NTSB Factual Report

HISTORY OF FLIGHT

On June 14, 1999, at 2208 Eastern Daylight Time, a Sikorsky S-76A, N2743E, operated by Petroleum Helicopters Incorporated (PHI), was destroyed when it collided with terrain in Jackson, Kentucky. The two certificated commercial pilots and two medical personnel were fatally injured. Instrument meteorological conditions prevailed for the positioning flight, which had departed from Julian Carroll Airport (JKL), Jackson, Kentucky, and was destined for University of Kentucky heliport (37KY), Lexington, Kentucky. The flight was conducted on an instrument flight rules (IFR) flight plan under 14 CFR Part 91.

The flight crew was on the fourth day of a seven-day rotation when the accident occurred. They had logged on duty at 1100.

According to records recovered at the accident site, the helicopter departed 37KY at 1356, and arrived at JKL at 1426. While at JKL, the pilots and medical crew had access to a lounge area for rest. While on the ground, the helicopter was serviced with 35 gallons of Jet-A with prist. According to the airport manager, the pilots refueled the helicopter.

The pilots had a computer with a direct user access terminal system (DUATS) in their flight lounge, which had been used to check weather and file flight plans.

According to records from the Federal Aviation Administration (FAA), the pilot-in-command (PIC) accessed DUATS three times prior to the accident flight.

The first time occurred at 1912, when the pilot requested an abbreviated weather briefing for the State of Kentucky. He specifically requested aviation routine weather reports (METAR) and aerodrome forecasts (TAF). Included was the data on Lexington, Kentucky (LEX) and JKL.

The second contact occurred at 2005. The pilot filed an IFR flight plan for a direct flight from JKL to the LEX VOR. He did not request any weather data.

The third contact occurred at 2121. Again, the pilot requested an abbreviated weather briefing for the State of Kentucky. He specifically requested METARs, and TAFs. The JKL weather included winds calm, visibility 1/2 mile, sky obscured, vertical visibility 100 feet, weather fog, temperature and dewpoint 18 C. The LEX weather was visibility 10 miles, sky clear below 12,000 feet, temperature 24 C, and dewpoint 18 C.

The airport manager observed the flight crew walk to the helicopter. He reported that visibility was reduced by fog and he could not recognize the pilots, but only saw vague shapes as they boarded the helicopter.

At 2154:31, the flight crew checked the JKL automated surface observation system (ASOS). The helicopter was equipped with a cockpit voice recorder (CVR). According to the CVR transcript, the weather recorded by the CVR was:

"...Carroll airport Jackson Kentucky. automated weather observation, zero one five four zulu, visibility less than one quarter, fog, sky condition overcast two hundred, temperature one eight Celsius, dewpoint one eight Celsius, altimeter three zero zero six, remarks density altitude one thousand niner hundred...."

Following the weather, which was played through several times, the flight crew proceeded to prepare for an instrument departure. No comments were recorded about the visibility being less than 1/4 mile.

The flight crew made initial radio contact with Indianapolis Air Traffic Control Center, Hazard Radar (AZQ), and at 2159:51, AZQ transmitted, "november ah seven two seven four three echo, you're cleared ah to lexington from julian carroll as filed, climb and maintain four thousand, squawk four two six two, contact indy center on this frequency on departure, and clearance is void if not off by zero two...one zero if not off by zero two one zero then advise center no later than one five of intentions." This was acknowledged and read back by the flight crew.

A certified weather observer at the National Weather Service facility at JKL observed the takeoff and reported:

"...When they rolled onto the runway I walked out to watch them takeoff. At the runway/taxiway intersection, they turned left for runway 19 and pulled up into a hover about 20 feet above the runway. They then proceeded down runway 19. I lost them in the fog about halfway between the taxi/runway intersection and the end of the runway. As a certified weather observer I concur with the ASOS visibility of [less than] <1/4 mile. I estimate that the visibility was about 1/8 of a mile or slightly more...."

At 2205:51, the CVR recorded the pilot-in-command (PIC) transmitting on UNICOM frequency, "...we'll be a uh... south departure right turn we, be uh west out of the area." The airport manager acknowledged this.

At 2206:18, the CVR recorded the second-in-command (SIC) on interphone, "I'm gonna lift to a hover, and we'll un get sixty knots before we get solid in it I guess. Try to keep it within the lights down here." The PIC acknowledged this.

At 2206:51, the PIC stated, "airspeed's alive, positive rate of climb.", and the PIC subsequently said, "your at thirty [knots]", and then "heading one nine zero." This was followed by the PIC stating, "I'm gonna kill the landing....[lights]." The SIC acknowledged this.

At 2207:22, the CVR recorded the PIC on interphone, "and you're at eighty... wanna hold eighty. Or Vbroc [Velocity best rate of climb] rather." The SIC acknowledged this.

At 2207:32, the PIC transmitted, "indy center sikorsky ah two seven four three echo we're ah passing one thousand six hundred for four thousand." AZQ replied, "november two seven four three echo indy center roger, and ah understand climbing to four thousand say altitude leaving.", to which the PIC replied, "one thousand six hundred for ah four thousand." This transmission was acknowledged by AZQ.

At 2207:51, the PIC was heard to say, "go ahead and stay on your heading.", after which two unidentified intercom transmissions were recorded, "alright.", and then, "its ok, you got five hours."

At 2208:03, the PIC stated, "ok your in a right hand turn and descending." There was no acknowledgement from the SIC.

At 2208:05, the SIC stated, "ok I think my gyro just quit." There was no acknowledgement from the PIC.

At 2208:10, the SIC asked, "you have the controls?" There was no acknowledgement from the PIC.

At 2208:11, the PIC stated, "you're in a left hand turn and descending...turn turn back and level level us off. There was no acknowledgement from the SIC.

At 2208:16, the CVR recorded an increase in ambient noise level through the microphone-summing amplifier.

At 2208:18, the PIC stated, "right hand turn.....right hand turn." There was no acknowledgement from the SIC.

At 2208:24, the CVR recorded the initial sound of impact and ceased operation.

A witness located near the accident site reported:

"The sky was foggy...I heard a helicopter coming, it sounded different than normal. I was outside and tried to see it but did not see any lights. Next the sound shifted as it went behind the hill. I then heard a pop in the distance. I knew what happened and jumped in my jeep to go and call 911. It was about 30 to 45 seconds into my trip, about 1/8 of a mile I saw the explosion to my left. I continued and called 911."

In a follow-up interview conducted by a FAA Inspector, the witness explained the helicopter sounded different because it was at a lower than normal altitude.

The accident occurred during the hours of darkness at 37 degrees, 33.945 minutes north latitude, and 83 degrees, 17.462 minutes west longitude.

PERSONNEL INFORMATION

Pilot-In-Command

The PIC held a commercial pilot certificate with rotorcraft-helicopter and instrument helicopter ratings. He was last issued a second class airman medical certificate on January 2, 1999, with a limitation to carry corrective lenses for near vision.

According to employment records from PHI, the pilot had received his initial rotorcraft flight training in the US Army, and was employed by PHI on October 27, 1984. His total flight experience was 6,859 hours, with 2,319 hours in the S-76A. His total instrument flight experience of 382 hours, which included 111 hours in simulators, and 39 hours of actual instrument time.

The PIC's initial checkout in the S-76A was as a SIC in February 1990, with no problems noted. On March 29, 1996, during a 6 month recurrent instrument flight check, one item, Stabilized Approach Concept, was marked U/S. The form noted that the pilot failed to call for a missed approach with the airspeed 25 knots slow. On September 8, 1996, he was upgraded to PIC on the S-76A with no problems noted. On March 30, 1997, the PIC failed a 6-month recurrent instrument flight check. He was rated unsatisfactory in the following areas; use of checklists; emergency procedures; flight planning; ILS approaches; VOR approaches; and missed approach. He took another checkride on March 31, 1997, and passed all items. He subsequently passed checkrides on September 26, 1997, and April 11, 1998, with no problems noted.

The PIC had been in Cleveland, Ohio, and elected to return to Gulf of Mexico flight operations. He transferred to Lafayette, Louisiana, and received offshore training in the S-76A. While there, he received training in the Bell 412, and took a checkride on June 21, 1998. The flight check form showed all areas satisfactory. However, the form also noted that he was only qualified as a SIC, and not as a PIC for the Bell 412. The training form noted several areas of deficiency found during the training. The PIC re-qualified in the S-76A on September 5, 1998, and subsequently transferred to Lexington on October 9, 1998, as a PIC. He took a 6-month instrument flight check on February 8, 1999 with no problems noted.

A review of the PIC's training file with copies of all checkrides from date of employment to date of accident revealed no other discrepancies.

Second-In-Command

The SIC held a commercial pilot certificate with airplane, single and multi-engine land, and rotorcraft helicopter ratings. In addition, he held an instrument rating for airplanes and helicopters. He also held a flight instructor certificate (expired) for single engine land airplanes, and a mechanic certificate with airframe and powerplant ratings. He was last issued a first class airman medical certificate on August 14, 1998. His total flight experience was 7,739 hours with 6,574 hours in helicopters. His total instrument flight experience was 181 hours, which included 92 hours of actual instrument time. He had passed his last instrument flight check on February 7, 1999.

According to employment records from PHI, he was initially hired as a mechanic in 1976. He then participated in a company upgrade program to transition to a pilot. He started flying the Bell 206 in 1982, and subsequently left the company in 1987. He returned to PHI as a pilot on February 23, 1990.

The SIC's initial checkout in the S-76A occurred on May 17, 1997. The upgrade and two subsequent 6-month instrument flight checks, September 27, 1997, and April 4, 1998 were accomplished with no problems noted. On May 30, 1998, the SIC took a PIC checkride in the S-76A. He failed the oral exam and the flight check was not conducted. According to training records, he was weak in several areas related to instrument procedures and flight planning. He took another oral exam on June 1, 1998, and re-qualified in the S-76A as a SIC. He then transferred from Cleveland, Ohio, to Lexington on October 12, 1998. He passed 6-month instrument flight checks on September 16, 1998, and February 7, 1999, with no problems noted.

A review of the SIC's training file with copies of all checkrides from date of employment to date of accident revealed no other discrepancies.

Interviews

Interviews were conducted with other pilots from the Lexington base where the accident pilots were assigned. The interviews disclosed the accident pilots were paired as a team and normally flew with each other. While other pilots had flown with them, it was not on a regular schedule. Both pilots were reported to have demonstrated varying degrees of assertiveness in the cockpit. No negative comments were generated for either pilot. However, one pilot did report that the SIC told him he felt uncomfortable flying with the PIC under IFR conditions. No specifics were given for the reported statement of the SIC.

AIRCRAFT INFORMATION

The helicopter was equipped with three sets of attitude indicators and directional gyros. The primary sets were at each pilot station, and a standby set was located on the center instrument panel. Each cockpit indicator had its own gyro supplying information to the cockpit indicator, and the information could not be shared with another indicator.

PHI operated a fleet of 24 S-76s. According to company records, in the 6 months that preceded the accident, fleetwide, there had been a total of 40 vertical gyro replacements on 15 helicopters, and a total of 11 attitude indicator replacements on 7 helicopters. On N2743E, in the preceding 6 months, there were two attitude indicators, and three vertical gyros replaced. According to company records, fleetwide, in the preceding 6 months, the maximum number of attitude indicators replaced on a helicopter was three, and maximum number of vertical gyros replaced was six.

According to a representative of Sikorsky, the manufacturer of the helicopter, the landing lights will extinguish when the landing gear is unlocked for retraction, and will not illuminate until the landing gear is down and locked. The Chief Pilot of PHI reported that the landing gear lights had not been modified, and worked as described by Sikorsky.

AIDS TO NAVIGATION

The helicopter was equipped with dual very high frequency omni directional radio range (VOR) receivers, distance-measuring equipment (DME), and an IFR approved global positioning navigation system (GPS). The planned departure did not require the pilot to navigate to the Hazard VOR (AZQ). The chief pilot of PHI reported that once airborne from JKL, the Lexington VOR (LEX) would be received and the pilots could navigate towards LEX.

AIRDROME INFORMATION (Departure)

Julian Carroll Airport (JKL) was an uncontrolled airport on the top of a hill with a published field elevation of 1,381 feet. There was one fixed base operation, which sold fuel and performed minor maintenance. According to the US Terminal Procedures, Southeast, Volume 1 of 4, takeoff criteria were published for a runway 1 departure due to an obstruction located off the departure end of the runway. However, no criteria were published for a runway 19 departure. The runway was equipped with medium intensity runway edge lights. There was a VOR/DME and GPS Runway 1 approach. The AZQ VOR was located 12.4 nautical miles on a bearing of 172 degrees magnetic. Weather observations were obtained from an on-airport US Weather Bureau Office, and an ASOS. A check of the fuel supply at the JKL airport revealed that the fuel filter was absent of debris. A check of the underground storage tank for water revealed none present.

FLIGHT RECORDERS

The cockpit voice recorder was recovered and forwarded to the Safety Board vehicle recorder laboratory for readout. After a review of the data, a transcript was made of the departing flight. During the investigation, it was discovered the helicopter was not equipped with a cockpit area microphone (CAM), nor was it required. The helicopter was equipped with continually energized lip microphones at the first and second pilots' stations.

RADAR AND OTHER REMOTELY RECORDED DATA

Radar data was received from Indianapolis Air Traffic Control Center (ARTCC) in the NTAP format. The data was overlaid on a computer generated topographic map. The data revealed the helicopter initially climbed to 1,600 feet, and while turning left, it descended. The final radar contact occurred at 2208:14, at an altitude of 1,300 feet.

WRECKAGE AND IMPACT INFORMATION

On-site investigation revealed the helicopter had impacted rising terrain on a tree-covered slope, at an elevation of about 1,000 feet. The tops of the trees on the top of the ridge were estimated to be about 1,200 feet high. The average slope of

NTSB Probable Cause

the failure of the PIC to adequately supervise the SIC, and maintain a positive climb. Factors were the fog and dark night.