WPR16FA037

The pilot's loss of control and collision with terrain while attempting a course reversal after inadvertently entering an area of reduced visibility weather conditions. Contributing to the accident was the pilot's lack of recent experience with night time operations.

The commercial pilot of the helicopter air ambulance flight, which was operating under visual flight rules, departed in night visual meteorological conditions (VMC) to transport a patient from Porterville, California, to a hospital in Bakersfield, California; a flight nurse and a paramedic were also aboard the helicopter. GPS data indicated that, after takeoff, the helicopter proceeded on a southerly course paralleling a highway and ascended to a maximum GPS altitude of 1,554 ft with groundspeeds varying between 124 and 144 mph. About 13 minutes after takeoff, the helicopter began to descend; 20 seconds later, the helicopter entered a left descending turn with groundspeeds that initially increased and then decreased. According to the last 6 seconds of GPS data, the descent rate of the helicopter was about 2,210 ft per minute. Although both the departure airport and an airport near the helicopter's intended destination reported VMC shortly after the accident flight began, no recorded weather observation stations were located along the route of flight. Meteorologists at the National Weather Service field office nearest to the accident site indicated that the conditions at the time and the location of the accident were conducive to fog. They also referenced a Twitter post from an individual that observed fog in the area of McFarland, however the Twitter post was unavailable. The pilot of the helicopter that located the wreckage about 1 hour, 51 minutes after the accident reported ground fog in the area. In addition, that pilot stated that he encountered heavy rainfall in the general search area. Thus, it is likely that the accident pilot encountered an area of reduced visibility due to rain or fog. Examination of the accident site indicated that the helicopter impacted open, sparsely populated, unlit, and hilly terrain in a descending left turn. Postaccident examination of the helicopter structure, systems, and engine revealed no evidence of any anomalies that would have precluded normal operation. The operator used two Bell 407 helicopters for helicopter air ambulance operations; one was equipped with an advanced (glass cockpit) instrument display system (the accident helicopter), and one was equipped with analog instruments. A review of the pilot's logbook and company records revealed that the pilot had primarily flown the Bell 407 helicopter that was equipped with analog instruments. The pilot's commercial pilot certificate included an instrument helicopter rating, so he most likely had the operational skills necessary to safely conduct a flight in a familiar helicopter. However, during the almost 7 months preceding the accident, the pilot had 11.2 hours of total flight experience in the accident helicopter that included 2.3 hours of night flight time, of which 2 hours comprised of night flight training and night vision goggles (NVG) training about 4 months before the accident. The pilot had logged .3 hours of night time in the accident helicopter 48 hours prior to the accident.  Thus, the pilot lacked recent nighttime experience with the accident helicopter's advanced avionics, which may have increased his susceptibility to spatial disorientation or loss of control during maneuvering flight.

HISTORY OF FLIGHT On December 10, 2015, at 1903 Pacific standard time, a Bell 407 helicopter, N408FC, was destroyed when it impacted terrain during cruise flight near McFarland, California. The commercial pilot, flight paramedic, flight nurse, and patient sustained fatal injuries. The helicopter was registered to American Airborne EMS, Fresno, California, and was operated by Rogers Helicopters, Inc., doing business as SkyLife, under the provisions of 14 Code of Federal Regulations Part 135 Air Medical Flight as call sign SkyLife 4. Night visual meteorological conditions prevailed, and a company visual flight rules (VFR) flight plan was filed. The cross-country flight originated from the Porterville Municipal Airport (PVT), Porterville, California, at 1849 with an intended destination of San Joaquin Community Hospital, Bakersfield, California. Information provided by the helicopter operator, the Federal Aviation Administration (FAA), and local law enforcement officials indicated that the helicopter was initially dispatched from Visalia Municipal Airport (VIS), Visalia, California, to facilitate the transfer of a patient from PVT to a hospital helipad in Bakersfield. Data recovered from a handheld Garmin GPSMap 396 GPS unit revealed that the helicopter departed from VIS about 1734, arrived at PVT about 1756. The operator's check pilot stated that he talked with the accident pilot via telephone about 1800. During this conversation, the accident pilot told the check pilot that he had just arrived at PVT and had checked the weather for Bakersfield, noting that visibility of 6 miles had been reported. The check pilot expressed his concern that the weather would be worse in the area than predicted. The accident pilot agreed and stated that he would carefully check the weather for the flight. The flight departed from PVT at 1849:47. The recorded data showed that the helicopter was on a southerly course, along State Highway 65, and that the helicopter ascended to a GPS altitude of about 1,000 ft for the first 6 minutes 11 seconds of the flight with groundspeeds that varied between 125 mph and 141 mph. Beginning at 1855:58, the helicopter continued along a southerly course and began to ascend, reaching a maximum GPS altitude of 1,554 ft at 1902:43; the groundspeed varied between 124 and 144 mph. Between 1903:08 and 1903:20, the helicopter's GPS altitude decreased from 1,535 to 1,476 ft, and the groundspeed increased from 135 to 138 mph, while the helicopter flew along a magnetic heading of 185°. At 1903:28, the helicopter began a left turn while descending through 1,300 ft at a groundspeed of 141 mph. The last three recorded data points—at 1903:32, 1903:35, and 1903:38—showed that the helicopter continued to descend; the GPS did not indicate a groundspeed for the last data point, which was recorded when the helicopter was about 590 ft southwest of the accident site. The calculated rate of descent for the last three data points was 2,210 ft per minute. Figure 1 shows the GPS-derived data points between 1902:43 and 1903:38. At 1927, the dispatcher radioed the pilot to determine the flight's status but did not receive a response. The dispatcher contacted personnel at the destination hospital and Meadows Field Airport (BFL), Bakersfield, California, and learned that the flight had not reached the intended destination. An FAA alert notification was issued at 2034, and the helicopter wreckage was located by pilots in a sheriff's office helicopter at 2054. The pilot-in-command of the sheriff's office helicopter reported that, during the search for the accident helicopter, he observed dense ground fog between 200 and 500 ft above ground level and encountered heavy rainfall. Figure 1. Final eight GPS-recorded data points.PERSONNEL INFORMATION The pilot, age 49, held a commercial pilot certificate with rotorcraft helicopter and instrument rotorcraft ratings and a flight instructor certificate with rotorcraft helicopter and instrument helicopter ratings. He held a second-class medical certificate dated April 8, 2015, with the limitation "must wear corrective lenses." Company records and the pilot's most recent logbook showed that the pilot was hired on August 15, 2012 and conducted mostly ferry flights and LIDAR utility work in Bell 206 and McDonnell Douglas MD530 and MD500 helicopters. On June 4, 2015, the pilot was reassigned to the Bell 407 with a special training authorization for emergency medical services. Before his employment with Rogers Helicopters, the pilot conducted air tours mostly in the Airbus Helicopters AS350 BA helicopter. According to his most recent logbook, with entries dated from August 27, 2009, to December 10, 2015 the pilot had accumulated 11,415.3 hours of total flight experience, 159.3 hours of which were at night. The logbook also showed that, between August 27, 2009, and the accident date, the pilot had accumulated 17.8 hours of night flight experience; 4 hours of flight in actual instrument conditions; and 55.3 hours of simulated instrument time, including 0.5 hours in the accident helicopter between May 30 and June 4, 2015. Between May 28, 2015, and the accident date, the pilot had accumulated 48.8 hours of total flight experience in the Bell 407, 11.2 hours of which were in the accident helicopter. During this timeframe, he accumulated 15 hours of night flight time, including 2.3 hours in the accident helicopter, which comprised 2 hours of night training that included 0.78 hours of night vision goggle (NVG) training. During the 90 days that preceded the accident, the pilot had accumulated 5.2 hours of night flight time, including 0.3 hours in the accident helicopter 2 days before the accident. A review of FAA records indicated that the pilot had not flown a helicopter equipped with advanced avionics (glass cockpit displays) before his first flight in the accident helicopter. During a postaccident interview, the pilot's wife reported that he expressed numerous concerns about not having NVG. She stated that the pilot had started, but had not yet completed, company NVG training. In addition, she stated that the pilot's night training was limited but that, with his skill level, he was "fine" with night flying; however, he wasn't comfortable flying at night without the use of NVG's. A company pilot also reported that the accident pilot expressed concern about flying near terrain in the area during periods of darkness without the use of NVG's. AIRCRAFT INFORMATION The accident helicopter, serial number 53450, was configured for helicopter air ambulance (HAA) operations. The FAA type certificate required one flight crewmember (a pilot) and permitted operations under day or night visual flight rules (VFR). The helicopter was equipped with a Garmin G500H glass cockpit system, which was installed in February 2013. As shown in figure 2, the system comprised a Garmin GDU 620 primary flight display and multifunction display, a Garmin GRS 77 attitude heading reference system (AHRS), and a Garmin GDC 74 air data computer. The helicopter also had an analog airspeed indicator and altimeter; however, no additional attitude reference instruments were installed. The helicopter was also configured for the use NVG's. Figure 2. Garmin G500H system similar to that installed in N408FC (the accident helicopter) , Obtained from Garmin.Com. The helicopter was powered by a Rolls-Royce model M250-C47B turboshaft engine, serial number CAE-847778, with maximum takeoff and maximum continuous power ratings of 650 and 600 shaft horsepower, respectively. A review of the airframe logbooks showed that the helicopter's most recent annual inspection completed on June 1, 2015, with an airframe total time of 9,017.5 hours. The pilot primarily flew another company Bell 407 helicopter, N101HF, that was also configured for HAA operations. As shown in figure 3, this helicopter had analog instruments and no