NTSB Factual Report

"THIS CASE WAS MODIFIED MAY 29, 2009."

HISTORY OF FLIGHT

On June 29, 2008, at 1547 mountain standard time, a Bell 407 emergency medical service (EMS) helicopter, N407GA, and a Bell 407 EMS helicopter, N407MJ, collided in mid air while approaching the Flagstaff Medical Center (FMC) helipad (3AZ0), Flagstaff, Arizona. Both helicopters were destroyed. N407GA's commercial pilot, flight nurse, and patient sustained fatal injuries; and N407MJ's commercial pilot, flight paramedic, flight nurse, and patient sustained fatal injuries. N407GA was operated by Air Methods Corporation, Englewood, Colorado, and registered to FMC, Flagstaff, Arizona. N407MJ was operated by Classic Helicopter Services, Page, Arizona, and registered to M&J Leisure, L.L.C., Ogden, Utah. Visual meteorological conditions prevailed, and company flight plans were filed for the 14 Code of Federal Regulations Part 135 air medical flights. N407GA's flight departed Flagstaff Pulliam Airport (FLG), Flagstaff, Arizona, at 1544, and N407MJ's flight departed the Grand Canyon National Park Service South Rim helibase, Tusayan, Arizona, at 1517.

Audio recordings were obtained from Classic's communications center (Classic Control), Guardian Control, FMC, and the FLG Air Traffic Control Tower (ATCT).

At 1516, the pilot for the Air Methods helicopter, N407GA, call sign Angel 1, contacted Guardian Control via aircraft radios and reported that they were departing Winslow, Arizona, with four people on board; the pilot, two flight nurses, and a patient. The pilot stated that his estimated time en route was 25 minutes and he was either going to land at FLG or at FMC. He was not sure if he would be at the proper weight to land with enough power to execute a safe out of ground effect hover at FMC with all four occupants onboard.

At 1517, the pilot of Angel 1 contacted Guardian Control via onboard radios and requested the current weather conditions at FLG. The on-call transportation coordinator (TC) provided the requested information, and within two minutes, she contacted FMC and told them that Angel 1 was inbound to the helipad in approximately 23 minutes.

At 1517, the pilot for Classic helicopter, N407MJ, call sign Lifeguard 2, contacted Classic Control via onboard radios and reported that they had departed the south rim of the Grand Canyon and were en route to the FMC with an estimated time of arrival of 32 minutes. There were four people on board; the pilot, a flight nurse, a flight paramedic, and a patient.

Approximately one minute later, the pilot on Angel 1 called Guardian Control via onboard radios and reported that they were going to "drop one" at FLG before proceeding to FMC.

At 1523, the dispatcher on duty at Classic Control contacted Guardian Control via landline and reported that Lifeguard 2 was en route to the FMC and would be arriving from the north. He also reported that it would be a "cold drop" and the emergency department at the hospital had already been notified. The Guardian Control TC then informed the Classic dispatcher that Angel 1 was also en route and would be landing at FMC in 20 minutes. The Classic dispatcher then stated, "Ohh okay, I'll let them know when I talk to them next, and I'll tell them to be sure and get a hold of you."

At the end of this call, the Guardian Control TC called FMC's emergency department (ED) via land-line and stated that Lifeguard 2 would also be landing at the hospital in "about 28 minutes...and they know about mine coming in." The person who answered the landline responded, "All right." The TC then contacted the pilot of Angel 1 via onboard radio and informed him that Lifeguard 2 would also be landing at FMC in approximately 28 minutes. The Angel 1 pilot responded, "Roger will be looking for 'em thanks."

At 1532, the pilot of Lifeguard 2 contacted Classic Control via onboard radios, provided a position report and said they were 15 minutes from landing at FMC. The dispatcher on duty responded, "Comm center copies all sir...I'll talk to you on the ground in 15 minutes, 1532." This was the last recorded communication from the Lifeguard 2 pilot.

Also at 1532, the Angel 1 pilot contacted Guardian Control via onboard radios and reported that they were 10 minutes from landing at FLG in order to drop off a flight nurse due to weight considerations.

At 1534, the Angel 1 pilot called Guardian Control via onboard radios and asked the TC to contact FMC and request additional ground support to assist in moving the patient from the helicopter. The TC then contacted FMC and made the request.

At 1541, the Angel 1 pilot contacted the FLG ATCT via onboard radios and reported that he was one mile out. A controller provided traffic advisories and cleared Angel 1 to land.

At 1543, the Angel 1 pilot contacted the FLG ATCT via onboard radios and said, "...Angel 1 would like to depart to the north to the hospital with foxtrot." A controller responded, "Lifeguard Angel 1 wind variable at five taxiway alpha cleared for take off northbound to the hospital approved."

At 1544, the Angel 1 pilot contacted Guardian Control via onboard radios and stated, "Control Angel 1 if you haven't figured it out we've uh landed at the...airport departed and we're about two minutes out of the hospital." The TC responded and copied the transmission. This was the last recorded communication from the Angel 1 pilot.

At 1550, the Classic dispatcher contacted Guardian Control via landline and asked the TC if she had had any contact with "my ship." The TC said, "negative."

A review of the recorded transmissions made between both medical crews and the hospital revealed that both of the medical crews contacted the FMC ED and provided medical reports on their respective patients.

A Classic medical crewmember contacted FMC via an onboard cellular phone at 1525. The conversation ended 1528, at which time the crewmember reported an estimated arrival time of 18 minutes, or 1546.

The Air Methods medical crewmember contacted FMC via onboard radio (Med Channel 3/EMSCOMM) at 1532. The conversation ended at 1534; at which time the crewmember provided an estimated time of arrival of 15 minutes, or 1549.

Each crewmember spoke with a different nurse and physician. A review of both transmissions indicated normal communications and that both patients were medically stable.

The hospital staff that received the phone calls from both aircraft did not provide any information about the other helicopter that was also en route to the FMC. There is no requirement for FMC staff to provide arrival or departure information regarding other aircraft to medical flight crews. If any information is provided it is given as a courtesy only.

A surveillance camera, mounted on a parking garage at FMC, captured the collision on digital video. The video depicted one helicopter approaching from north and one helicopter approaching from the south, and shows both aircraft descending after the collision. The NTSB Vehicle Recorders Laboratory, Washington, DC, examined the video, and extracted a series of still images which showed the collision sequence.

N407GA was equipped with a GPS-based OuterLink tracking system that recorded the helicopter's position every 30 seconds. A review of the data revealed that N407GA flew in a straight line from FLG to the location of the accident site, about 1/4-mile east of the FMC helipad. The data indicated that the aircraft had not initiated a turn onto final approach when the data ended.

N407MJ was equipped with a GPS-based Sky Router tracking system, which recorded the helicopter's position every five minutes. A review of the data revealed that the last recorded position was approximately ten miles northwest of the helipad. In addition, a Garmin GPSMAP 496 handheld GPS was located in the wreckage. The unit was shipped to the Vehicle Recorders Division at NTSB Headquarters, Washington, DC where it was downloaded on June 30, 2008. Examination of the unit revealed that it was not programmed to record the helicopter's flight track and there was no usable stored data for the accident flight.

No Federal Aviation Administration (FAA) radar services were available for the airspace surrounding FMC.

One witness, located approximately 1 mile southwest of the accident site, observed the collision of the two helicopters. He observed "a light aircraft" traveling west to east. As the aircraft turned to the south, he noticed a second helicopter traveling from the east to the west. The first helicopter appeared to be at the same altitude as the second helicopter when it started a turn to the south. The witness stated, "I saw both aircraft on what appeared to be a collision course. From the angle I was at, the second helicopter (red and white) did not appear to change direction and the first collided with it."

Two other witnesses observed the collision from the back porch of their residence approximately 1/2 mile south and west of the accident site. They observed the [Air Methods] helicopter approaching from the south and east on a "usual landing pattern." One of these witnesses observed a second helicopter "approaching the other from the [right], back side" just prior to the collision. The other witness observed the second helicopter just as the helicopters collided.

Another witness observed the collision from her residence four-tenths of a mile north and west of the accident site. She first heard a helicopter approaching from the north. She then heard a second helicopter coming from the south. The witness stated that she "looked up just as the northbound helicopter apparently clipped the rotor of the southbound [helicopter]. At that time, they both were in a turn to the hospital."

Several people witnessed the collision and reported seeing both helicopters descending into wooded terrain about 1/2-mile east from the heliport. There was a small fire noted rising from the hilly terrain, followed by a loud explosion about ten minutes after the collision.

PERSONNEL INFORMATION

N470GA; Air Methods Corporation

Pilot Information

The pilot, age 51, held a commercial pilot certificate for single-engine land airplanes and rotorcraft-helicopters, and an instrument rating for both airplanes and helicopters. His most recent first-class medical certificate was issued on September 12, 2007, and contained the limitation of "Cleared Class I with near vision restriction."

A review of the pilot's last Flight Training and Qualification Record revealed that his last Airman Competency/Proficiency Check was accomplished on August 15, 2007. At the time of the accident, the pilot had accrued a total of approximately 5,241 hours, including 4,500 hours in helicopters.

In the previous three months, the pilot had accrued 150 hours, including 53 hours at night. During the last 30 days, the pilot flew 51 hours, including 19 hours at night. All of this time was accrued in the Bell 407. According to the company the pilot attended and satisfactorily completed all company initial, recurrent, and NVG training courses.

The pilot was hired on October 7, 2003, as a full-time EMS pilot flying the Bell 407 at the operator's base in Flagstaff, Arizona. When hired, the pilot had accrued a total of approximately 4,353.6 hours, including 341.2 hours as pilot-in-command (PIC) in the Bell 407. According to the operator, he did not work elsewhere as a pilot at the time of the accident.

During his tenure at Air Methods, he served as the Safety Officer and the Safety Coordinator, and was also night-vision goggle (NVG) qualified.

A search of the National Driver Register found no record of driver's license suspension or revocation.

Flight Nurse Information

The flight nurse, who was dropped off at FLG before the accident, was hired by FMC on June 26, 1995, as an emergency medical technician (EMT) with Guardian Medical Transport (GMT). On March 27, 2006, he became a flight registered nurse (RN).

The flight nurse had been employed with Northern Arizona Healthcare for four years and was authorized for medical flights on fixed-wing aircraft and helicopters. In the summer months, he normally worked onboard the helicopters because of his low body weight. He was considered a neo-natal specialist and received his training in the Army.

He worked a continuous 48-hour shift starting at 0800. He came on duty after four days rest at 0800 on the day of the accident. At the time of the accident, he had been on duty approximately seven hours and 44 minutes.

The flight nurse stated that the pilot came on duty at 0900. Prior to any flights that day, he had a conversation with the pilot, and the other flight nurse about a recent EMS accident that had occurred two days prior. They discussed what may have happened on that flight and how important it was to be safe since "they all wanted to go home at the end of their shift."

He always flew with another flight nurse specializing in adult care. He had flown often with the pilot and other flight nurse, and described his relationship with them as "excellent." They communicated well and the pilot was always open to medical crew input.

The crew's first flight occurred around 1030 from FLG to Cottonwood, Arizona, for an infant pick-up. Upon their return, they stopped at FLG and dropped off the other flight nurse for weight restrictions (who later drove to FMC to rejoin the crew). The flight continued to FMC, where the helicopter landed without incident. The pilot stayed at FMC, cleaned the helicopter, and then flew back to FLG. The two flight nurses drove back to FLG with the infant isolette.

After returning to FLG, the crew had a 1 1/2 hour break before being dispatched to Winslow, Arizona, for an adult patient pick-up. The patient weighed approximately 260 pounds and there would likely be a weight restriction (about 100 pounds) on the return flight requiring the neo-natal nurse to be dropped FLG. Approximately five minutes after they departed Winslow, he heard the pilot contact Guardian Control and reported they were about 20 minutes from FLG. He also heard Guardian Control report that Classic was inbound to FMC and had an estimated time of arrival (ETA) of 28 minutes.

About 15 minutes later, he heard the pilot report that he was 15 minutes out and would be landing at FLG to drop him off.

According to the flight nurse, the medical crew can hear the pilot communications, and he did not hear any communications from or about the Classic helicopter. In addition, he did not hear the Air Methods pilot discuss the Classic flight after the initial notification. The entire crew is trained to practice a "sterile cockpit" during takeoff and once the approach to land is established unless there is an emergency. Only the pilot talks to Guardian Control and ATC. The medical crews only communicate on the medical radios to respective emergency departments and relay patient information.

During previous flights, he had noticed several helicopters operating in and around the FMC heliport. If there were multiple aircraft in the area, they will have to hold, then approach and do a "hot drop." He described it as "musical chairs."

The medical crew is trained to be an extra set of eyes if the patient is stabilized. The flight nurse stated he would visually clear the left side of the helicopter for the pilot on each flight, and that it was rare for two pilots to talk air-to-air.

N407MJ; Classic Helicopter Services

Pilot Information

The pilot, age 55, held a commercial pilot certificate for single-engine land airplanes and rotorcraft-helicopters, and an instrument rating for both airplanes and helicopters.

His most recent second-class medical certificate was issued on March 4, 2008, and contained the limitation that he must wear corrective lenses for near vision.

According to the operator, the pilot had accrued a total of approximately 14,500 hours, including, approximately 9,780 hours in helicopters. A review of the pilot's last Flight Training and Qualification Record revealed that on May 31, 2008, he had completed a recurrent Federal Aviation Regulation (FAR) Part 135 check ride in a Bell 407 with an FAA designated check airmen, who was the

NTSB Probable Cause

Both helicopter pilots’ failure to see and avoid the other helicopter on approach to the helipad. Contributing to the accident were the failure of N407GA’s pilot to follow flight arrival route guidelines, and the failure of N407MJ’s pilot to follow communications guidelines requiring him to report his position within a minimum of 5 miles from the helipad.