WPR21FA143

The pilot’s failure to adequately respond to an encounter with whiteout conditions, which resulted in the helicopter’s collision with terrain. Contributing to the accident was the (1) operator’s inadequate pilot training program and pilot competency checks, which failed to evaluate pilot skill during an encounter with inadvertent instrument meteorological conditions, and (2) the Federal Aviation Administration principal operations inspector’s insufficient oversight of the operator, including their approval of the operator’s pilot training program without ensuring that it met requirements. Contributing to the severity of the surviving passenger’s injuries was the delayed notification of search and rescue organizations.

A local lodge had contracted with the helicopter operator to transport passengers from a private residence to a heli-ski area at a nearby mountain. The surviving passenger stated that, before the last ski run of the day, the pilot attempted to land on a ridgeline but that the helicopter lifted off for an attempted second landing. The passenger also stated that, during the second landing attempt, the snow was “real light” but that the helicopter became “engulfed in a fog which made it appear like a little white room.” The helicopter subsequently began “going backward real fast” and impacted the ridgeline and rolled backward down the mountain. Postaccident examination of the airframe and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation of the helicopter. The passenger’s recollection of the conditions just before the accident was consistent with whiteout conditions caused by rotor wash while the helicopter was hovering near the ridgeline. Thus, the pilot likely experienced whiteout conditions during the second landing attempt, which caused him to lose visual reference with the ridgeline and resulted in the helicopter impacting terrain. Title 14 Code of Federal Regulations Part 135 required flight-locating for the helicopter in case it was overdue so that information about the helicopter’s location could be reported to a Federal Aviation Administration (FAA) or a search and rescue facility. The helicopter operator stated that it had delegated the responsibility for flight-locating to the local lodge. However, this delegation was not documented in the company’s FAA operations specifications or general operations manual, as required by Part 135. On the day of the accident, the local lodge was providing flight-following for the accident helicopter, which, unlike flight-locating, was not required by Part 135. The helicopter was expected to depart the heli-ski area for the principal operations base once all the ski runs had been completed. The flight-follower informed his supervisor that 40 minutes had elapsed since the helicopter moved from its last recorded position and that there had been “no positive comms” with the ski guide during the last 1.5 hours; this notification was made 41 minutes after the last “ping” from the helicopter. However, the remote area in which the accident flight was operating had limited communication capabilities, and no clear evidence indicated that an accident had occurred. The flight-follower’s supervisor contacted another heli-ski company to help determine the status of the helicopter. The heli-ski company considered the flight to be “ops normal” and expected that the last lift would occur shortly. The supervisor instructed the flight-follower to “keep an eye on” the accident helicopter; however, the lodge’s emergency response plan stated that a search and rescue facility should be contacted “if communication with the helicopter is not established by the end of the prearranged [time] or 30-minute grace period.” Therefore, it would have been reasonable for the lodge to activate its emergency response plan at this point given that the helicopter’s location was unknown at the time. The flight-follower continued to try to reach the helicopter but was unsuccessful. About 90 minutes after the last flight-following “ping” for the helicopter, the lodge received erroneous information from the heli-ski operator that the accident helicopter was “inbound” for the private residence; however, lodge personnel did not realize that this information was not accurate and that the accident had occurred immediately after the last ping. This incorrect information likely played a role in the lodge’s further delay in activating its emergency response plan. About 1 hour and 50 minutes after the accident (and the last flight-following ping), the heli-ski operator notified the accident helicopter operator about the overdue aircraft. Five minutes later, the lodge notified the helicopter operator that it was activating its emergency response plan. About 2 hours after the accident occurred, the helicopter operator activated its emergency response plan. About 17 minutes later, the helicopter operator notified the Alaska Rescue Coordination Center. The director of operations for the helicopter operator stated that the search and rescue notification did not occur before that time because he had been “working through the information that was provided” about the helicopter. The helicopter wreckage was located about 3.5 hours after the accident. Rescue personnel launched within 1 hour of notification and arrived on scene less than 30 minutes later (about 5 hours 40 minutes after the accident). The surviving passenger was transported via helicopter to a local hospital. Upon arrival at the hospital, the surviving passenger had hypothermia and severe frostbite. A shorter exposure to the cold would likely have decreased the severity of the surviving passenger’s injuries. However, a faster emergency response time (and thus shorter exposure to the cold) could only have occurred if the notification to search and rescue personnel had been timelier. Thus, because the lodge and the helicopter operator did not activate their emergency response plans sooner, the initiation of search and rescue operations was delayed. Given the circumstances of this accident, the investigation considered three types of training that the pilot should have received: inadvertent instrument meteorological conditions (IIMC) training; controlled flight into terrain-avoidance (CFIT-A) training, during which instruction in whiteout conditions would be conducted; and ridgeline training. Review of the operator’s pilot training program showed that ridgeline training was not provided for the make and model of the accident helicopter (or the previous helicopter in which the accident pilot had been trained). Further, IIMC training was a part of CFIT-A training, and the CFIT-A manual stated that pilots were required to complete IIMC training annually. However, the chief pilot for the helicopter operator stated that the related test for pilots (to demonstrate understanding of the subject) was only administered when a pilot was first hired, and the director of operations stated that the company’s only IIMC flight training involved recovery from unusual attitudes. In addition, review of the accident pilot’s flight training records found that he completed IIMC training 14 months before the accident (which was about 1 year after he began working for the operator), but the records did not reflect the specific IIMC training that the pilot received. Based upon the information provided by the operator, it could not be determined if the accident pilot had fulfilled the training requirement. The director of operations reported that the helicopter operator did not accomplish flight training as part of its CFIT-A training; however, flight training was not required for that subject, and the pilot received CFIT-A ground training. The CFIT-A manual stated that, if inadvertent whiteout conditions were encountered, the pilot was to rely on flight instruments and carefully attempt to maneuver the helicopter away from obstacles and terrain. Additional review of training records revealed that, during competency checks, the helicopter operator was not evaluating several requirements of 14 CFR 135.293, including recovery from IIMC, navigation, air traffic control communication, and instrument approach flying. Paragraph (c) of the regulation required a pilot to demonstrate the ability to maneuver the helicopter into visual meteorological conditions after a simulated encounter with IIMC, a skill that was needed during the accident flight. The operator stated that it did not have any instrument-flight-rules (IFR) aircraft capable of IFR approaches, but the GPS mod

A review of the pilot’s training records indicated that he completed recurrent training on January 21, 2021, including a pilot competency check and a line check, as required by 14 CFR 135.293 and 135.299, respectively. In addition, the pilot completed CFIT-A ground training in January 2021 and IIMC flight training in January 2020. Records showed that the IIMC flight training lasted 1 hour and covered “T/R [tail rotor] failures, autorotations, emergency ops.” The records did not indicate the specific IIMC training that the pilot received, and no other record was found showing IIMC flight training for the pilot. The IIMC flight training also included pinnacle landings and slopes and heli-ski and snow operations. Pilot The State of Alaska Medical Examiner’s Office in Anchorage performed an autopsy of the pilot. His cause of death was multiple blunt force injuries. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory detected no tested for substances. Ski Guides According to the autopsy inspection report (which comprised an external examination only) issued by the State of Alaska Medical Examiner’s Office, the senior lead guide’s cause of death was blunt force head injury. Toxicology tests performed by NMS Labs identified the following in the senior lead guide’s blood specimen: amphetamine at 96 ng/ml, cocaine at 52 ng/ml, and the inactive cocaine metabolite benzoylecgonine at 1,000 ng/ml. The autopsy inspection report for the other lead guide showed that his cause of death was multiple blunt force injuries. Toxicology tests of the lead guide’s blood specimen performed by NMS Labs identified delta 9-tetrahydrocannabinol (THC), the primary psychoactive component in cannabis, at 1.1 ng/ml. Amphetamine is a central nervous system stimulant drug that is available by prescription for the treatment of attention deficit disorder and narcolepsy. It carries a boxed warning about its potential for abuse and has warnings about an increased risk of sudden death and the potential for mental health and behavioral changes. In some preparations, a prescription drug is metabolized to amphetamine; commonly marketed names include Adderall, Dexedrine, and Vyvanse. Amphetamine may also be produced and used illicitly. Cocaine is another central nervous system stimulant drug. Initial effects of cocaine use include euphoria, excitation, general arousal, dizziness, increased focus, and alertness. At higher doses, effects can include psychosis, confusion, delusions, hallucinations, fear, antisocial behavior, and aggressiveness. Late effects, beginning within 1 to 2 hours after use, include depression, agitation, nervousness, drug craving, fatigue, and insomnia. Additional performance effects would be expected after higher doses, with chronic ingestion, and during drug withdrawal, including agitation, anxiety, distress, inability to focus on divided-attention tasks, inability to follow directions, confusion, hostility, time distortion, and poor balance and coordination. THC's mood-altering effects include euphoria and relaxation. Also, THC can cause alterations in motor behavior, perception, cognition, memory, learning, endocrine function, food intake, and body temperature regulation. Specific performance effects may include a decreased ability to concentrate and maintain attention. In addition, impairment in retention time and tracking, subjective sleepiness, distortion of time and distance, vigilance, and loss of coordination in divided-attention tasks have been reported. Significant performance impairments are usually observed for at least 1 to 2 hours after marijuana use, and residual effects can occur for up to 24 hours. THC may be detected at low levels in the blood for days or weeks after use. The accident helicopter was equipped with a Garmin Aera 660 GPS, which was certified for visual flight rules (VFR) flight but had the capability to display IFR procedures and maps. The helicopter was also equipped with a Kannad 406-MHz AF Compact emergency locator transmitter (ELT) that was installed on the upper right side of the right baggage compartment. Aerial assessment of the accident site on the day after the accident revealed that the helicopter impacted terrain about 15 to 20 ft below the top of the ridgeline. The main wreckage came to rest on its right side about 500 ft downslope from the initial impact area, as shown in figure 2. The debris field extended about 900 ft downslope from the top of the ridgeline. Figure 2. Accident site (Source: Alaska State Troopers). Postaccident examination of the airframe and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation of the helicopter. The ELT’s installed location (the upper right side of the right baggage compartment) was found packed with snow. The ELT remained secured to its airframe mount via a velcro strap. The ELT’s antenna coaxial cable and remote cockpit control wiring remained connected. The ELT switch was found in the ARM position. The external antenna had been fractured from its mount and was not located. Postaccident testing of the ELT found that it was working properly and that the ELT had transmitted during and after the accident sequence for 178 hours (12,884 bursts at 50-second intervals). On March 27, 2021, about 1836 Alaska daylight time, an Airbus Helicopters AS350-B3, N351SH, was substantially damaged when it was involved in an accident near Palmer, Alaska. The pilot and four passengers were fatally injured, and one passenger was seriously injured. The helicopter was operated under Title 14 Code of Federal Regulations (CFR) Part 135 as an on-demand air charter flight. Representatives from the operator, Soloy Helicopters, reported that the helicopter was under contract to Tordrillo Mountain Lodge (TML) to transport passengers from a private residence on Wasilla Lake, Wasilla, Alaska, to the Chugach Mountains to conduct heli-ski operations. (The Organizational and Management section of this report provides additional information about Soloy Helicopters and TML.) According to Heli Ski US (HSUS), which is a trade association that promotes helicopter skiing safety and provides support, heli-ski operations involve a “helicopter [that] is utilized to provide up-hill transportation for participants” of “guided winter recreation activities including, but not limited to skiing.” GPS data showed that the helicopter arrived at the Wasilla Lake residence about 1450. About 53 minutes later, the helicopter departed the residence and flew toward the Chugach Mountains. The surviving passenger recalled “nice” but “kind of creepy weather” in the mountains, which delayed the departure for the ski trip. The helicopter arrived at the intended operating area about 19 minutes later and subsequently flew multiple runs between about 1612 and 1807. GPS data showed that the helicopter departed for the last run of the day at 1827:05 on a northwest heading and climbed to about 5,900 ft mean sea level (msl). The helicopter's final movements began about 1833 over a ridgeline at an altitude of 6,266 ft msl (about 14 ft above ground level) and at a groundspeed of 1 knot. The helicopter maintained its low altitude and groundspeed as it maneuvered over the ridgeline. The data track ceased at 1836:42 near the location of the accident site, which is shown in figure 1. Figure 1. Location of departure point, previous operating areas, and the accident site. The surviving passenger stated that the passengers had completed five or six runs and that the accident occurred while the helicopter was relocating for the last run of the day. The surviving passenger also stated that the pilot first attempted to land the helicopter normally on the ridgeline but that the helicopter subsequently “went up to try to get into the right position.” The surviving passenger further stated that the snow w