MIA00GA184

the pilot's failure to maintain control of the helicopter for undetermined reasons. Factors in this accident were self-induced pressure and fatigue due to lack of sleep and rest.

During a fire-fighting flight, witnesses observed the helicopter heading back towards the fire with an external bucket of water. The helicopter was seen in level flight heading in a northeasterly direction away from the lake were the bucket was refilled. A witness said the helicopter banked steeply and went into a nose-low attitude until it disappeared behind trees. Shortly after disappearing behind the trees, the witnesses heard the sound of impact. An aircraft mechanic, who saw the pilot before the flight stated, "...[the pilot]...complained that someone...at 1230 AM...woke him up to tell him they wanted him in at 8:00 AM. He mumbled something about sleepwalking. That he couldn't get back to sleep...I cautioned him about the heat and told him not to overwork himself." On Saturday June 3, 2000, the day before the accident the pilot had put in a 14 hour 20 minute workday, and 3 hours of that was flight time after 1800. According to the pilot's medical records he had been under treatment for chronic hepatitis C, and had been taking interferon for his disease. According to the pilot's girlfriend's statement, "...[the pilot] stopped taking all medications prior to August 1998...during the period of August 1998-June 2000, [the pilot] did not see a doctor for any reason, [the pilot] knew his condition was worsening...the [pilot] would have his good days and his bad, but would still push himself to the limit of almost shear exhaustion, and then almost collapse and rest on days off to maintain his physical ability to work for the State......[the pilot] was an alcoholic and would not drink for any reason...[the pilot] was extremely tired the morning of June 4, 2000, when she dropped him off at...[the] airport...[he] had a poor night sleep and was still aggravated from receiving the midnight phone call from the...dispatch." A search of the pilot's last FAA flight physical, dated November 9, 1999, did not indicate any pre-exiting disease. However medical records obtained from the Tallahassee, Florida, Veterans Administration, Out Patient Clinic, revealed the following; "[Patient] on interferon for hep c [hepatitis...advised to continue medication, interferon...results showed some changes...and...to continue interferon as ordered...family member took message that labs ok to continue Rx as ordered." The pilot was transferred to Fort Myers on November 1, 1999, and the VA Out Patient Clinic at Fort Myers had no record of the pilot at their facility. The following medical information it was extracted from the medical records maintained on the pilot by the FAA Civil Aeromedical Institute Aeromedical Certification Division: Applications for 2nd Class Airman Medical Certificates on November 25, 1997, November 9, 1998, and November 9, 1999 each indicate "no" under item 17 ("Do you currently use any medication") and under item 18 ("Have you ever had or have you now any of the following") for sections ("stomach, liver, or intestinal trouble") and x ("other illness, disability, or surgery"). The following information was extracted by the NTSB Medical Officer, from the report of autopsy performed on the pilot by the Office of the District Medical Examiner in Fort Myers, Florida: - Under "Microscopic Examination" is noted, "LIVER: Cirrhosis, portal triads with chronic inflammatory cells, micro and macrovesicular steatosis and focal areas of congestion." The most common symptom of chronic hepatitis C is fatigue. Interferon therapy is often used in individuals with hepatitis C, and had been prescribed by the VA for the pilot. There were, however, no recent medical records to suggest that the pilot had continued that therapy or to indicate how his liver was functioning at or near the time of the accident. The autopsy findings indicate that his disease had progressed to cirrhosis, but the cirrhosis was not noted to be severe. FAA Aviation Medical Examiners are instructed to deny or defer medical certification to the FAA Aeromedical Certification Division for any airmen who have chronic hepatitis with impaired liver function. Examination and test on the Collective Servo Actuator, the Cyclic Servo Actuator, the hydraulic pump, the hydraulic shut-off valve, the engine, and the Bambi (water) Bucket, revealed no discrepancies other then impact damage.

HISTORY OF FLIGHT On June 4, 2000, about 1030 eastern daylight time, a Bell UH-1H, N127FC, registered to and operated by the United States Department of Agriculture Forest Service as a Title 14 CFR Part 91 public-use local flight, crashed 10 miles south of Southwest Florida International Airport, Fort Myers, Florida. Visual meteorological conditions prevailed, and a company flight plan was filed. The commercial-rated pilot sustained fatal injuries. The flight originated in Fort Myers, the same day, about 0820. The helicopter was operating as a fire-fighting flight, and had been in the area of a fire for about 1 1/2 hours. The accident occurred after the pilot had refilled the water in the external bucket, and was returning to the fire after filling up at the lake/pond. Witnesses observed the helicopter in level flight heading in a northeasterly direction away from the lake/pond. A witness said the helicopter banked steeply and went into a nose-low attitude until it disappeared behind trees. Shortly after disappearing behind the trees, the witnesses heard the sound of impact. In addition, the witness said, "I saw Helicopter 27 head back to the fire with a full bucket of water, I saw him go down over the pond...and come up with water in it. I saw water trailing the helicopter and the bucket." A Forestry Service, aircraft mechanic, who saw the pilot before the flight stated, "...I walked into the hangar at 6:45 [0645] [the pilot] was here, complained that someone from Forestry called him at 12:30 [0030] and woke him up to tell him they wanted him in at 8:00 AM. He mumbled something about sleepwalking. That he couldn't get back to sleep. [The pilot] took my truck and went to McDonalds...[pilot] returned with our breakfast, [and] we ate...[the pilot] moved the aircraft to fuel it, I watched him from 3 feet away. He did everything right, and made a normal takeoff. He returned about an hour later...to pick up a helmet and headset. I cautioned him about the heat and told him not to overwork himself." The accident occurred during the hours of daylight about 35 degrees, 27 minutes North, and 085 degrees, 06 minutes West. PERSONNEL INFORMATION The pilot's personal logbook listing his flight hours was not recovered. Based on company records the pilot had all of his flight hours in helicopters. It was estimated that the pilot had about 4,000 hours of total flight time. His employment with the Department of Forestry started on December 23, 1991, and he was transferred to Fort Myers, Florida, November 1999. The pilot received his initial flight training in the United States Army. METEOROLOGICAL INFORMATION The weather conditions at Fort Myers, about 10 miles north of the crash site, about the time of the accident were VFR, with a reported visibility of 10 miles; winds were from 030 degrees at 4 knots. The temperature was 84 degrees F, and the dew point was 75 degrees F. MEDICAL AND PATHOLOGICAL INFORMATION Dr. Rebecca A. Hamilton performed an autopsy on the pilot, on June 5, 2000, at the Lee-Hendry County Medical Examiner's Office, Fort Myers, Florida. According to the autopsy report, the cause of death was "Multiple blunt force injuries." Toxicological tests were conducted at the Federal Aviation Administration, Research Laboratory, Oklahoma City, Oklahoma, and revealed, "No ethanol or drugs detected." A search of the pilot's last FAA flight physical, dated November 9, 1999, did not indicate any pre-existing disease. However medical records obtained from the Tallahassee, Florida, Veterans Administration, Out Patient Clinic, revealed the following; "Progress Notes...Note date: 06/22/1998...09:25...General note...Visit: 06/22/1998...GMED/Nursing...Pt [Patient] on interferon for hep c [hepatitis C]. Most recent Labs done 6/1 topc [Tallahassee Veteran's Administration Outpatient Clinic] showed several improved values. Called home today to report ok and continue Rx. Family member who answered thought pt still taking Rx, but away now, firefighting...Note dated 05/28/1998...phone call to pt home-wife took message. Advised to continue medication, interferon, but platelets low so may bruise easily, be careful...Note date: 05/11/1998...Pt had labs drawn @TOPC [Tallahassee Veteran's Administration Outpatient Clinic] 5/5/98. Results showed some changes...and Pt to continue interferon as ordered...family member took message that labs ok to continue Rx as ordered." The pilot was transferred to Fort Myers on November 1, 1999, and the VA Out Patient Clinic at Fort Myers had no record of the pilot at their facility. The NTSB Medical Officer, extracted the following medical information from the pilot's medical records obtained under subpoena from the Tallahassee Veteran's Administration Outpatient Clinic: June 11, 1998 - Nurse's note indicates "... labs ... showed some changes ... patient to continue interferon ... PLT 114, T.BILI 1.0, D.BILI 0.5, AST 88, ALT 90, remainder basically same..." June 22, 1998 - Nurse's note indicates "Patient on interferon for hepatitis C. Most recent labs ... showed several improved values ... HCT 42.1, WBC 7.2, PLT 142, T.BILI 0.8, D.BILI 0.5, ALK 117, AST 50, ALT 46." The NTSB Medical Officer, from the medical records maintained on the pilot by the FAA Civil Aeromedical Institute Aeromedical Certification Division, extracted the following medical information: Applications for 2nd Class Airman Medical Certificates on November 25, 1997, November 9, 1998, and November 9, 1999 each indicate "no" under item 17 ("Do you currently use any medication") and under item 18 ("Have you ever had or have you now any of the following") for sections ("stomach, liver, or intestinal trouble") and x ("other illness, disability, or surgery"). The following information was extracted by the NTSB Medical Officer, from the report of autopsy performed on the pilot by the Office of the District Medical Examiner in Fort Myers, Florida: - Under "External Examination" is noted, "...massive traumatic damage of the face and skull..." - Under "Internal Examination" is noted, "... Remnants of the 1790-gram liver have a diffusely nodular, yellow tan, firm surface. The cut hepatic surfaces are minimally congested, yellow tan, extremely firm and diffusely nodular." - Under "Microscopic Examination" is noted, "LIVER: Cirrhosis, portal triads with chronic inflammatory cells, micro and macrovesicular steatosis and focal areas of congestion." According to the medical records the pilot had been under treatment for chronic hepatitis C. The most common symptom of that disease is fatigue. Interferon therapy is often used in individuals with hepatitis C, and had been prescribed by the VA for the pilot. There are, however, no recent medical records to suggest that the pilot had continued that therapy or to indicate how his liver was functioning at or near the time of the accident. The pilot's girlfriend told investigators that he stopped taking his medication prior to August 1998. The autopsy findings indicate that his disease had progressed to cirrhosis, but the cirrhosis was not noted to be severe. FAA Aviation Medical Examiners are instructed to deny or defer medical certification to the FAA Aeromedical Certification Division for any airmen who have chronic hepatitis with impaired liver function. WRECKAGE AND IMPACT INFORMATION The helicopter impacted in a pasture, north of Burgundy Farms Road. The pasture was a large open field located north of a second field. A wooded area separated both fields. South of the crash site was a hedgerow of brush, which ran east and west, and was not dense. Both areas were searched for helicopter parts, and none were found. The pasture that the helicopter impacted in consisted of numerous small ditches that ran north and south. The ditches were uniformly spaced from each other. About 1 mile west of the crash site was the lake/pond th