NTSB Factual Report

HISTORY OF FLIGHT

On January 11, 2000, at 2100 hours Pacific standard time, an Arrow Falcon Exporters, Inc. OH-58A helicopter, N901SF, was destroyed when it impacted terrain in an agricultural field 3 miles southwest of Crows Landing, California. The airline transport certificated pilot and one passenger were fatally injured. The helicopter, operated as a public-use aircraft under 14 CFR Part 91 by the San Francisco (California) Police Department (SFPD), was conducting a night cross-country flight. The helicopter departed from Porterville, California, at 1915, and was destined for San Francisco. Instrument meteorological conditions prevailed at the nearest weather reporting locations and no flight plan was filed.

According to police department personnel, the helicopter was flown to Porterville the prior day for routine (50-hour) maintenance. Porterville is the location of Arrow Falcon Exporters, Inc., holder of the helicopter's type certificate. Personnel at Arrow Falcon said that the helicopter arrived in Porterville about 1230 on Monday, January 10. The pilot had intended to arrive earlier (about 0730), but was delayed departing by fog in San Francisco. They departed from Porterville for the return flight at 1915 on January 11th.

The pilot's wife said she spoke with him between 1400 and 1600 on the afternoon of the accident, before he left Porterville. She did not recall anything in the conversation that suggested he felt he was under pressure to return. He asked her about the weather, and she told him there was a storm approaching and to wait another night in Porterville if necessary.

En route, in proximity of Los Banos, the pilot advised Stockton Approach Control that he intended to navigate via interstate highway 5 at 1,000 feet altitude (msl). Radar and radio contact with the helicopter were subsequently lost. The wreckage was located the following morning.

Recorded radar track data (Continuous Data Recording, CDR) was obtained from the Federal Aviation Administration (FAA) Stockton Terminal Radar Approach Control (TRACON) facility (attached). At 2052:09, the helicopter was 3 miles west of the town of Gustine, and about 1 mile east of highway 5. In the next minute the aircraft track veered northeast, away from highway 5, and, in the following minute, the track made a wide left turn to a northwesterly heading, which placed the helicopter back on a converging heading with highway 5 from about 2.5 miles east of the highway. At 2056, the track was back near highway 5 and proceeded northbound along the east side of the highway. At 2056:59, the track was approximately 1/4 mile east of highway 5 and, in the next minute, the track made a right-hand turn to a south-southeasterly heading at which time radar contact was lost near the accident site at 2058:00. In the same 6-minute period, the helicopter's mode-C altitude readout varied from 500 feet (msl), down to 300 feet, then up to 800 feet, then down to 300 feet, up to 600 feet, down to 400 feet, and then up to 700 feet before radar contact was lost at 600 feet.

PERSONNEL INFORMATION

The pilot was employed by the SFPD in 1974 and performed various ground-based law enforcement duties until August 21, 1999, when he was transferred to the Special Operations Division (Air Support Unit) and became a police department helicopter pilot.

Prior to 1999, and unrelated to his law enforcement duties, the pilot was issued fixed wing and rotary wing pilot certificates on his own initiative. He earned a private pilot certificate in 1978; a commercial pilot certificate in 1979; an instrument rating in 1979; a multiengine rating in 1985; and an airline transport pilot certificate in 1986. The pilot also earned a flight instructor rating for single engine airplanes in 1984, for multiengine airplanes in 1985, and for instrument instruction in 1990. Prior to March, 1996, the pilot accumulated approximately 4,700 hours in fixed wing aircraft performing flight instruction, charter flying (Part 135), and personal flying. Between September 1989 and March 1990, the pilot took a leave of absence from the police department and flew with a regional airline as a first officer in twin-engine turboprop aircraft.

According to a flight instructor who flew with the pilot, the pilot began training in rotary wing aircraft in 1996, on his own initiative, in anticipation of the reactivation of the police department air support unit. He desired to become a pilot in the unit, which had been deactivated since 1977. He acquired a private pilot helicopter rating in September 1996; a commercial helicopter rating in November 1997; and an instrument helicopter rating in February 1998. At the time of the accident the pilot had logged 392 total helicopter flight hours, of which 147 were in the same make and model helicopter. In the previous 6 months the pilot logged total flying time of 256 hours (165 in helicopters); 42 hours at night (31 in helicopters); and 18 hours of simulated or actual instrument time (3 in helicopters). He logged 34 instrument approaches (6 in helicopters).

The pilot's training was received from a civilian school flying Schweizer 269 (piston engine) helicopters. After completing his helicopter instrument training in February 1998, with a total of 160 hours in the Schweizer 269, the pilot acquired 23 hours of Bell 206 (turbine engine) helicopter experience, flying with a traffic reporter in Los Angeles in August 1999. Following assignment to the Special Operations Division in August 1999, the pilot received an additional 17.2 hours of training during October and December 1999.

The chief flight instructor at the school, who did not personally instruct the pilot, said that after the pilot obtained his helicopter ratings, he returned to the school and rented a Schweizer 269 to gain experience. It was during this time that the chief instructor had to give the pilot additional training regarding his inadequate radio procedures, and for not complying with the airport noise abatement procedure. He characterized the pilot as a "do it my way kind of guy" who was somewhat arrogant and did not accept advice from other, more experienced, helicopter pilots. The chief instructor reported that he had "some reservations" when he learned that the pilot was going to be the SFPD helicopter pilot because he was "very bold with little experience in helicopter operations."

The flight instructor, who did instruct the pilot, characterized him as an aggressive, mission-oriented pilot/law enforcement officer who, although qualified in the OH-58, on several occasions flew missions requiring skills that were beyond his rotary wing experience level. The flight instructor felt that the pilot's personal commitment to the mission objective sometimes influenced his judgment. According to the instructor, the pilot was the sole pilot in the Air Support Unit and reported to police department managers who did not possess specific aviation expertise. The unit did not have, or operate in accordance with, an Operations Manual.

AIRCRAFT INFORMATION

The helicopter was manufactured by Bell Helicopter Company and delivered to the United States Army in 1972. The helicopter was surplused by the Army and ownership was transferred to the city of San Francisco. The helicopter was subsequently converted for civil use, and was issued a civil (Restricted Category) airworthiness certificate in accordance with the Arrow Falcon Exporters, Inc., Restricted Category type certificate. Under the type certificate, the helicopter was approved for agricultural application operations under visual flight rules only. In November 1999, because the helicopter was not being used for agricultural operations, the SFPD surrendered the Restricted Category airworthiness certificate to the FAA's Oakland (California) Flight Standards District Office, and, at the time of the accident, the helicopter was being operated as a public-use aircraft. The helicopter retained the Bell serial number but with an Arrow Falcon sequence number. N901SF's sequence number was -6, its production date was May 6, 1997, and delivery date was June 16, 1997.

The helicopter's pitot-static, altimeter, and transponder systems were tested and certified in accordance with 14 CFR Part 91.411 and 91.413 requirements on November 9, 1999.

The helicopter was equipped with a wire strike protection kit installed by Bell Helicopter Company during manufacture of the helicopter.

METEOROLOGICAL CONDITIONS

At 1628, the pilot contacted the Rancho Murrietta Automated Flight Service Station (AFSS) and received a (pilot) abbreviated weather briefing. The pilot was advised that instrument meteorological conditions prevailed along the route of flight and that visual flight rules were not recommended.

The pilot initially asked the briefer for surface weather at Oakland and San Francisco. The briefer replied "there's a slew of weather advisories, did you want me to give you all those, AIRMETS and SIGMETS?" The pilot declined to receive the advisories. The San Francisco surface observation was for scattered clouds at 1,000 feet, broken clouds at 2,000 feet and overcast ceiling at 4,5000 feet with visibility of 2.5 miles in mist. The Oakland surface observation was for broken clouds at 1,000 feet, and overcast ceiling at 2,000 feet with visibility of 1.5 mile in light rain and mist. The briefer then volunteered the San Jose surface observation, which was a few clouds at 1,900 feet, a broken ceiling at 3,500 feet, and an overcast ceiling at 4,700 feet with unrestricted visibility. As the briefer was reading the San Jose observation and said there were few clouds at 1,900 feet, the pilot interrupted him and said "1,900 feet at San Jose, oh good," and after the briefer finished the observation, the pilot said "so San Jose is basically staying VFR."

The briefer then volunteered the San Francisco and Oakland terminal forecasts, which both forecast (until 2000) scattered clouds at 1,500 feet, broken clouds at 2,500 feet, and broken (Oakland) or overcast (San Francisco) clouds at 4,000 feet with visibilities of 5 miles or greater with occasional conditions of broken clouds at 1,000 feet, overcast clouds at 2,000 feet, and visibility of 2 miles (Oakland) or 4 miles (San Francisco) in light rain showers. The briefer then further volunteered that AIRMETS were in effect for mountain obscuration and IFR conditions and that "VFR would not be recommended."

The pilot then inquired about weather reports along the western side of the San Joaquin valley, and the briefer replied that there were only a limited number of reporting points. The Merced surface observation, an automated (AWOS) report, was scattered clouds at 2,000 feet, broken clouds at 3,700 feet, and overcast clouds at 4,500 feet with visibility of 1.75 miles in light rain and mist. The pilot expressed concern about the visibility, and the briefer noted that several special observations from Merced in the last hour showed the visibility varying between 1.25 and 3 miles. Naval Air Station Lemoore was reporting scattered clouds at 8,000 feet, broken clouds at 15,000 feet, and visibility of 7 miles.

The pilot then asked for the Livermore surface observation. The briefer replied that 20 minutes earlier a special observation (AWOS) was broken clouds at 2,800 feet, and overcast clouds at 3,700 feet with 6 miles visibility in light rain and mist. Over the previous hour the visibility had varied between 2.5 and 6 miles. The pilot then replied "sounds good," and stated that he intended to fly via the San Luis reservoir to San Martin and then to San Jose and San Francisco. The briefing ended at 1641.

At Modesto, 18 miles north of the accident site, at 2053, the weather was: a few clouds at 200 feet (agl), broken clouds at 2,500 feet, and overcast clouds at 3,000 feet with visibility of 2 statute miles in fog; temperature 51 degrees Fahrenheit; dew point 50 degrees Fahrenheit; and the altimeter setting was 30.12 inHg. At 2113, the weather was: scattered clouds at 2,900 feet, overcast clouds at 3,400 feet; and the visibility, temperature, and dew point were unchanged. The altimeter setting was 30.13 inHg.

At Merced, 30 miles east of the accident site, at 2141, the weather was: scattered clouds at 2,700 feet, broken clouds at 3,500 feet, and overcast clouds at 4,500 feet; visibility was 2 statute miles in fog; temperature 51 degrees Fahrenheit; dew point 50 degrees; and the altimeter setting was 30.14 inHg.

An airman's meteorological notice, AIRMET SIERRA, was in effect for the area where the accident occurred. The AIRMET called for areas of instrument flight conditions and mountain obscuration until 0100 the following morning. Cloud ceilings were forecast to be below 1,000 feet agl, and visibilities less than 3 statute miles in precipitation, fog, and mist.

A witness, who lives about 4 miles southeast of the accident location, reported that, near the time of the accident, there was a low overcast ceiling with local areas of fog, and that it was a very dark night.

COMMUNICATIONS

The Safety Board investigator listened to a re-recording of communications between the pilot and Stockton Approach Control (Castle Radar at Stockton Air Traffic Control Tower). The tape was provided by the FAA's Southwest Region Quality Assurance Office. The times are approximate based upon elapsed time from the start of the recording.

At 2029, the pilot contacted Stockton Approach Control and reported his position was 20 miles north-northwest of [NAS] Lemoore, en route to Oakland, and requesting flight following at 1,500 feet msl. The controller issued a transponder code (5125) and subsequently radar identified the helicopter 4 miles south of Firebaugh and issued the Stockton altimeter (30.12). The pilot questioned the position south of Firebaugh and the controller verified the position relative to Firebaugh airport. At 2032, the controller asked the pilot to verify his altitude and the pilot replied "900 climbing back to 1,200". At 2034, the pilot requested a radio check and the controller replied loud and clear. The pilot said, "we just changed radios, that's all." At 2040, the pilot asked "could you give us a steer for Los Banos," and the controller replied that the heading was 300 degrees and the distance 6 miles. The pilot acknowledged "6 miles at our 12 o'clock, 300 degrees, thank you." At 2043, the pilot requested the current altimeter setting for Stockton and the controller issued the setting (30.12).

At 2044, the pilot asked the controller "you show Los Banos at one o'clock, one mile," and the controller replied "No, actually I show it just off your right, abeam, 3 o'clock, a mile and a half". The pilot replied "good call, we're follow highway 5. We did an update on the weather and it looks like we're gonna have to go all the way to Concord and come back to Oakland." The controller replied that the Livermore weather was 1,400 foot broken ceiling, 4,700-foot overcast, and visibility 10 miles. The pilot replied, "OK, Livermore is 1,400 broken, 1,700 overcast and visibility 10. How's Oakland?" At 2045, the controller replied that the Oakland weather at 1953 was wind 240 degrees at 7 knots; visibility 12 miles; 2,500 foot scattered clouds, 5,000 foot broken clouds; and the altimeter setting was 30.19 inHg. The pilot replied, "OK, very good, if I can get through the Livermore pass, the Altamont, I'll proceed on into Oakland." At 2051, the pilot told the controller that he was going to parallel highway 5 at 1,000 feet. This was the last communication from the helicopter. At 2100 hours, the controller transmitted three times "01 Sierra Fox, Stockton Approach" without receiving a reply.

WRECKAGE AND IMPACT INFORMATION

The accident location was in a level, unplanted, recently plowed, dry, agricultural field on the western side of the San Joaquin Valley in central California. The latitude was 37 degrees 21.57 minutes north, and the longitude 121 degrees 05.54 minutes west (GPS). The elevation was approximately 170 feet msl. To the west and northwest, the terrain slopes gently upward to the coastal mountain range. Interstate highway 5 was visible about 2 miles west and approxima

NTSB Probable Cause

The failure of the pilot to maintain altitude and clearance from terrain during a turn to reverse direction after encountering instrument meteorological conditions. A factor in the accident was the pilot's failure to obtain a full weather briefing before departure which accurately forecast the conditions encountered.