air traffic control services were available for the helipad operations to ensure separation. However, if N407MJ's pilot had contacted the FMC communications center, as required, the FMC transportation coordinator likely would have told him directly that another aircraft was expected at the helipad. If the pilot had known to expect another aircraft in the area, he would have been more likely to look for the other aircraft. Nevertheless, the pilots were responsible for maintaining vigilance and to see and avoid other aircraft at all times. Under 14 Code of Federal Regulations Sections 91.111 and 91.113, all pilots are responsible for keeping a safe distance from other aircraft and for maintaining vigilance so as to see and avoid other aircraft. Advisory Circular 90-48C, "Pilots' Role in Collision Avoidance," amplifies the see-and-avoid concept by stating that all pilots should remain constantly alert to all traffic movement within their field of vision and that they should scan the entire visual field outside of their aircraft to ensure that conflicting traffic would be detected. Examination of the wreckages revealed that N407MJ's tail rotor contacted the forward fuselage of N407GA, and N407GA's main rotor blades contacted and separated N407MJ's tail boom. The recovered wreckages showed no evidence of any preimpact structural, engine, or system failures.

"THIS CASE WAS MODIFIED MAY 29, 2009." HISTORY OF FLIGHT On June 29, 2008, at 1547 mountain standard time, a Bell 407 emergency medical service (EMS) helicopter, N407GA, and a Bell 407 EMS helicopter, N407MJ, collided in mid air while approaching the Flagstaff Medical Center (FMC) helipad (3AZ0), Flagstaff, Arizona. Both helicopters were destroyed. N407GA's commercial pilot, flight nurse, and patient sustained fatal injuries; and N407MJ's commercial pilot, flight paramedic, flight nurse, and patient sustained fatal injuries. N407GA was operated by Air Methods Corporation, Englewood, Colorado, and registered to FMC, Flagstaff, Arizona. N407MJ was operated by Classic Helicopter Services, Page, Arizona, and registered to M&J Leisure, L.L.C., Ogden, Utah. Visual meteorological conditions prevailed, and company flight plans were filed for the 14 Code of Federal Regulations Part 135 air medical flights. N407GA's flight departed Flagstaff Pulliam Airport (FLG), Flagstaff, Arizona, at 1544, and N407MJ's flight departed the Grand Canyon National Park Service South Rim helibase, Tusayan, Arizona, at 1517. Audio recordings were obtained from Classic's communications center (Classic Control), Guardian Control, FMC, and the FLG Air Traffic Control Tower (ATCT). At 1516, the pilot for the Air Methods helicopter, N407GA, call sign Angel 1, contacted Guardian Control via aircraft radios and reported that they were departing Winslow, Arizona, with four people on board; the pilot, two flight nurses, and a patient. The pilot stated that his estimated time en route was 25 minutes and he was either going to land at FLG or at FMC. He was not sure if he would be at the proper weight to land with enough power to execute a safe out of ground effect hover at FMC with all four occupants onboard. At 1517, the pilot of Angel 1 contacted Guardian Control via onboard radios and requested the current weather conditions at FLG. The on-call transportation coordinator (TC) provided the requested information, and within two minutes, she contacted FMC and told them that Angel 1 was inbound to the helipad in approximately 23 minutes. At 1517, the pilot for Classic helicopter, N407MJ, call sign Lifeguard 2, contacted Classic Control via onboard radios and reported that they had departed the south rim of the Grand Canyon and were en route to the FMC with an estimated time of arrival of 32 minutes. There were four people on board; the pilot, a flight nurse, a flight paramedic, and a patient. Approximately one minute later, the pilot on Angel 1 called Guardian Control via onboard radios and reported that they were going to "drop one" at FLG before proceeding to FMC. At 1523, the dispatcher on duty at Classic Control contacted Guardian Control via landline and reported that Lifeguard 2 was en route to the FMC and would be arriving from the north. He also reported that it would be a "cold drop" and the emergency department at the hospital had already been notified. The Guardian Control TC then informed the Classic dispatcher that Angel 1 was also en route and would be landing at FMC in 20 minutes. The Classic dispatcher then stated, "Ohh okay, I'll let them know when I talk to them next, and I'll tell them to be sure and get a hold of you." At the end of this call, the Guardian Control TC called FMC's emergency department (ED) via land-line and stated that Lifeguard 2 would also be landing at the hospital in "about 28 minutes...and they know about mine coming in." The person who answered the landline responded, "All right." The TC then contacted the pilot of Angel 1 via onboard radio and informed him that Lifeguard 2 would also be landing at FMC in approximately 28 minutes. The Angel 1 pilot responded, "Roger will be looking for 'em thanks." At 1532, the pilot of Lifeguard 2 contacted Classic Control via onboard radios, provided a position report and said they were 15 minutes from landing at FMC. The dispatcher on duty responded, "Comm center copies all sir...I'll talk to you on the ground in 15 minutes, 1532." This was the last recorded communication from the Lifeguard 2 pilot. Also at 1532, the Angel 1 pilot contacted Guardian Control via onboard radios and reported that they were 10 minutes from landing at FLG in order to drop off a flight nurse due to weight considerations. At 1534, the Angel 1 pilot called Guardian Control via onboard radios and asked the TC to contact FMC and request additional ground support to assist in moving the patient from the helicopter. The TC then contacted FMC and made the request. At 1541, the Angel 1 pilot contacted the FLG ATCT via onboard radios and reported that he was one mile out. A controller provided traffic advisories and cleared Angel 1 to land. At 1543, the Angel 1 pilot contacted the FLG ATCT via onboard radios and said, "...Angel 1 would like to depart to the north to the hospital with foxtrot." A controller responded, "Lifeguard Angel 1 wind variable at five taxiway alpha cleared for take off northbound to the hospital approved." At 1544, the Angel 1 pilot contacted Guardian Control via onboard radios and stated, "Control Angel 1 if you haven't figured it out we've uh landed at the...airport departed and we're about two minutes out of the hospital." The TC responded and copied the transmission. This was the last recorded communication from the Angel 1 pilot. At 1550, the Classic dispatcher contacted Guardian Control via landline and asked the TC if she had had any contact with "my ship." The TC said, "negative." A review of the recorded transmissions made between both medical crews and the hospital revealed that both of the medical crews contacted the FMC ED and provided medical reports on their respective patients. A Classic medical crewmember contacted FMC via an onboard cellular phone at 1525. The conversation ended 1528, at which time the crewmember reported an estimated arrival time of 18 minutes, or 1546. The Air Methods medical crewmember contacted FMC via onboard radio (Med Channel 3/EMSCOMM) at 1532. The conversation ended at 1534; at which time the crewmember provided an estimated time of arrival of 15 minutes, or 1549. Each crewmember spoke with a different nurse and physician. A review of both transmissions indicated normal communications and that both patients were medically stable. The hospital staff that received the phone calls from both aircraft did not provide any information about the other helicopter that was also en route to the FMC. There is no requirement for FMC staff to provide arrival or departure information regarding other aircraft to medical flight crews. If any information is provided it is given as a courtesy only. A surveillance camera, mounted on a parking garage at FMC, captured the collision on digital video. The video depicted one helicopter approaching from north and one helicopter approaching from the south, and shows both aircraft descending after the collision. The NTSB Vehicle Recorders Laboratory, Washington, DC, examined the video, and extracted a series of still images which showed the collision sequence. N407GA was equipped with a GPS-based OuterLink tracking system that recorded the helicopter's position every 30 seconds. A review of the data revealed that N407GA flew in a straight line from FLG to the location of the accident site, about 1/4-mile east of the FMC helipad. The data indicated that the aircraft had not initiated a turn onto final approach when the data ended. N407MJ was equipped with a GPS-based Sky Router tracking system, which recorded the helicopter's position every five minutes. A review of the data revealed that the last recorded position was approximately ten miles northwest of the helipad. In addition, a Garmin GPSMAP 496 handheld GPS was located in the wreckage. The unit was shipped to the Vehicle Recorders Division at NTSB Headquarters, Washington, DC where it was d