NTSB Factual Report

HISTORY OF FLIGHT

On September 30, 2012, approximately 0932 central daylight time, an Augusta 109E Emergency Medical Service (EMS) helicopter, N144CF, registered to Wells Fargo Bank NW NA Trustee, Salt Lake City, Utah, crashed after an uneventful 26 minute cross-country flight. The crash occurred while the helicopter was being maneuvered to avoid local weather prior to setting up for an instrument approach to the Eastland Airport, Eastland, Texas. All three occupants, the airline transport rated pilot, flight nurse, and a flight paramedic, sustained serious injuries. The flight was being operated by CareFlite of Grand Prairie, Texas, and was conducted under the provisions of 14 CFR Part 91 as a repositioning flight to pick up a patient. The helicopter departed the CareFlite base located at Granbury Airport (GDJ), Granbury, Texas, at 0906. Its intended destination was the Eastland Airport (ETN), Eastland, Texas. Visual meteorological conditions prevailed along the route of flight from Granbury to Eastland, however, marginal visual meteorological conditions or instrument conditions were reported in the vicinity of the accident site. A company VFR flight plan was activated upon departure from Granbury and an IFR flight plan was placed on file with ATC, but was not activated.

According to first responders to the accident site, the helicopter impacted the ground in an open field, approximately 4.4 miles south of Eastland Airport. Emergency responders transported the occupants to a nearby hospital. The helicopter was transported to a secure facility for detailed examination.

Flight Nurse was located in the rear cabin, Aft-facing seat which is located on the right side of the aircraft. The Flight Paramedic was seated in the Co-Pilots seat. All three crew members' observations/recollections of the flight/event are as follows:

Flight Paramedic

According to the Paramedic, the crew received a call from CareFlite dispatch and the pilot accepted the mission. The pilot checked the weather and asked the CareFlite communications center to put an IFR flight plan on file and requested that the helicopter be topped off with fuel prior to departure. After preflight, the helicopter took off and began the flight in visual meteorological conditions (VMC). As we approached Eastland, visibility toward the north appeared to be decreasing. The pilot made the decision to continue the flight under IFR and stated to the Paramedic and Flight Nurse that he would slow down the helicopter's airspeed and follow a roadway below while he set up the autopilot to fly an instrument approach to the airport.

The Paramedic felt the airspeed decrease and the pilot handed him a book with the approach plate for Eastland. The Paramedic held the book open to reference as needed. The Paramedic then became a little concerned with the situation. He looked back over his left shoulder at the weather conditions and made a statement to the pilot that he did not like the situation that we were getting into. The Paramedic then watched the navigational instruments and tried to remain calm. He noticed the pilot activate and deactivate different autopilot settings. During this time, the Paramedic noticed that the airspeed was continually decreasing as the altitude increased and at this point the helicopter was in complete IMC. The paramedic then noticed some fluctuation in the artificial horizon but it didn't seem too severe. He then felt a vibration, similar to that of an aircraft accelerating. He looked at the altimeter and it was spinning extremely fast and told the pilot that he felt as if the helicopter was in a steep dive. He stated that the pilot did not reply. The Paramedic then looked at the artificial horizon on the pilot side and observed that it was in an extremely askew orientation.

At this point the pilot frantically stated that we were about to crash. Seconds later, the helicopter broke through the clouds pointing straight down at the ground. The Paramedic recalled seeing the pilot using the collective to attempt to pull up. The next thing he recalled was moments after the helicopter came to rest, he was still was still in his seat, the flight nurse had exited the helicopter, and the pilot was turned sideways and appeared to be standing in front of him inside the helicopter as it rested on its side. He recalled that at least one engine was still running. The Paramedic then saw the pilot turn both engine switches to the 'OFF" position. At this point, a bystander helped the pilot exit the helicopter through the pilot door and helped me exit through the window just above the co-pilot door.

Flight Nurse

The Flight Nurse had been with CareFlite for 16 years and had was familiar and trained in the company's IFR program for flight crewmembers. According to the Flight Nurse, the crew was initially notified that the flights destination was to be directly to the Eastland Hospital. The flight destination was then changed to the Eastland Airport due to the pilot having stated he did not have weather reporting available in Eastland prior to the flight, and in case of the need for IFR flight into Eastland Municipal Airport. She stated that the pilot had filed an IFR flight plan as a back-up.

While preparing to go out to the aircraft, the Flight Nurse discussed the flight with the Flight Paramedic. The paramedic was not a permanent crewmember at the CareFlite base in Granbury, TX, but was called in to work from a different base. During their conversation, the Flight Nurse mentioned to the Flight Paramedic that she was concerned over the pilot's limited IFR experience in that particular helicopter (the Agusta 109). She understood that the pilot was one of the last pilots in the company to go through the certification of the IFR program. It was stated that as medical crewmembers that they would need to support the pilot in the event that the weather deteriorated and the flight plan would require IFR.

During the crew duties before take-off the Flight Nurse remembered that the pilot mentioned that he had programmed the flight data into the aircraft in the event that an IFR approach was necessary going into Eastland. She stated that takeoff and departure was normal. The Flight Nurse was speaking with Eastland EMS on the progress of the flight and stated that they had an ETA of approximately 4-5 mins to the airport. Over the intercom, the Flight Nurse heard the Flight Paramedic state that, "I'm not comfortable with this." At that time, the Flight Nurse turned to the right to look forward into the cockpit and the helicopter was in the clouds – totally "Whited Out." The Flight Nurse replied to the Paramedic, "Oh, I'm not either." She said that prior to the aircraft entering into the clouds the flight was normal, doing just fine and no issues. It seemed to be a direct route.

The Flight Nurse asked the pilot if there was anything that they could do to help and the pilot did not reply. She noted that the IFR Approach plates were out and that the Paramedic was assisting the pilot with them. She also noted that the pilot did not communicate much and said that there was no communication from the pilot on the possibility of entering the clouds. She said that the helicopter had been climbing and the altimeter instrument was reading approximately 4,500 feet. Pilot did state that "we should be fine here." The Flight Nurse heard the pilot make an attempt to contact the tower.

Flight Nurse observed the pilot push a button up front on the panel. Almost immediately the aircraft seemed to go out of control, rolling to the left and right, and seemed to be pitching up and down at times. She stated that the upset was very scary and disorienting to her, and that she could not tell whether the aircraft was going up or down from her seat. The helicopter seemed to be out of control. The helicopter seemed to be not responding to the pilot's inputs and was descending at a rapid rate. She said that she could not tell if the pilot was hand-flying the aircraft or not and remembered hearing the Paramedic state, "We are in a nose dive, Pull Up, Pull Up." The Flight Nurse also repeated, "Pull Up, Pull Up."

The Flight Nurse stated that there was serious tension due to the "G" forces during the descent. There seemed to be pressure on her lungs and chest. When the aircraft came to rest, the Flight Nurse stated that it took time for her to gain her breath and thought that she may have a possible collapsed lung. The Flight Nurse was also concerned with her back hurting and thought that her back was broken. At this time she tried to stand up in the cabin of the aircraft and cleared herself from the medical equipment and debris that was everywhere in the cabin. She tried to contact the pilot and paramedic up front and did not receive a reply. Within seconds, a gentleman arrived at the accident scene. The Flight Nurse dialed the CareFlite communications center on her personal cell phone and notified them of the accident.

All 3 flight crewmembers were prepared for ground transportation by first responders and loaded into ambulances. While the Flight Nurse was at Fort Worth Harris Methodist Hospital the crew was visited by many other CareFlite crewmembers. Many crewmembers stated that the accident aircraft had a similar event with the training pilot. They stated it was some sort of an upset event, included a steep nose-dive but he was able to pull out of the dive. He was not IFR. It was also stated that maintenance could not duplicate some of the reported issues/concerns. The Flight Nurse stated that she had flown with the accident pilot for the past 2 years, but never IFR with him – only the other pilots at the base. Also, the Flight Nurse stated that the flights were usually started under IFR and then the complete route would be flown and not changed over to IFR enroute.

Pilot

The pilot stated that at his request, CareFlite Dispatch had filed an IFR Flight plan for the flight to Eastland. He said that all was normal on the flight until approximately 10 miles from Eastland. Initial cruise altitude was 2,500 feet MSL. The weather had deteriorated to high overcast, mid-level scattered to broken with some rain showers and reduced visibility. As a precaution, the pilot began a climb, initiated using auto-pilot VSI Mode to an altitude of approximately 4,000 feet. The climb was necessary to communicate with Fort Worth (FTW) Approach. The pilot then communicated with FTW Approach to activate flight his IFR flight plan that was previously on file. Fort Worth Approach replied to standby. He then engaged auto-pilot (AP) Altitude hold. He said that everything was normal before initiating the AP. After engaging the AP the aircraft abruptly pitched down 90 degrees and began spinning simultaneously with the airspeed increasing. The pilot scanned the instruments and identified a disagreement between the Pilot and Co-Pilot ADI. He then turned the AP off and moved his scan to the Back-up Vertical Reference Gyro (Back-up ADI). The pilot then attempted an unusual attitude recovery and tried to stop the spinning and rotation of the helicopter. He initiated back pressure on cyclic control and scanned the instruments to verify that the helicopter was still descending. He said that the attitude was leveled and the VSI and altimeter were moving rapidly.

He eased up on cyclic back pressure because he did not want to overstress the rotor system and entered the clouds below and used the instruments. The helicopter came out of the bottom of the cloud base very close to the ground in VMC. He said that he did not feel that he was flying against non-pilot initiated control inputs during the recovery sequence. The pilot saw power lines and he attempted an emergency landing. The helicopter touched down in a level attitude, bounced several times and skidded to a stop.

After the landing, the pilot was dazed ad had no memory of losing consciousness. He turned off both Power Management Systems switches and engines continued to operate. Both throttles were bent over on the overhead control panel. The pilot then turned off both fuel shutoff valves.

PILOT INFORMATION

The pilot was hired by CareFlight on January 28, 2009. At the time of hire, had over 7,000 hours of total helicopter flight time with over 6,000 hours as Pilot-In-Command (PIC) in helicopters. Prior to his employment with CareFlight, the pilot had many years of flight experience as an Electronic News Gathering (ENG) helicopter pilot within the Dallas/Fort Worth metro area. The pilot was assigned the position of pilot-in-command of the A109E aircraft.

The pilot held an Airline Transport Certificate with Rotorcraft-Helicopter and Instrument ratings and a Flight Instructor Certificate with Rotorcraft-Helicopter and Instrument ratings. His valid FAA Second Class Medical Certificate was issued on 08/09/12.

Initial Training

The pilot's initial 14 CFR Part 135.293 and 135.299 check ride was administered on March 31, 2009 with satisfactory results in the A109E aircraft. The company check airman administered the check ride. On January 20, 2012, the pilot completed additional training and a Part 135.293, 135.297, and a 135.299 check ride was completed to act as VFR and IFR pilot in command.

Historical Recurrent Training

Recurrent training flights in the A109E were completed on January 6, 2012 and the pilot passed a Part 135.297 check ride on July 10, 2012.

Transition Training

The pilot received several company IFR training flights starting November 22, 2011 thru January 6, 2012. He completed a Part 135.297 check ride on January 20, 2012.

Current Qualification

On January 20, 2012 a recurrent check ride in the A109E was completed. The check ride was administered by a company check airman.

Flight and Duty Time

On September 30, 2012, the day of the accident, the pilot had not flown. He arrived on duty at 0645 and planned to log off duty time of 1900, according to the duty log. The estimated duty period for the day would have been 12.25 hours. The previous day (09/29/12), the pilot's duty time was logged from 0645 to 1900, a duty period of 12.25 hours. He logged 0 hours of flight time on this day. The following flight times were listed on the company Pilot Duty Record: (The flight times below do not include the approximate flight time of 0.4 hours accumulated on the accident date.)

September 13.4 hours

August: 15.9 hours

Calendar quarter: 50.1 hours

Last two consecutive quarters: 116.1 hours

Calendar year 2012 total: 176.3 hours.

According to the pilot's Pilot in Command Qualifications form, which was completed by the pilot in January 2009, he had logged over 7,600 hours of flight time.

Flight time last 90 days in A109: 50.1 hours

Flight time last 30 days in A109:13.4 hours

Flight time last 24 hours in A109:0 hours

According to the records kept by the operator, the pilot is appropriately rated and medically qualified. The pilot is qualified to act as pilot-in-command of the A109E aircraft in 14 CFR Part 135 operations. The airman is current in qualification and, according to company records, adheres to the appropriate flight and duty time limitations. The pilot's most recent Part 135.299 check ride occurred on January 20, 2012, with satisfactory results.

Pilot 72 Hour History (Information Provided by the Chief Pilot)

The pilot was off duty on September 26, 2012.

The pilot worked September 27, 2012. He logged in at 0645 am and logged off at 1900, with no flights.

The pilot worked September 28, 2012. He logged in at 0645 am and logged off at 1900, with no flights.

The pilot worked September 29, 2012. He logged in at 0645 am and logged off at 1900, with no flights.

The pilot worked September 30, 2012. He logged in at 0645 am. He received is company flight release at 0659 which was valid until 2045. He received a radio call from Comm. Center at 0853 for a weather check for a scene flight to Eastland, TX. He said the weather was good and that he would top off the fuel and be ready to go. The Comm. Center dispatched him at 0855 and he was enroute at 0907. There were no out of the ordinary issues for any of the last days the pilot was on duty.

AIRCRAFT INFORMATION

The Augusta A109E helicopter, serial numbe

NTSB Probable Cause

The loss of helicopter control after an in-flight upset, which occurred when the pilot selected the autopilot’s altitude hold mode; the reason for the reported in-flight control anomaly could not be determined during postaccident helicopter examinations. Contributing to the accident was the pilot's delay in transitioning to instrument flight rules flight before entering instrument meteorological conditions.