Primary finding
Probable cause
An in-flight encounter with ground level fog due to the pilot's decision to continue VMC flight into instrument conditions, resulting in an in-flight collision with trees.
Investigator assessment
Analysis narrative
According to a witness, N525BM, operated by the North Carolina Forest Service, departed Macon County Airport, Franklin, North Carolina, on September 7, 2000, about 0850 into visual flight rules weather. The FAA flight service stations had been promulgating "Airmet Sierra" warning of low ceilings and mountain obscurations for the Franklin/Waynesville area from 2000 of the night of September 6, 2000, to 1000 of the morning of September 7. The flight followed highway 23/74 to Sylva, continuing toward Waynesville's Haywood County Mountain Research Station where the rotorcraft, its onboard fire fighting equipment, and crew were to serve as a static display for school children. About 5 minutes out, the pilot radioed the Haywood County Forest Ranger who had the landing zone secured for his arrival that he would put the rotorcraft down and wait for unexpected fog to lift. Residents in West Waynesville saw and heard the rotorcraft try to pick its way in very heavy ground fog. The rotorcraft collided with trees in mountainous terrain south of West Waynesville at the 4,400-foot level. Examination at the crash site and factory examinations of the engine and rotor mast revealed no precrash mechanical malfunctions. Use of over-the-counter pharmaceutical compounds of cold and allergy medicines were found in toxicological testing of specimens of the pilot.
Source record
Factual narrative
HISTORY OF FLIGHT On September 7, 2000, about 0905 eastern daylight time, a Bell UH-1H, N525BM, registered to the USDA Forest Service, operated by the North Carolina Forest Service as a Title 14 CFR Part 91 positioning flight, crashed while maneuvering in the vicinity of Waynesville, North Carolina. Instrument meteorological conditions prevailed and no flight plan was filed. The rotorcraft was destroyed, and the commercially rated pilot and a crew chief sustained fatal injuries. The flight departed Macon County Airport, Franklin, North Carolina, under Forestry Service flight following about 0840. The same pilot, crewman, and rotorcraft, had spent the previous day at the same location displaying the machine and its onboard fire fighting equipment as part of a 2-day Conservation Day display for Haywood County fifth-grade students. Although the North Carolina Forest Service normally operates their fire-fighting aircraft as strickly "public use", the positioning to a static display would have been performed under the provisions of Federal Air Regulations, Part 91. According to a Haywood County forest ranger located at the Haywood County Mountain Research Station, Waynesville, who was securing the landing zone, (LZ) for the rotorcraft's arrival, at about 0900, the pilot advised by radio that he was 5 minutes from landing, following highway 23-74 inbound from the southwest, but that ground fog was precluding his progress, and that he would look for a place to land until the fog lifted. The pilot asked for the weather conditions at the LZ and was given, ceiling, 500 to 1,000 feet and 1-mile visibility. There was no acknowledgement. Beginning about 0910, numerous telephone calls started coming into the Haywood County 911 operator about a low flying helicopter near residences in West Waynesville, (about 3,600 feet elevation). Statements from three witnesses positioned outside, nearby their residences at about 0900, along the rotorcraft's flight path just before the crash, stated the rotorcraft's course from their first sighting to the crash site was generally southwesterly and then southerly through a ravine called the Redbank Branch. One witness stated the rotorcraft flew by her driveway, "at an extremely low altitude" and, "There are power lines in back of the house and he couldn't have been more than 20 feet above them." Following the near miss, she heard a definite change of rotor blade pitch, and the flight disappeared into the fog. The visibility was characterized as, "extremely foggy" and, "...so thick, I couldn't see 50 yards away". A witness further along in the helicopter's flight path could clearly make out the N-numbers on the rotorcraft as it hovered over her driveway, and the sighting gave her the impression that she should ask her sister to move her car so the rotorcraft could land. Soon after its departure up the ravine she heard the definite sounds of blades hitting trees just before the cessation of engine sounds, altogether. Reference to a topographical map of the crash site revealed that the terrain rises 800 feet within a horizontal distance of 2,375 feet in the direction that she observed the flight continue. The direction of flight stated by the witnesses represents a course away from the known landing zone. The wreckage was located by North Carolina Forestry Service pilots in dense forest the next day about 1210. PERSONNEL INFORMATION The pilot held a private pilot certificate for airplane, single-engine land, and a commercial certificate for airplane, multiengine land and helicopter, with instrument ratings, airplane and helicopter. His most recent FAA second-class medical certificate was issued on April 26, 2000, with no limitations. According to North Carolina Forestry Service pilot employment records, as of August 3, 1999, the pilot listed his flight time as: 1,893 hours-helicopter, 523 hours-single engine, and 638 hours-multiengine for a total of 3,054 flight hours. He had held USDA/USDI Bell 206 series helicopter qualification for reconnaissance and surveillance, mountain flying, snow operations, external load (sling), fire suppression, retardant/water dropping, and long line. He held USDA/USDI copilot qualifications for the C-130, P2V, and PB4Y type aircraft from 1995 to 1997. He spent 6 years 3 months as an Army UH-1H and CH-47D helicopter pilot, and was honorably separated from the Army Reserve as a Chief Warrant Officer-2 on February 28, 1994. On June 14 and 15, 2000, the pilot satisfactorily completed a UH-1H flight procedures training course given by the Bell Helicopter Customer Training Academy at the North Carolina Forestry Service, Fayetteville, North Carolina. The flight portion of the course consisted of three flights, and the remarks annotated on the training form by the instructor were, "flight procedures refresher complete. Safe in all maneuvers. A pleasure to fly with." On November 5, 1999, the pilot underwent a North Carolina Forestry Service proficiency check flight. The comments section of the evaluation form stated, "Tim gave a good ride". One of the procedures on the form, "Inadvertent IMC Proc" was not checked. AIRCRAFT INFORMATION The 1966 Bell UH-1H helicopter, serial No. 66-16023, was military excess, operated by the North Carolina Forestry Service as "Helicopter 9", for the primary purpose of forest fire fighting. The maintenance program used by the forestry service was in accordance with U.S. Army TM 55-1520-210-PM series phase inspections. The rotorcraft was placed into forestry service in 1993, and had undergone a transmission change in March 2000. At the time of the accident, the airframe had accumulated about 6,350 hours and the T53-L-13B turbine engine, ser. No. LE21527, which was installed on November 18, 1998, had accumulated about 849 hours. The rotorcraft had undergone a phase inspection, (phase #4) on March 16, 2000, by the North Carolina Forestry Service at an aircraft total time of 6278.1 hours. The rotorcraft's altimeter and static system had been tested and certified in accordance with FAR 91.411 on January 19, 1999, although the pilots and helicopters of the North Carolina Forestry Service have no requirement to maintain instrument flight currency. Firefighting tools aboard N525BM for static display were the following: (1) two 240- gallon flexible water buckets called the "Bambi Bucket", (2) parachutes for dropping cargo and, (3) an assortment of fire extinguishers, hand tools, markers, and chain saws. METEOROLOGICAL INFORMATION The nearest weather reporting facility was Asheville, elevation 2,165 feet, located about 25 miles to the east of the crash site. The 0854 weather observation was: winds calm, visibility 10 statute miles, 1,500 feet overcast, temperature 58 degrees, dew point 56 degrees, altimeter 30.33 inHg. A 1,500-foot overcast condition translates to solid clouds at ground level at an elevation of 3,665 feet or higher. The wreckage site elevation was about 4,400 feet. Ashville's reported 0954 weather revealed lowering ceiling and visibility. There was an FAA Automated Flight Service Station (AFSS) promulgated Airman's Meteorological Information, (AIRMET) in effect for the area that included the origination and the destination of the flight. It first came out as "AIRMET Sierra" warning of mountain obscuration for the period 09/06/00 @ 2000 to 09/07/00 @ 0400, and was subsequently extended to 09/07/00 @ 1000. A copy of the AIRMET is included as an attachment to this report. A forestry service pilot stated that, generally speaking, Macon County Airport was usually the first place affected by low ceilings and fog, and that if you could make it out of there under visual flight rules, the rest of the area would be as good or better. WRECKAGE AND IMPACT INFORMATION The crash site was located about a mile south and upslope of milepost 441 on the Blue Ridge Parkway at the 4,400-foot level of the Pinnacle Ridge in the Great Balsa