Primary finding
Probable cause
The pilot's failure to maintain aircraft control resulting in the helicopter impacting the water. Factors contributing to the accident were the pilot's inadvertent flight into instrument meteorological conditions, the low ceiling, dark night conditions, and the pilot's lack of recent instrument flying experience.
Investigator assessment
Analysis narrative
The EMS helicopter departed in dark night visual meteorological conditions en route to pick up a patient. The helicopter approached the intended landing zone from the west and reported to approach control that he had the landing zone in sight when he was at 1,000 feet above ground level and approximately 4 miles west of the landing zone. Shortly after that, the helicopter began a left turn approximately two miles to the west of the landing zone, followed by a tighter radius right turn. Several radio recordings from the flight nurse onboard the helicopter were heard to transmit the following: "uh i got lights here...follow the uh the lights out...ok follow the lights out...we're in the clouds again we're gonna abort transport patient by ground." The last radar position was at an altitude of 1,000 feet. Several witnesses saw the lights of the helicopter fall almost straight down, and the helicopter wreckage exhibited damage consistent with a high speed, port side, inverted impact with water. No anomalies were noted with the airframe, systems, and engine. A review of the pilot's experience showed that his most recent actual instrument experience was in 1997 when he completed an instrument competency check in a single-engine airplane. The only instrument experience in a helicopter entered in the pilot's logbook within the past ten years was two entries of simulated instrument time of 0.8 hours in December, 2005. and 0.2 hours in September, 2007.
Source record
Factual narrative
HISTORY OF FLIGHT On February 5, 2008, at 2054 central standard time, a Eurocopter France AS350B2 emergency medical service (EMS) helicopter, N911VA, operated by Metro Aviation, Inc., Shreveport, Louisiana, and was registered to Harlingen Comm Emergency Care Foundation, Inc., doing business as Valley Air Care, Harlingen, Texas, impacted the Laguna Madre near South Padre Island, Texas. The helicopter was destroyed. The airline transport pilot, flight nurse, and flight paramedic sustained fatal injuries. Visual meteorological conditions prevailed, and a company flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 flight. The helicopter departed the Valley Baptist Medical Center Heliport (49TX), Harlingen, Texas, at 2040 and was en route to pick up a patient at an emergency landing zone in the parking lot of the South Padre Island Convention Center at South Padre Island, Texas. The flight to the emergency landing zone at South Padre Island from 49TX was 26.7 miles on a magnetic course of 88 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 2037:09 and departed the 49TX helipad at 2040:35. At 2041:12, the pilot using the call sign Air Care One, contacted the controlling Federal Aviation Administration (FAA) air traffic control facility, Valley Approach Control, located in the Corpus Christi Air Traffic Control Tower, Corpus Christi, Texas, and initiated visual flight rules (VFR) flight following for the flight to the destination landing zone. At 2052:24, the pilot told Valley Approach Control "...air care one has the landing zone in sight we're out of nine hundred for landing padre island." Beginning at 2053, the flight nurse on board made several transmissions on the MedCom radio. At 2053:01, he said, "uh i got lights here," then "(unintelligible) follow the uh the lights out," followed by "ok follow the lights out," and at 2053:23, he said "(unintelligible) we're in the clouds again we're gonna abort transport patient by ground." Valley Approach Control's radar system recorded a radar hit every 5 seconds. The first radar contacts with the helicopter began at 2040:38 as it departed the 49TX helipad. The radar data showed the helicopter was generally eastbound until it was about 2 miles west of the intended destination and then made a left turn back westbound followed by a tighter radius right turn. Emergency responders waiting for the helicopter at the emergency landing zone saw the helicopter go down and immediately notified the 911-call center. An immediate search began, and search and rescue teams located the wreckage at 2320, about 2.4 miles west of the destination landing zone. According to several witnesses located near the destination landing zone, they saw the lights of the helicopter fly eastbound toward the landing zone and then make a left turn westbound. One of those witnesses remembers seeing the lights on the helicopter go almost straight down and shortly afterward heard the sounds of impact. Another witness staying in an RV camping area about 500 feet from the destination landing zone had watched several times before when medical helicopters came in to meet the ground ambulance and saw the lights of the accident helicopter fly toward the convention center parking lot, but it did not descend as it normally did. The helicopter then made a left turn and headed back to the west. Shortly after the helicopter departed to the west, she saw lights spiraling down, and shortly after that, she heard the sounds of impact. Another witness was standing in a parking lot behind a restaurant approximately one mile south of the intended landing zone. He was watching the accident helicopter approach the island from the west when it made a turn back to the west and appeared to not be descending to land. He recalled that there were clouds above and it was windy, but the visibility was good. PERSONNEL INFORMATION The pilot, age 55, held an airline transport pilot certificate dated April 3, 2003, with ratings in airplane single-engine land, rotorcraft helicopter, and with commercial privileges in airplane multi-engine land, and airplane single-engine sea. He was issued a second class airman medical certificate on December 11, 2007. The medical certificate contained the limitation "must wear corrective lenses." Metro Aviation, Inc., initially hired the pilot as an EMS helicopter pilot at the Harlingen base, in December 2005, and he worked in that position until April of 2006. They rehired the pilot for the same position in September 2007. At the time of the accident, the pilot had logged 16,896 total hours; with a total of 11,518 hours in helicopters, 1,100 of which in the make and model of the accident helicopter, 18 hours of which were in the past 90 days, and 7 hours within the past 90 days at night. Metro Aviation, Inc. records showed that the pilot had no previous experience with night vision goggles (NVG) and he had not previously been trained in the use of NVGs. The pilot's logbook shows he had logged a total of 115 hours of actual instrument flying experience and 46 hours of simulated instrument experience. In 1997, the pilot logged 3.1 hours of actual instrument experience in a single-engine airplane during an instrument competency check. In 2003, the pilot logged 9.5 hours of simulated instrument experience when he completed training and a practical test for his airline transport pilot rating for single-engine land airplanes. The only instrument experience in a helicopter entered in the pilot's logbook within the past ten years was two entries of simulated instrument experience for Part 135 training and testing of 0.8 hours in December, 2005. and 0.2 hours in September, 2007. According to the pilot's logbook, he had a general pattern of employment of flying EMS helicopters during the winter months and agricultural airplanes during seasonal months. His pilot logbook showed he began flying AS350 helicopters at the Harlingen EMS base for Tex-Air Helicopters, Inc. a different Part 135 air carrier beginning in 1998. His logbook showed he had accumulated a total of 1,780 hours in EMS operations within the past twenty years. The pilot's most recent Part 135.293 competency check, and Part 135.299 line check was completed with a satisfactory rating in all tested areas on September 12, 2007. A Metro Aviation, Inc., check airman conducted the flight check in daylight hours in a Eurocopter France AS350B2 helicopter. According to company records, the pilot had seven consecutive days off ending on January 25, 2008, and would have been scheduled for another seven day rest period beginning at 0700, on the morning of February 8, 2008. He had been on the day shift (0645 to 1815) from January 25th through the 31st, 2008, and on February 1, 2008, he had started a seven-day period of duty for the night shift (1800 to 0700). AIRCRAFT INFORMATION The accident helicopter was a Eurocopter France AS350B2 model, S/N 2588, that had been converted from a Eurocopter AS350BA at the American Eurocopter facility, Grand Prairie, Texas, in June of 2007. The airframe had accumulated 10,307.3 hours total time at the time of the accident, with an engine total time of 218.8 (engine S/N 19124). The helicopter was configured with a right pilot seat, a swivel medical seat on the right side behind the pilot, and a medic jump seat on the center aft bulkhead. A stretcher extended from the left front cabin aft, with a Plexiglas shield to separate the patient from the pilot. The accident helicopter was equipped for NVG operations. METEOROLOGICAL INFORMATION National Weather Service (NWS) Surface Analysis for February 6, 2008, at 2100, showed a cold front just west of the accident site, which had moved well to th