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N992AA accident description

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Tail numberN992AA
Accident dateOctober 15, 2008
Aircraft typeBell 222
LocationAurora, IL
Near 41.769445 N, -88.245555 W
Additional details: None

NTSB description

The following is an INTERIM FACTUAL SUMMARY of this accident investigation. A final report that includes all pertinent facts, conditions, and circumstances of the accident will be issued upon completion, along with the Safety Board's analysis and probable cause of the accident. ------------------------------------------------------------------------------------------------------

HISTORY OF FLIGHT

On October 15, 2008, at 2358 central daylight time, a Bell 222 helicopter, N992AA, operated by Air Angels Inc., and piloted by a commercial pilot, was destroyed when it impacted a radio station tower and the ground in Aurora, Illinois. A post crash fire ensued. The emergency medical services (EMS) transport flight was conducted under 14 Code of Federal Regulations Part 135, and was en route from the Valley West Hospital Heliport (0LL7), Sandwich, Illinois, to the Children’s Memorial Hospital Heliport (40IS), Chicago, Illinois, when the accident occurred. Night visual meteorological conditions prevailed in the area of the accident site. All four occupants, including the pilot, a flight paramedic, a flight nurse, and the patient, were fatally injured. The flight originated about 10 minutes prior to the accident.

Reach dispatch (Air Angels flights were dispatched by Reach Air Medical Services in Santa Rosa, California) was notified of the need for EMS transport at 2112 and opened a case record at that time. At 2113, the flight was accepted by Air Angels; however, the flight did not depart the Air Angels base in Bolingbrook, Illinois until 2254. The flight had been delayed until a receiving hospital could be identified. At 2311, N992AA arrived at 0LL7. At 2338, the pilot made a flight following call to Reach dispatch as required in Reach/Air Angels protocol. The flight following call was made prior to takeoff from 0LL7.

At 2355, the pilot checked in with the DuPage Airport (DPA) air traffic control tower (ATCT) and reported his position, "over Aurora," and that the helicopter was at 1,400 feet above mean sea level (msl). Radar data showed that at the time of the radio call to DPA ATCT, the helicopter was about 12 nautical miles (nm) and 066 degrees from the departure heliport. Radar data showed that the helicopter continued on a 072 degree magnetic heading. The radar data showed the helicopter in straight and level flight at an altitude of 1,300 feet MSL. The radar track ended at 2358:25 and the location of the last radar return coincided with the location of a radio station antenna tower.

PERSONNEL INFORMATION

The pilot, age 69, held a commercial pilot certificate with rotorcraft-helicopter and instrument helicopter ratings. The certificate also listed private pilot privileges for single-engine land airplanes. The pilot's most recent second class medical certificate was issued in January 2008 and stated that the pilot must wear corrective lenses for near and distant vision.

The pilot was hired by Air Angels in July 2006. A review of the pilot's Air Angels training records indicated that he had accumulated 3,564.7 flight hours total time including 3,182.7 hours in helicopters and 382 hours in fixed wing aircraft. While employed by Air Angels he had accumulated 282.7 hours in the Bell 222 including approximately 50 hours and 23 hours in the preceding 90 and 30 days respectively.

Training records showed that the pilot completed new hire and initial training in July 2006 and his most recent recurrent training was accomplished in August 2008. The pilot's most recent annual line check (FAR Part 135.299) was completed on September 25, 2008.

The pilot resided in Carmel, Indiana, approximately 200 miles southeast of the Air Angels base of operations. Due to this, the pilot would not commute to his home during his duty week and would stay in a bunk room located at the Air Angels facility. On the night of the accident, the pilot was one day into his second week of night shift work. The pilot did not fly on the night before the accident and his most recent flight was on October 13, 2008, with 54 minutes of flight time. A review of the pilot's activities during the 72 hours prior to the accident revealed that he maintained his normal routine and stayed in the bunk room at Air Angels during the day. According to other employees at Air Angels, the pilot appeared well rested and his demeanor seemed normal when he reported for his shift on the accident date.

The Air Angels DFO reported that the accident pilot was a very experienced helicopter pilot having flown helicopters during Vietnam. The DFO reported that the pilot looked forward to flying each day and was conscientious and flew landing approaches in a slow meticulous manor. The DFO reported that during the pilot's most recent line check, they received a call for a patient transport and the pilot performed the flight in accordance with the company’s general operating manual and he observed that the pilot did use the helicopter's autopilot function during the en route phase of the flight.

AIRCRAFT INFORMATION

The helicopter was a Bell 222, serial number 47062. It was configured for medical transport of a single patient on a gurney. Air Angels acquired the helicopter in February. 1999. The crew consisted of a single pilot, flight nurse, and paramedic. A review of the helicopter's maintenance records revealed that it had 5,302.6 hours total time as of October 14, 2008. The helicopter had two Lycoming LTS-101-650C engines. The number 1 engine had 5,694.0 hours total time, and the number 2 engine had 3,717.1 hours total time. The most recent phase inspection was performed on September 24, 2008, at 5,270.9 hours total airframe time.

During the flight following call, the pilot reported the weight of the helicopter as 7,635 pounds, the center of gravity (CG) at 251.7 inches and a CG range of 247.65 to 256.0 inches. The Bell 222 Flight Manual, limitations section listed the maximum gross weight for takeoff and landing as 7,850 pounds. Referring to the Bell 222 Flight Manual gross weight center of gravity chart, the CG that the pilot reported was within the normal operating limits as defined by that chart.

The helicopter had been equipped with a Garmin GNS 430, which was a combined GPS, navigation, and communications radio that was mounted into the instrument panel. The maintenance records included a FAA form 337 (Major Repair and Alteration) that documents the GNS 430 installation on April 8, 1999, and a placard reading "GPS not approved for IFR operation" had been placed on the instrument panel. The GNS 430 software was updated on January 9, 2008. The DFO and Director of Maintenance (DM) stated that the GNS 430 was configured with the Jeppesen aviation database, last updated on June 1, 2008. Although the GNS 430 could display terrain and obstacles, the software for that function was not installed, and had never been installed. The DFO stated that the GNS 430 was their primary source of navigation information.

The helicopter was equipped with four radios, which were normally set to the following: local ATC frequency, on the GNS 430, dispatch on a Kenwood radio, and 123.025 (helicopter air-to-air common) on the third radio. The medical crewmembers had a Technosonic radio in the cabin that they would use to communicate with the hospital.

COMPANY INFORMATION

Air Angels Inc was a commercial on demand air taxi operator. The company was established in 1998 and operated out of Clow International Airport, Bolingbrook, Illinois. Air Angels received its FAR Part 135 Operating Certificate, number X34A833I, on March 11, 1999. The company provided air and ground critical care transportation throughout Northern Illinois and Northwest Indiana.

At the time of the accident Air Angels operated two Bell 222 helicopters and had recently purchased an additional Bell 222 that was being outfitted for medical transport. In June 2007, Reach Medical Holdings, Inc. acquired Air Angels. Reach was a California based company that operates numerous medical transport companies throughout the United States. Air Angels employed 3 pilots, 3 full time mechanics, 1 part time mechanic, and 10 to 12 full time medical personnel. The company's Chief Pilot had just left the company a week prior to the accident to pursue different employment. The Director of Air Operations took on the responsibilities of the Chief Pilot until they could find a replacement.

Air Angels operated in accordance with FAA approved Operations Specifications (Ops Spec) for Part 135 operations under certificate number X34A833I. The latest Ops Spec revision was dated August 8, 2008. Contained in the Ops Spec was authorization for visual flight rules (VFR) day and night operations with nine or less passengers. Conducting flights under instrument flight rules (IFR) was not authorized when exercising their Part 135 certificate.

Air Angels utilized an approved training program as required by 14 CFR Part 135.341. The training manual contained sections addressing new hire training, initial aircraft training, recurrent training, requalification training, transition training, and upgrade training. Within each of these training categories, subject matter regarding ground training, emergency training, flight training, differences training, testing and checking were outlined. Additionally an appendix contained maneuver diagrams, check airman and instructor training, a list of company instructors, and company training forms. The FAA approved the training manual on October 5, 2001, and the latest revision was revision seven, dated August 1, 2008.

The Director of Flight Operations (DFO) managed and exercised operational control of Air Angels aviation operations and was responsible for crew scheduling. The DFO started working for Air Angels early in 2004. He became the Chief Pilot in June 2004, and then became the DFO in July 2006. He was a former Army aviator and the majority of his 6,900 flight hours were in helicopters. He held an airline transport pilot certificate (ATP), and was the company's check airman. The pilots were normally scheduled for a week on (7 days), week off (7 days) schedule, with a crew day consisting of a 12-hour shift, from 0700 to 1900, and 1900 to 0700. The duty schedule consisted of alternating a week of day shift, followed by week of night shift. When the Chief Pilot left the company the number of company pilots was reduced from four to three. To cover the schedule with three pilots, the DFO requested the other two pilots perform an extra week of duty until another pilot could be hired, effectively extending one of their duty periods from 7 days to 14 days. The accident pilot volunteered to extend his week on the night schedule an additional week.

Air Angel flights were dispatched from the Reach Air Medical Services office in Santa Rosa, California. The dispatch office received requests for medical transport and helped coordinate with the sending and receiving facilities. Reach dispatch kept a detailed log of all coordinating activities and aircraft status. Once a receiving facility was identified dispatch would contact the duty pilot via a dedicated cell phone and brief him regarding the sending and receiving facility details. The duty pilot would check the weather along the route of flight and report back to dispatch accepting or rejecting the flight based on weather. A formal risk assessment was not an action required to be performed by the pilot. Once the flight had been accepted, dispatch then briefed the medical crew about the condition of the patient being transported. Once airborne, the pilot communicated with dispatch utilizing a dedicated radio in the helicopter that transmitted to a repeater, which then routed the communications through a VOIP (voice over internet protocol) connection to Santa Rosa. While en route to the sending facility, the paramedic usually sat in the right hand seat and assisted the pilot with radios and visual lookout. While transporting the patient, both the flight nurse and paramedic were in the cabin with the patient.

Before takeoff, the pilot was required to check in to dispatch with a flight following call. The flight following call included the following information; total take-off weight, helicopter center of gravity (CG) and CG range, destination, estimated time en route (ETE), souls on board, and fuel (time). Every 15 minutes the pilot was required to send dispatch a position report. The position report included the following information; latitude, longitude, estimated time of arrival (ETA), ground speed, and heading.

The Chief Pilot said that he had never experienced a problem communicating with dispatch using this system. The en route segment of the flight was usually flown around 1,500 feet mean sea level (msl) during the day and 1,500-1,700 feet msl at night; 1,800 feet msl would usually provide 1,000 feet agl for the local area. Airspeed was normally between 125 and 130 knots, 90% engine torque.

COMMUNICATIONS

At 2338:25, the pilot contacted Reach dispatch for his pre-takeoff flight following call. The call included the following information: Initial heading 080 degrees; distance 38 miles; estimated time en route 18 minutes; destination-Children's Memorial Hospital; 4 people onboard; 1.5 hours fuel onboard.

At 2355:21, the pilot of N992AA, identifying himself as Lifeguard Angel 1, contacted DuPage ATCT. The controller acknowledged the transmission. At 2355:28, the pilot stated, "Ah sir we are just over Aurora en route to Children's Hospital ah downtown Chicago at about 1,400 feet." At 2355:36, the controller responded, "Lifeguard Angel 1 cleared through the delta current altimeter 3014." The pilot acknowledged the altimeter setting at 2355:42. At 2358:26, an unidentified transmission similar to "ahhhhhhhh" was heard on the frequency. There were no further contacts with the aircraft.

METEOROLOGICAL CONDITIONS

At 1152, the reported weather conditions at the DuPage Airport, about 8 nautical miles north of the accident, were: winds 330 degrees at 8 knots; visibility 10 statute miles; clear skies; temperature 9 degrees Celsius (C); dew point 5 degrees C; altimeter 30.14 inches of Mercury (in. Hg).

At 1152, the reported weather conditions at the Aurora Municipal Airport, about 10 nautical miles west of the accident, were: winds 340 degrees at 5 knots; visibility 9 statute miles; clear skies; temperature 7 degrees C; dew point 6 degrees C; altimeter 30.15 in. Hg.

At 1151, the reported weather conditions at the O’Hare Airport, about 20 nautical miles northeast of the accident, were: winds 350 degrees at 11 knots; visibility 10 statute miles; 3,300 feet overcast ceiling; temperature 10 degrees C; dew point 5 degrees C; altimeter 30.13 in. Hg.

At 1145, the reported weather conditions at the Lewis University Airport, about 12 nautical miles southeast of the accident, were: winds 340 degrees at 9 knots gusting to 14 knots; visibility 10 statute miles; 1,900 foot broken ceiling, 2,400 foot overcast ceiling; temperature 11 degrees C; dew point 8 degrees C; altimeter 30.12 in. Hg.

WRECKAGE AND IMPACT INFORMATION

The helicopter impacted the ground in a forest preserve. The terrain at the location was flat with prairie grass that stood about 6 feet high

A 734-foot tall radio station tower was impacted on its west side about 50 feet from the top of the tower. The tower structure had buckling of the vertical structure. The tower was supported by guy-wires that extended from the tower structure at an outward angle toward the ground. The uppermost guy-wire on the west side of the tower was severed and found lying on the ground. The tower was equipped with a high intensity strobe lighting system with the one set of strobes installed at the top of the tower and another set installed about 2/3 of the height of the tower. The conduit that contained the electrical wiring that supplied power to the strobe light system was severed about 50 feet from the top of the tower and the strobe lighting system was not operational after the accident. The distance and direction from the radio station tower to the main wreckage site were about 1,250 feet and 070 degrees respectively.

The helicopter was severely fragmented and also suffered damage due to fire. The vertical t

(c) 2009-2011 Lee C. Baker. For informational purposes only.