NTSB Factual Report

HISTORY OF FLIGHT

On October 17, 2012, at 0636 eastern daylight time, an Aerospatiale AS 355 F2, Canadian registration C-FXGM, operated by Catalyst Aviation LLC, was substantially damaged when it impacted trees and terrain shortly after takeoff from Brigham Heliport (4PN5), Erwinna, Pennsylvania. The airline transport pilot was fatally injured. Dark night instrument meteorological conditions prevailed, and no flight plan was filed. The positioning flight, destined for Wings Field (LOM), Philadelphia, Pennsylvania, was conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to the operator, the pilot was scheduled to position the helicopter from 4PN5 to LOM, where after fueling; passengers would embark for a local pipeline patrol flight. The pilot reported to the operator his intent to depart from the heliport via a text message that was received at 0637. No further communications were received from the pilot.

Several witnesses reported hearing the helicopter as it overflew their rural neighborhood about the time of the accident. The witnesses reported that it was not unusual to observe the accident pilot operating helicopters from the heliport in his backyard, particularly during his prior years of service as a State Police pilot. The witnesses reported that on the morning of the accident flight, the helicopter they heard sounded "abnormal." The witnesses generally described that the helicopter was low, loud, and that it sounded different than previous times they had heard helicopters departing the heliport. One witness, who happened to be looking out a window at time of the accident, observed two lights that she presumed to be the accident helicopter as they descended into trees behind her home.

After hearing the sounds of impact, some of the witnesses responded to the accident scene and attempted to render assistance.

Several witnesses who lived in the vicinity of the accident site were interviewed separately shortly after the accident. Each was asked to describe the weather and lighting conditions that prevailed at the time. The witnesses consistently described the weather as "foggy," with some stating that it was "very" or "extremely" foggy. One witness described the fog as being very dense, like "pea soup," while another estimated the visibility to be about 1/8th-mile. The witnesses also consistently described the lighting conditions as "dark" or "very dark". Another witness who lived about 1 mile north of the accident site described the weather conditions about 1 hour after the accident as cloudy with no fog.

PERSONNEL INFORMATION

The pilot, age 52, held an airline transport pilot certificate with a rating for rotorcraft-helicopter, as well as a commercial pilot certificate with ratings for airplane single and multi-engine land, and instrument airplane. He additionally held a flight instructor certificate with ratings for airplane single engine, rotorcraft-helicopter, and instrument helicopter. His most recent Federal Aviation Administration (FAA) second class medical certificate was issued on July 23, 2012 with the limitation, "must wear corrective lenses."

According to a résumé provided to the operator by the pilot, he was previously employed as a Trooper with the Pennsylvania State Police. Between 1993 and 1996, he was employed as a pilot operating airplanes, after which he operated helicopters through 2004. The pilot was employed as the helicopter unit supervisor between 2004 and 2011. During that period the pilot reported several other part time jobs with other helicopter operators. According to the pilot's personal flight log, his final flight as a State Police pilot was logged on January 5, 2011. When asked to describe the pilot, the operator stated that she was very confident in his abilities, judgment, and training; stating that he was a "go-to" person, and that he was the best representative of the company. She further described the pilot as very safety conscious, and related an anecdote about an instance where the pilot had refused to depart on a daytime mission until a burnt-out position light had been replaced.

The pilot's personal flight log was recovered at the accident site, and reflected flights logged between November 2002 and October 9, 2012. The pilot's flight hours between October 9 and October 14 were recovered from the accident helicopter's maintenance journey log. According to the logs, the pilot had accumulated 7,106 total hours of flight experience, 4,599 hours of which were in helicopters. The pilot recorded about 100 hours of flight experience in the accident helicopter make and model.

As of January 2011, the pilot had accumulated 593 total hours of flight experience at night, 228 hours of which were with the aid of night vision goggles. Between that time and the pilot's most recent flight log entry on October 9, 2012, he had logged an additional 4.1 hours of night flight experience, 2.9 hours of which were accumulated in the 90 days preceding the accident in the accident helicopter make and model.

According to the operator's records, the pilot's most recent FAR Part 135 recurrent check was completed on April 27, 2012. While a remark on the evaluation form noted, "Inadvertent IMC tested & passed," the proficiency check did not cover instrument operations. According to the pilot's personal flight records, his most recent instrument proficiency check was completed in an airplane on February 25, 2012. The pilot's most recent logged instrument flight experience in a helicopter included 0.3 hours of simulated instrument experience logged in June 2010, and 1.0 hour of simulated instrument experience logged June 2008. No evidence of any more recent instrument flight experience in helicopters or an instrument proficiency check in a helicopter was contained within the pilot's personal flight log or other records provided by the operator.

Activities Preceding the Accident

The operator entered into a lease agreement with the accident helicopter's owner for use of the helicopter while another of the operator's helicopters underwent repairs. The accident pilot subsequently retrieved the accident helicopter from the owner on October 7, and flew it from Buffalo Niagara International Airport (BUF), Buffalo, New York, to one of his homes in Binghamton, New York. After performing four local flights in the vicinity of Binghamton between October 9 and 12, the pilot positioned the helicopter to his home at 4PN5 on October 14. The operator last contacted the pilot via telephone on October 16 at 2000. At that time the pilot was at the local fire department, receiving training as a volunteer fireman.

On the morning of the accident the pilot was scheduled to arrive at LOM about 0730 in preparation for the pipeline patrol flight that was to follow.

AIRCRAFT INFORMATION

According to the Canadian Civil Aircraft Register, the accident helicopter was manufactured in 1991, and imported to Canada in 2010. The helicopter was equipped with a three-blade main rotor system and two Rolls Royce/Allison 250-C20F engines each rated at 420 horse power. According to the operator, the helicopter was not equipped for operation in instrument meteorological conditions.

The helicopter's most recent annual inspection was completed on February 21, 2012, and at that time the helicopter had accumulated 7,534 total flight hours. According to the maintenance journey log, which was recovered from the wreckage, the helicopter had accumulated 7,556 total flight hours prior to the accident flight. A log entry made by the accident pilot on the date of the accident noted compliance with Airworthiness Directives 2001-26-55 (tail rotor blade inspection) and 2011-22-05 (tail rotor control rod bearing play inspection) and that no discrepancies were found during either inspection.

METEOROLOGICAL INFORMATION

The National Weather Service (NWS) Area Forecast applicable to the area surrounding the accident site, which was issued at 0445, predicted broken to scattered ceiling with visual meteorological conditions generally prevailing around the region. No AIRMETS or SIGMETS were current for the area of the accident flight at the time of the accident.

Geostationary Operational Environmental Satellite -14 infrared satellite image for 0645 depicted a band of mid-level stratiform-type clouds over the accident site with a radiative cloud top temperature that corresponded to cloud tops near 16,000 feet. The first available visible satellite image at 0732 showed a band of low stratiform clouds or fog/mist over the accident site, and along the Delaware River Valley.

The weather conditions at Doylestown Airport (DYL), Doylestown, Pennsylvania, located about 11 nautical miles south of the accident site, at 0654, included calm winds, clear skies below 12,000 feet, 10 statute miles visibility, a temperature and dew point of 1 degree C, and an altimeter setting of 29.99 inches of mercury.

The weather conditions at LOM, located about 25 nautical miles southwest of the accident site, at 0635, included calm winds, clear skies below 12,000 feet, 5 statute miles visibility, a temperature and dew point of 3 degrees C, and an altimeter setting of 29.97 inches of mercury.

According to the U.S. Naval Observatory, on October 9, 2012, the beginning of civil twilight occurred at 0648 and sunrise occurred at 0716. The moon set at 1902 on the preceding evening, and did not rise again until 0949 on the morning of the accident.

Several witnesses who lived in the vicinity of the accident site were interviewed separately shortly after the accident. Each was asked to describe the weather and lighting conditions that prevailed at the time. The witnesses consistently described the weather as "foggy," with some stating that it was "very" or "extremely" foggy. One witness described the fog as being very dense, like "pea soup," while another estimated the visibility to be about 1/8th-mile. The witnesses also consistently described the lighting conditions as "dark" or "very dark". Another witness who lived about 1 mile north of the accident site described the weather conditions about 1 hour after the accident as cloudy with no fog.

According to the NWS, "Radiation fog forms at night under clear skies with calm winds when heat absorbed by the earth's surface during the day is radiated into space. As the earth's surface continues to cool, provided a deep enough layer of moist air is present near the ground, the humidity will reach 100% and fog will form. Radiation fog varies in depth from 3 feet to about 1,000 feet and is always found at ground level and usually remains stationary. This type of fog can reduce visibility to near zero at times and make driving very hazardous." Radiation fog is most common under high pressure systems and ridges during the fall and winter months, where clear skies and light winds prevail.

AIRPORT INFORMATION

The departure heliport, 4PN5, was located about 1,000 feet southwest of the accident site. The heliport was comprised of a 65-foot square turf and gravel helipad, which was located in the backyard of the pilot's home at an estimated elevation of 400 feet. A rural neighborhood surrounded the heliport to the north, east, and south. The west bank of the Delaware River was located about 1/2-mile east of the heliport, at an elevation of 120 feet.

FLIGHT RECORDERS

The helicopter was not equipped with any flight data recording devices, nor was it required to be; however, a hand-held global positioning system (GPS) receiver was recovered from the wreckage, and found to contain data pertaining to the accident flight. The initial data point was recorded at 0634, at the 4PN5 helipad. The helicopter's position began tracking northeast at 0635:59, at a GPS altitude of 442 feet. Over the next 27 seconds, the helicopter began to accelerate to about 85 knots ground speed, while turning to the right and maintaining a relatively constant altitude, within about 50 feet of the helicopter's initial recorded altitude as it began to accelerate.

The helicopter maintained a consistent right-turning track for the entirety of the flight. Between 0636:09 and 0636:17, the calculated turn rate of the helicopter increased from about 3 degrees per second to about 18 degrees per second. Over the next 7 seconds, the turn rate decreased to about 14 degrees per second. The calculated turn rate between the final two recorded GPS positions increased again to about 31 degrees per second. Over the final 5 seconds recorded for the flight, the helicopter descended from a GPS altitude of 503 feet to 455 feet, which corresponded to an approximate 575-foot per minute average descent rate for that portion of the flight.

The initial impact point (IIP) was located about 300 feet northwest of the helicopter's final GPS recorded position.

WRECKAGE AND IMPACT INFORMATION

The accident site was located in a densely wooded area approximately 1,000 feet northeast of 4PN5. The IIP was identified by several damaged tree limbs about 75 feet above the ground, a height which was roughly the same as that of the departure heliport. A wreckage path approximately 300 feet long, oriented roughly 350 degrees magnetic, extended from the initial impact point to where the main wreckage came to rest against a tree. The main wreckage was oriented on a westerly heading, and was largely consumed by a post-impact fire. Each of the three main rotor blades was accounted for at the accident scene, and all came to rest within 30 feet of the main wreckage.

The wreckage was subsequently recovered from the accident scene and examined in detail at an aircraft recovery facility.

The tailboom had severed from the fuselage forward of the horizontal stabilizer, and was found along the wreckage path about 30 feet south of the main wreckage. The severed tail section consisted of the tailboom structure, left horizontal stabilizer, the inboard portion of the severed right horizontal stabilizer, the vertical stabilizer, and the tail rotor. The forward end of the tailboom was crumpled with a leftward directionality. The examined fracture surfaces of the tailboom structure all exhibited signatures consistent with overstress failure. The right horizontal stabilizer was severed from the tailboom via a fracture that began at the inboard forward end of the horizontal stabilizer with an aft and upward directionality. Examination of the fracture surfaces revealed signatures consistent with overstress failure and wooden splinters lodged between the top skin and doubler of the right horizontal stabilizer. The left horizontal stabilizer remained mostly intact and attached to the tailboom, albeit with a slight downward bend and with a small section of the outboard trailing edge that was severed. The vertical stabilizer suffered no major damage except for a large dent near the leading edge of the top portion of the vertical stabilizer.

The landing skids were recovered as an assembly. Both forward and aft crosstubes did not exhibit severe bending. The main fuselage attachment points remained on the crosstubes and did not exhibit significant movement or extreme rotation about the crosstubes.

All three main rotor blades exhibited significant impact-related damage to their respective leading edges, consistent with the damage observed to the trees at the accident site. Each of the main rotor blades (identified as red, blue, and yellow) exhibited the majority of the impact signatures at their tip, mid span, and root, respectively. The portions of the blades outboard of each impact was displaced aft, toward each of the blades trailing edge. The Starflex arms each exhibited signatures consistent with tensile failure on their advancing sides and compressive failure on their trailing sides. The composite main rotor blade sleeves for the yellow blade had fractured and exhibited severe splintering consistent with a high energy impact. The sleeves for the red blade exhibited less severe fractures, while the blue blade sleeves were consumed by the post-impact fire.

The tail rotor blades exhibited scuffing on the blade skin as well as damage to the blade tips. Several fractures that ruptured through the blade skin were observed on both blades, but the blades themselves rem

NTSB Probable Cause

The pilot’s decision to depart under visual flight rules in dark night instrument meteorological conditions, which resulted in subsequent spatial disorientation, uncontrolled descent, and impact with trees and terrain.