NTSB Factual Report

HISTORY OF FLIGHT

On June 4, 2000, about 1030 eastern daylight time, a Bell UH-1H, N127FC, registered to and operated by the United States Department of Agriculture Forest Service as a Title 14 CFR Part 91 public-use local flight, crashed 10 miles south of Southwest Florida International Airport, Fort Myers, Florida. Visual meteorological conditions prevailed, and a company flight plan was filed. The commercial-rated pilot sustained fatal injuries. The flight originated in Fort Myers, the same day, about 0820.

The helicopter was operating as a fire-fighting flight, and had been in the area of a fire for about 1 1/2 hours. The accident occurred after the pilot had refilled the water in the external bucket, and was returning to the fire after filling up at the lake/pond. Witnesses observed the helicopter in level flight heading in a northeasterly direction away from the lake/pond. A witness said the helicopter banked steeply and went into a nose-low attitude until it disappeared behind trees. Shortly after disappearing behind the trees, the witnesses heard the sound of impact. In addition, the witness said, "I saw Helicopter 27 head back to the fire with a full bucket of water, I saw him go down over the pond...and come up with water in it. I saw water trailing the helicopter and the bucket."

A Forestry Service, aircraft mechanic, who saw the pilot before the flight stated, "...I walked into the hangar at 6:45 [0645] [the pilot] was here, complained that someone from Forestry called him at 12:30 [0030] and woke him up to tell him they wanted him in at 8:00 AM. He mumbled something about sleepwalking. That he couldn't get back to sleep. [The pilot] took my truck and went to McDonalds...[pilot] returned with our breakfast, [and] we ate...[the pilot] moved the aircraft to fuel it, I watched him from 3 feet away. He did everything right, and made a normal takeoff. He returned about an hour later...to pick up a helmet and headset. I cautioned him about the heat and told him not to overwork himself."

The accident occurred during the hours of daylight about 35 degrees, 27 minutes North, and 085 degrees, 06 minutes West.

PERSONNEL INFORMATION

The pilot's personal logbook listing his flight hours was not recovered. Based on company records the pilot had all of his flight hours in helicopters. It was estimated that the pilot had about 4,000 hours of total flight time. His employment with the Department of Forestry started on December 23, 1991, and he was transferred to Fort Myers, Florida, November 1999. The pilot received his initial flight training in the United States Army.

METEOROLOGICAL INFORMATION

The weather conditions at Fort Myers, about 10 miles north of the crash site, about the time of the accident were VFR, with a reported visibility of 10 miles; winds were from 030 degrees at 4 knots. The temperature was 84 degrees F, and the dew point was 75 degrees F.

MEDICAL AND PATHOLOGICAL INFORMATION

Dr. Rebecca A. Hamilton performed an autopsy on the pilot, on June 5, 2000, at the Lee-Hendry County Medical Examiner's Office, Fort Myers, Florida. According to the autopsy report, the cause of death was "Multiple blunt force injuries."

Toxicological tests were conducted at the Federal Aviation Administration, Research Laboratory, Oklahoma City, Oklahoma, and revealed, "No ethanol or drugs detected."

A search of the pilot's last FAA flight physical, dated November 9, 1999, did not indicate any pre-existing disease. However medical records obtained from the Tallahassee, Florida, Veterans Administration, Out Patient Clinic, revealed the following; "Progress Notes...Note date: 06/22/1998...09:25...General note...Visit: 06/22/1998...GMED/Nursing...Pt [Patient] on interferon for hep c [hepatitis C]. Most recent Labs done 6/1 topc [Tallahassee Veteran's Administration Outpatient Clinic] showed several improved values. Called home today to report ok and continue Rx. Family member who answered thought pt still taking Rx, but away now, firefighting...Note dated 05/28/1998...phone call to pt home-wife took message. Advised to continue medication, interferon, but platelets low so may bruise easily, be careful...Note date: 05/11/1998...Pt had labs drawn @TOPC [Tallahassee Veteran's Administration Outpatient Clinic] 5/5/98. Results showed some changes...and Pt to continue interferon as ordered...family member took message that labs ok to continue Rx as ordered." The pilot was transferred to Fort Myers on November 1, 1999, and the VA Out Patient Clinic at Fort Myers had no record of the pilot at their facility.

The NTSB Medical Officer, extracted the following medical information from the pilot's medical records obtained under subpoena from the Tallahassee Veteran's Administration Outpatient Clinic:

June 11, 1998 - Nurse's note indicates "... labs ... showed some changes ... patient to continue interferon ... PLT 114, T.BILI 1.0, D.BILI 0.5, AST 88, ALT 90, remainder basically same..."

June 22, 1998 - Nurse's note indicates "Patient on interferon for hepatitis C. Most recent labs ... showed several improved values ... HCT 42.1, WBC 7.2, PLT 142, T.BILI 0.8, D.BILI 0.5, ALK 117, AST 50, ALT 46."

The NTSB Medical Officer, from the medical records maintained on the pilot by the FAA Civil Aeromedical Institute Aeromedical Certification Division, extracted the following medical information:

Applications for 2nd Class Airman Medical Certificates on November 25, 1997, November 9, 1998, and November 9, 1999 each indicate "no" under item 17 ("Do you currently use any medication") and under item 18 ("Have you ever had or have you now any of the following") for sections ("stomach, liver, or intestinal trouble") and x ("other illness, disability, or surgery").

The following information was extracted by the NTSB Medical Officer, from the report of autopsy performed on the pilot by the Office of the District Medical Examiner in Fort Myers, Florida:

- Under "External Examination" is noted, "...massive traumatic damage of the face and skull..." - Under "Internal Examination" is noted, "... Remnants of the 1790-gram liver have a diffusely nodular, yellow tan, firm surface. The cut hepatic surfaces are minimally congested, yellow tan, extremely firm and diffusely nodular." - Under "Microscopic Examination" is noted, "LIVER: Cirrhosis, portal triads with chronic inflammatory cells, micro and macrovesicular steatosis and focal areas of congestion."

According to the medical records the pilot had been under treatment for chronic hepatitis C. The most common symptom of that disease is fatigue. Interferon therapy is often used in individuals with hepatitis C, and had been prescribed by the VA for the pilot. There are, however, no recent medical records to suggest that the pilot had continued that therapy or to indicate how his liver was functioning at or near the time of the accident. The pilot's girlfriend told investigators that he stopped taking his medication prior to August 1998. The autopsy findings indicate that his disease had progressed to cirrhosis, but the cirrhosis was not noted to be severe. FAA Aviation Medical Examiners are instructed to deny or defer medical certification to the FAA Aeromedical Certification Division for any airmen who have chronic hepatitis with impaired liver function.

WRECKAGE INFORMATION

The helicopter impacted in a pasture, north of Burgundy Farms Road. The pasture was a large open field located north of a second field. A wooded area separated both fields. South of the crash site was a hedgerow of brush, which ran east and west, and was not dense. Both areas were searched for helicopter parts, and none were found. The pasture that the helicopter impacted in consisted of numerous small ditches that ran north and south. The ditches were uniformly spaced from each other. About 1 mile west of the crash site was the lake/pond that contained the water supply, where the helicopter had been filing its water bucket. The lake could not be seen from the ground. Another low hedgerow was located to the east of the crash site. The ground around the crash site was covered with dry grass, small brush, and sand.

The first ground scars along the wreckage path were located about 145 feet southeast of the where the helicopter came to rest, and were two impact gouges in the ground. The two gouges were evenly spaced and parallel to each other. The gouge mark to the east was larger then the west gouge mark. There was a long, narrow trench cut into the ground, running from the gouge marks. The trench ran from south to north, in an irregular line towards the helicopter. Pieces of the main rotor blades were found in the gouges and the trench. A circular pattern was found dug into the ground, east of the gouge marks. A piece of tailrotor blade was found on the northwest side of the circular pattern. Northwest of the trench mark was a large "U" shaped pattern in the ground, where a landing skid, door, and other debris were found. The measurements of the skid marks were 61 feet.

The larger of the two gouges measured about 40 feet long, 2 feet 10 inches wide, and 13 inches deep. The smaller gouge was located west (left) of the larger gouge measured about 13 feet long, 2 feet 6 inches wide, and 12 inches deep. An additional gouge located at the north end of a trench was about 2 feet 3 inches wide and 12 inches deep. The area of all gouges and impact marks south of the helicopter's resting place were about 17 feet long, 9 feet 4 inches wide and 9 inches deep.

The tailboom with rotor was found about 6 feet southeast of the fuselage, and was oriented to the northeast. The nose of the helicopter was oriented to the west. Both landing skids were separated from the helicopter. The mast with the main rotor blades were found forward of the main wreckage. The cabin area was destroyed, but none of the helicopter displayed any fire damage. The main transmission had come forward crushing and destroying the overhead switches, circuit breaker panel, center console, to include all the radios, and hydraulic switch.

The engine was found lying north of the helicopter with exhaust facing west. There was a burn pattern in the grass that came from the engine exhaust, and extended from the exhaust extending outward to the north. The engine was removed from the crash for further examination at the manufacturer.

The wreckage was removed from the crash site and examined at a hangar owned by the Lee County Mosquito Control, at Buckingham Airport, Fort Myers, Florida.

Examination of the fuselage revealed the main cabin and roof were heavily damaged. The cockpit was completely fragmented and the main cabin structure was destroyed aft of fuselage station 166 on the right side and aft to fuselage station 74 on the left side. The roof section was broken away from the cabin section and the pylon support structure had shifted forward at the top about 45 degrees. The cargo floor on the left side of the belly section displayed little damage, but the right side was fragmented. The belly fuel cell enclosure on the right side had been compromised, and the fuel cell had been ejected. The cell displayed impact damage and the breakaway valve was closed. The belly fuel cell on the left side was still contained in the structural cavity. The portion of the fuselage structure aft of fuselage station 155 displayed very little damage. The engine deck had received some impact damage, but the engine had separated from the mounts.

The pilot's seat had separated from the cockpit during the impact sequence. The shoulder harness and seat belt were found buckled. The left shoulder harness was found separated from the inertia reel.

The instrument panel had separated from the cockpit structure, was found distorted, and encrusted with sandy soil. Portions of the right side of the panel, along with the instruments from the right side were missing.

The fixed control system between the hydraulic servo actuators and cockpit were completely disrupted from the breakup of the fuselage. Observations of the fixed control system components revealed overload damage. No evidence of pre-impact control disconnects or discrepancies were found.

The hydraulic system displayed impact damage from the breakup of the fuselage. Multiple overload fractures were observed in the hydraulic lines and fittings of the system. The hydraulic pump was found mounted to the transmission sump. Removal of the pump revealed that the drive splines were not damaged. The tailrotor hydraulic servo actuator was found mounted in the aft compartment of the fuselage. The servo appeared undamaged and operable. The three main rotor hydraulic servo actuators had separated from their mounts during the breakup of the pylon area. The hydraulic pump, the three main rotor servo actuator, and hydraulic shutoff valve were removed from the wreckage for further examination.

Examination of the swashplate and main rotor control revealed that the left and right cyclic boost tubes, which attach to the arms of the swashplate inner ring displayed an overload fracture at the fastener holes at the lower ends of the tubes. The upper portions of the tubes remained attached to the swashplate arms. The synchronized elevator control tube displayed an overload fracture at the upper end, and the clevis remained attached to the arm on the swashplate inner ring. The collective boost tube was found with an overload fracture about 3 inches above the fasteners with the upper portion of the tube remaining attached to the collective lever. The swashplate and collective sleeve were in place and appeared operable. One of the drive link trunnion bearings had pulled out of the swashplate outer ring from overload fracturing of the clamp area ring. Both control tubes between the scissor levers and stabilizer bar assembly were overload fractured, as were both of the stabilizer bar damper link tubes. The stabilizer bar assembly was found separated from the main rotor hub by an overload fracture of the four mounting bolts on one side, and pulled out of the pivot bearings on the other side. One of the equalizer levers on the stabilizer bar assembly had separated from the frame, and remained attached to the separated main rotor pitch horn.

The main rotor hub assembly remained attached to the mast, however both blades were found separated from the grips. The hub assembly feathering and flapping bearings operated freely. Both main rotor pitch horns had separated from the grips at the inserts as a result of overload, and were still attached to their respective pitch links. Both main rotor blades were broken up, and displayed extensive impact damage. Overload fractures of the blade spars and breakup of the blade material was evidence that the blades impacted the ground with high rotational energy.

The main transmission and drive shaft were found separated from the fuselage. Each of the four pylon corner mounts on the support case had been pulled out of the fuselage structure due to overload. The sump had separated from the bottom of the support case due to an overload fracture of the mounting flange. The main rotor mast was separated from the transmission. In addition, the top case and planetary assemblies were removed. The internal gears and bearing of the transmission were found undamaged, and wet with lubricating oil. The freewheeling unit operated without discrepancies. The removal of the main input quill revealed the input pinion and ring were undamaged. The "Kaflex" main input drive shaft was heavely damaged due to an overload fracture of the forward and aft load beam assemblies.

The tailboom was found with an overload fracture at Boom Station 39 (Sta. 39), with the forward portion of the tailboom remaining attached to the aft fuselage structure. The tail rotor, 90-degree gearbox, the 42-degree gearbox, and the tail rotor drive shafts were found still attached to the aft section of the tailboom. Buckling was observed in the lower aft section of the vertical fin, and damage was observed on the left side of the fin, which had been caused by rotational contact of the tail rotor blades.

The tail rotor driv

NTSB Probable Cause

the pilot's failure to maintain control of the helicopter for undetermined reasons. Factors in this accident were self-induced pressure and fatigue due to lack of sleep and rest.