NTSB Factual Report

HISTORY OF FLIGHT

On June 21, 2002, at 1207 central daylight time, a Eurocopter AS-350-B2, N852HW, operated by Rocky Mountain Holdings LLC (RMH), as LifeNet flight 12, experienced a loss of control and collision with the terrain at the Karl Stefan Memorial Airport (OFK), Norfolk, Nebraska. The commercial rated pilot, paramedic, and flight nurse were all fatally injured. The Title 14 CFR Part 91 flight was operating in visual meteorological conditions on a company flight plan. The flight originated from the helipad at the Faith Regional West Hospital (NE68), in Norfolk, Nebraska, at 1200.

N852HW was based at the Faith Regional Health Services West Campus Heliport (NE68) in Norfolk, Nebraska. NE68 is located approximately 2.5 miles north-northwest from OFK.

The purpose of the flight was to fly to St. Anthony's Hospital in O'Neill, Nebraska, to pick up a patient. The patient was then going to be transported to the Mercy Medical Center in Sioux City, Iowa. At 1152:46, the pilot was informed of the mission by LifeCom dispatch. At 1201:20, the pilot radioed the LifeCom dispatcher and reported that he had departed. At 1203:25, the pilot reported to dispatch that he was going to land at OFK, and he asked the dispatcher to contact their mechanic and have him meet the aircraft. He reported "we're gonna have to land and get something checked out with maintenance before we can take this mission." The dispatcher began the process of locating the mechanic. At 1205:10, the pilot informed the dispatcher that they were experiencing "binding in the right pedal." This was the last transmission between the helicopter and dispatch.

Several witnesses reported seeing the helicopter just prior to the accident.

The person monitoring the Unicom radio at the Karl Stefan Airport reported that the pilot of N852HW made a radio call saying he was inbound for landing. She stated she responded to the call and asked if they were going to need fuel. There was no response to her inquiry. She stated she then saw the helicopter hovering over the ramp, about 10 feet off the ground, and thought he was gong to land. She stated she answered the telephone and seconds later when she looked back out the window she noticed the helicopter had crashed.

The pilot of an airplane that was landing at OFK reported that he was entering the traffic pattern for runway 19 when he heard the helicopter report being north of the city, landing to the south. He stated that he asked the helicopter three times for a position report, but he did not get a response. He stated that when he was on a one mile final, he saw the helicopter "high right [the witnesses right], descending across to low left [the witnesses left] view (at a high rate of descent)." The helicopter passed between his aircraft and the runway threshold. He stated he aborted his landing to avoid the helicopter. When he was turning crosswind, he saw the helicopter descend toward the north end of the ramp and he thought it was landing. He turned his attention to flying his airplane and when he looked back toward the helicopter he saw it "crashing on its side and coming to rest."

A witness who was traveling south on Highway 81 reported seeing the helicopter hovering over the northern quadrant of the airport. He lost sight of the helicopter, and then saw it climb to a height of about 100 to 200 feet where it leveled off and hovered. He reported, "it suddenly began to spin (I believe counter-clockwise, but upon reflection, I'm not positive) with its nose angled down, and a moment later it started to descend rapidly, still spinning, apparently out of control. After several complete revolutions, the helicopter dove to the ground, coming to rest on its right side." This witness went to the helicopter to help. He reported hearing an "occasional release of pressure from what I believed to be the hydraulic systems, and from time to time there would be a brief puff of smoke from the exhaust."

Another witness who was located approximately a quarter-mile northwest of the accident site reported that the helicopter stopped for a short time and hovered over his location. He reported that as the helicopter proceeded to the airport "it pitched side ways and the pilot hit the power and got the helicopter back up in the air." He reported the helicopter then began to spin clockwise (looking down from the top). He stated the spin slowed as the helicopter gained altitude then it "dove forward and down into the ground."

Another witness who was at the intersection of Highway 81 and Sherwood Road reported seeing the helicopter about 70 feet southwest of the 2 north buildings at the airport at an altitude of about 30 feet above the ground with its nose pointed to the east. The nose of the helicopter was at an angle, which was about 30 degrees lower than the tail. The witness stated the tail swung about 3 times from the northwest to the southwest and the nose of the helicopter remained in the same position. The helicopter then veered to the left. Buildings blocked his view and the next thing he saw was a cloud of dust.

Another witness reported seeing the helicopter prior to it reaching the airport. She stated that it was "rocking (nose to tail) and going in a circle, it was not spinning when I saw it."

A witness driving south on Highway 81 reported seeing the helicopter climbing out from the airport and thought it was taking off. She stated it reached an altitude about twice the height of the buildings (hangars) at which time it started to spiral. She stated the helicopter then turned and dove nose first into the ground.

A witness traveling north on Highway 81 reported he thought the helicopter was taking off prior to the accident. He reported the helicopter then started to fly "strangely" prior to it impacting the ground.

Another witness reported seeing the helicopter in a level attitude and traveling very slow as it approached the airport. She stated the helicopter banked a little when it got close to the hangars. It started spinning counterclockwise then it began to spin in a clockwise direction. She stated the helicopter descended and climbed back up at which time she was distracted. She then saw the helicopter dive into the ground. She stated the helicopter was about twice the height of the buildings when it started spinning.

PERSONNEL INFORMATION

The pilot, age 43, received a commercial pilot certificate with rotorcraft-helicopter and instrument-helicopter ratings on November 8, 1985. This certificate was issued based on the pilot's previous military experience. On December 31, 1989, an airplane-single engine land rating was added. On January 26, 2002, a multi-engine land rating was added. On the application for this certificate, the pilot reported having 161.1 hours of airplane flight time and 2,418.5 hours of rotorcraft flight time. On February 5, 2002, a multi-engine instrument rating was added to the pilot's commercial pilot certificate. On the application for this certificate, the pilot reported having 180.6 hours of airplane flight time and 2,399.7 hours of rotorcraft flight time.

The pilot's last Federal Aviation Administration medical certificate was issued on November 15, 2001. On that date, the pilot was issued a second-class medical certificate with no limitations.

The pilot was a member of the Nebraska Army National Guard in Lincoln, Nebraska. According to information supplied by his National Guard Unit, the pilot had approximately 2,550 hours of total flight time. They reported he had about 680 hours of flight time in UH-60 Blackhawk helicopters. The National Guard reported that between November 1, 2001, and May 1, 2002, there was a void in the pilot's flight hours. He had fixed wing aircraft training in May 2002, and he had flown 3 hours in June 2002.

The pilot submitted an Application for Employment to RMH, dated November 21, 2001. On this application the pilot listed having 2,551.6 hours of helicopter flight time. He listed experience in UH-60A Blackhawk, UH-1 Huey, CH-46 Boeing Vetol, TH-57 (Bell 206), and Bell 47 helicopters.

The pilot began his employment with RMH on May 6, 2002. According to information and records provided by RMH, the pilot traveled to Provo, Utah, on May 6, 2002, and began his training on May 7, 2002. Records indicate that he completed Initial Ground and Initial General Emergency training on May 8, 2002. His Initial Aircraft Ground training was completed on May 10, 2002. RMH reported the pilot traveled to Norfolk, Nebraska, on May 10, 2002, to begin his flight training. Records indicate the pilot completed his Initial Flight training on May 12, 2002. This training consisted of 3.2 hours of flight time. All the training was recorded as having been satisfactorily completed. The pilot passed a 14CFR Part 135 Airman Competency/Proficiency Check on May 12, 2002. This checkride was logged as having lasted 1 hour. Company records show the pilot flew 7.1 hours on May 14, 2002, and 6.1 hours on May 15, 2002. Both of these flights were logged as Part 91-Ferry. Records indicate the pilot had four additional flights between May 23, 2002, and June 9, 2002, which were listed as Part 91-Training. These flights totaled 6.8 hours of flight time. In addition, between May 25, 2002, and June 19, 2002, the pilot's Flight and Duty Time Record show the pilot flew 20.8 hours. The records for these flights did not contain any remarks indicating that they were training flights. Not counting the accident flight, the pilot had accumulated a total flight time in the AS350 of 45 hours while employed by RMH, 10 hours of which were listed as training.

According to the RMH Pilot Training Program syllabus, the rotor system, flight controls, and hydraulic system are addressed under the Aircraft Ground Training Curriculum. The Flight Training Curriculum states, "Pilots will be training on all maneuvers listed in the following flight training module." Item 8 in the Flight Training module lists landing with hydraulic off and Item 12 lists hydraulic system malfunction and anti-torque system failure. According to the pilot's instructor, these items were accomplished.

The training program syllabus contains RMH Approved Maneuvers. The procedures and cautions to be used while practicing hydraulics off landings are listed under this section. Two of the cautions listed for this maneuver state: "Maintain entry airspeed until apparent ground speed and rate of closure appear to be increasing. Continue forward movement to arrive 3 feet above the surface and above ETL [effective transational lift]. Note: Do not terminate to a hover."and" Due to heavy control forces encountered in this maneuver, the instructor must be immediately ready to assist in control of the aircraft." This section also contains the procedures and cautions to be used during flight training for simulation fixed position [jammed] tail rotor failure. A "Loss Of Tail Rotor Drive" and a "Loss Of Tail Rotor Effectiveness" are listed as a "Discussion Only" items.

The paperwork for the pilot's 14 CFR Part 135 Airman Competency/Proficiency Check indicated the pilot received a satisfactory grade during his oral examination on the topics of tail rotor failures, settling with power, dynamic rollover, and loss of tail rotor effectiveness. According to the paperwork, the emergency procedures that the pilot was actually flight checked were simulated engine failures, inadvertent IMC procedures, unusual attitude recovery, and partial panel procedures.

The pilots normally work a 24-hour shift beginning at 0700. Records indicate the pilot was off duty the day before the accident and he reported for duty at 0700 on the morning of the accident.

AIRCRAFT INFORMATION

The helicopter was a single engine multipurpose Eurocopter AS350B2, s/n 2630. The main rotor blades turn clockwise as viewed from the top. Therefore, the right tail rotor control pedal is used to over come the effects of torque generated by the main rotor blades. The main rotor blades on most United States manufactured helicopters rotate counter-clockwise as viewed from the top.

N852HW was issued an airworthiness certificate on July 27, 1992. In October 1992, the helicopter was operated by Memphis Medical AirAmbulance Service, Inc., from 1992 until September 1999, at which time it was returned to American Eurocopter. RMH purchased the helicopter in March 3, 2000, when it had a total time of 4,280 hours.

N852HW was being maintained in accordance with an Approved Aircraft Inspection Program (AAIP). According to the logbooks, an "A" check was performed on the airframe on June 15, 2002, at a total airframe time of 5,543.2 hours.

The engine, a Turbomeca Arriel 1, s/n 9221, was manufactured on January 30, 1992. The engine was installed in 3 other helicopters prior to being installed in N852HW, on April 28, 1998. The engine had a total time of 3,460.8 hours when it was installed in N852HW. The airframe total time at engine installation was 2,998.36 hours. On June 15, 2002, "W" and "X" checks were performed at a total engine time of 6,004.7 hours.

According to maintenance records, on June 21, 2002, the Hobbs time was recorded as 4,391.7 hours, aircraft total time was recorded as 5,562 hours, and the engine total time was 6,023.5 hours.

The mechanic assigned to N852HW stated that on June 19, 2002, he and the accident pilot flew the helicopter from Norfolk to Lincoln, Nebraska, to have some avionics work done. Shortly after they took off on their return flight, smoke filled the cabin. They returned to Lincoln and discovered the air conditioner compressor had locked up and the belt was burned. The mechanic changed the belt and when he was closing the cowling the hydraulic pump belt snapped. The mechanic stated the belt snapped because it was located near the locked up compressor and it had been heated. The mechanic changed the hydraulic pump belt and they flew the helicopter back to Norfolk without incident.

Upon landing at Norfolk, the helicopter was refueled with 25 gallons of Jet A fuel. The helicopter was then flown to NE68 where it remained until departing on the accident flight.

The mechanic stated that on the morning of the accident, he went to the hospital and performed his daily inspection/preflight of the helicopter. He then met with the pilot as he was beginning his shift. They discussed the status of the helicopter and the pilot conducted his own preflight inspection. The mechanic reported that there were no outstanding maintenance issues with the helicopter.

The pilot completed weight and balance calculations prior to the flight. The total weight was calculated to be 4,658.8 pounds with a center of gravity (cg) of 128.7 inches. The maximum gross weight for the helicopter was 4,961 pounds with forward and aft cg limits of 124.8 inches and 137.8 inches respectively.

METEOROLOGICAL INFORMATION

A weather observation station, located at OFK, recorded the weather as:

Observation Time: 1154 cdt

Wind: 200 degrees at 16 knots, gusts to 21 knots

Visibility: 10 Statute Miles

Sky Condition: Clear

Temperature: 29 degrees Celsius

Dew Point: 22 degrees Celsius

Pressure: 30.13 inches of mercury

WRECKAGE AND IMPACT INFORMATION

The National Transportation Safety Board's (NTSB) on-scene investigation began on June 22, 2002.

The main wreckage was located at the edge of taxiway "A", just south of the run up pad near the approach end of runway 19. The helicopter came to rest on its right side with the tail rotor on the taxiway and the nose of the helicopter on the grass. The nose of the helicopter was pointing to a magnetic heading of 215 degrees.

The first impact mark along the wreckage path was at the edge of the taxiway approximately 40 feet southeast of the main wreckage. The forward portion of the left skid was found at this impact point.

Approximately 25 feet after the first impact, two slash marks and a gouge were located on the taxiway. The total distance between the first slash, second slash, and the gouge was 3 feet 7 inches. These marks lined up along the wreckage path with the final resting position of the tail rotor. The marks contai

NTSB Probable Cause

A loss of tail rotor effectiveness and the pilot's failure to maintain control of the helicopter. Factors associated with the accident were the binding of the tail rotor pitch changed rod, the gusty wind conditions, and the pilot’s lack of total experience in this make and model of helicopter.