N911LZEurocopter Deutschland Gmbh MBB-BK 117 C-2 · 2003

On August 17, 2009, at 0031 eastern daylight time, a Eurocopter EC-145, N911LZ, operated by the Lee County Division of Public Safety, as MedStar 1, was substantially damaged when it impacted water near North Captiva Island, Florida. The pilot and two medical crewmembers were not injured. Night visual meteorological conditions prevailed, and no flight plan was filed for the flight that originated at Page Field Airport (FMY), Fort Myers, Florida. The medical evacuation positioning flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to the pilot, she received a call around midnight for a patient pickup on North Captiva Island. After departure from FMY, she flew west over the water, with the autopilot engaged (set on altitude hold), at an altitude of 1,000 feet. The helicopter remained at 1,000 feet to assure obstruction clearance (towers on Pine Island). After passing over the towers, the pilot descended to 800 feet, using the autopilot. At the same time, she was attempting to contact the Captiva Fire Department (FD) on the radio. The pilot reported she tried to call the FD 4 or 5 times with no response, and then contacted Lee County Dispatch to confirm which frequency the FD was using.

When the helicopter was approximately 3 minutes from landing, the pilot selected 500 feet using the autopilot and the helicopter initiated a descent to that altitude. She continued toward the airfield and made a final transmission to the FD that she was "one minute out."

The pilot commented to the medical crew that she could see the FD moving fire trucks to the center of the landing zone (a grass airstrip). She stated she wasn't concerned that she could not reach the FD since she was landing on an airfield, and was familiar with the obstructions in the landing zone.

The pilot could not remember the exact sequence of the final 500-foot descent; however, at some point she remembered the medical crew commenting they "couldn't see anything." She responded, that the flight to Captiva is usually very dark over the water and there's "never anything to see." She remembered turning on the search light and shortly after, impacting the water. She also stated she thought she "pulled power and cyclic" when she saw the water; but didn't have time to warn the crew. After the helicopter impacted the water, it flipped over and was submerged within seconds.

The pilot had flown to North Captiva Island numerous times prior to the accident flight. She reported that the "sight picture was the same as previous flights;" however, the pilot did remember that during the accident just prior to impact, she saw an amber altitude alert on the primary flight display. The pilot did not remember ever disconnecting the autopilot during the flight, and knew she was "at the controls at impact." The pilot additionally reported no mechanical problems with the helicopter.

Both paramedics reported the flight was routine (with the exception of being unable to contact the FD), until they were within a few minutes of landing at North Captiva Island. At that time, they commented that they "couldn't see anything" outside of the helicopter. They observed what appeared to be rain outside the helicopter; however, since they knew it was not raining at the time, they thought this was the rotorwash from the water below. The helicopter then immediately impacted the water, flipped over, and the cabin filled with water within 5 seconds.

According to the Upper Captiva Fire Department, MEDSTAR transport was requested at 0000 EDT, for a head trauma patient.

At 0015, the personnel on-scene could hear the helicopter, but were unable to reach the pilot on the radio. They attempted contact with the helicopter on VHF frequency 122.750 and the "air ops" 800 MHz frequency.

They attempted to contact MEDSTAR until 0021, at which time a witness reported that he observed an aircraft impact the water. The Fire Department launched their rescue boat, while they continued to attempt to contact MEDSTAR on the radio.

At 0044, personnel on the Fire Department rescue boat reported all three crewmembers had been rescued and were on the boat.

The pilot held an airline transport pilot certificate with a rating for rotorcraft-helicopter. She also held a commercial pilot certificate with a rating for airplane single-engine land. The pilot's most recent FAA second-class medical certificate was issued on February 24, 2009. At that time, the pilot reported 5,800 hours of total flight experience.

The pilot reported 21 years of EMS flying experience. She began her career in fixed-wing aircraft, and in 1982, completed U.S. Army Flight School. She flew helicopters for the National Guard and in 1988 began employment with another Part 135 EMS operator.

The pilot was hired by Lee County in 1998. Since then, she flew the Messerschmitt-Bölkow-Blohm/Eurocopter BO-105 and then the EC-145 (beginning in 2003).

According to records provided by Lee County, the pilot had accumulated 6,061 hours of total flight experience, 621 of which were in the accident helicopter. She had 4,810 hours of total rotorcraft flight experience, 28 of which were in the previous 90 days, and 11 were in the previous 30 days. The pilot had accumulated 1,975 hours of night experience, 14 of which were in the previous 90 days and 5 of which were in the previous 30 days.

The pilot' most recent training was employer provided factory recurrent training in July 2009. The factory recurrent training included ground instruction and flight instruction in the accident aircraft.

The pilot's also completed a Part 135 Airman Proficiency Check on April 9, 2009 in the accident helicopter. The check flight was completed in 1.5 flight hours, and the pilot received a "satisfactory" rating.

In a post-accident interview, the pilot was asked about the possibility of fatigue during the accident flight. She stated she did not feel fatigued at all. Although this was her seventh night on duty, she had adapted to the night shift. She normally slept from about 1000-1500 when she worked nights. On the night prior to the accident, she did not receive any calls while on duty so she rested between 2200-0000, and 0400-0700.

The Eurocopter EC-145 helicopter was manufactured in 2003, and Lee County was the only owner. The helicopter was powered by two Turbomeca Arriel 1E2 turboshaft engines.

The most recent inspection performed on the helicopter was a 100-hour inspection, completed on August 14, 2009. At that time, the helicopter had accumulated 2,979 hours of total time.

Radar Altimeter (RA)

The accident helicopter was equipped with a radar altimeter. According to the pilot, she could not remember to what altitude the radar altimeter was set for the accident flight. She additionally reported that a pilot must set the radar altimeter prior to every flight, as it defaults to 0 at shutdown.

The accident pilot stated that the company procedure required setting the radar altimeter at 500 feet for night flights, and 300 feet during the day. According to an email sent from the chief pilot to all pilots on April 30, 2009, pilots were required to set the radar altimeter to at least 250 feet as a warning on all flights.

According to the helicopter manufacturer, the decision height flag on the radar altimeter is displayed when the radio height is lower than the selected decision height. In addition to the decision height flag, an audio alarm is also given, as well as a brown colored symbol (radio height zero) displayed on the barometric altimeter.

Terrain Awareness and Warning System (TAWS)

The accident helicopter was equipped with TAWS, which would have given the pilot an aural and visual indication of the helicopter's proximity to terrain.

The accident pilot reported the TAWS was selected to the terrain page during the approach to North Captiva Island. She stated she heard a terrain warning during her descent; however, that was not uncommon during a descent for landing (at altitudes below 1,000 feet).

The Manager of Aircraft Operations reported if the system was set correctly, the pilot should have also observed a solid red screen to display the low altitude warning.

Night Vision Goggles (NVG’s)

According to the Manager of Aircraft Operations, at the time of the accident, pilots had not completed training in NVG’s yet, and the program had not been approved by the FAA. He estimated that NVG’s would be fully implemented by December 2009.

MaxViz

The accident helicopter was equipped with a Max Viz system, an operational infrared night vision imaging system. The enhanced vision system was designed to improve situational awareness in all phases of rotor-wing flight operations.

Autopilot System Description

The accident helicopter was equipped with an automatic flight control system (AFCS). The AFCS consisted, in part, of two dual electronic modules (autopilot modules - APMs) which acquire helicopter angles and rates, compute AFCS control laws (basic stabilization and upper modes functions) and transmit them to the actuators. Another component of the AFCS is the self-monitored duplex series actuators of the smart electro-mechanical (SEMA) type for pitch and roll axes. Simplex SEMA is used for the directional axis.

The autopilot mode selector (APMS) for AFCS engagement and mode selection is located in the center console. Additional controls are located on cyclic sticks and collective levers.

The push buttons on the APMS are of the momentary push-type, whereas the push buttons for heading (HDG) and altitude acquisition (ALT.A) modes are rotary knobs. The APMS also features illumination for mode status indication.

The APMS enables the pilot to perform the following:

Preflight test

Engagement/disengagement of both APMs

Engagement/disengagement of autotrim

Engagement/disengagement of the following upper modes:

• VOR/LOC approach (APP)

• Heading acquisition and hold (HDG)

• Navigation in combination with an NMS (NAV)

• Altitude acquisition (ALT.A)

• Glide slope (GS)

• Vertical speed hold (VS)

• Indicated airspeed hold (IAS)

• Altitude hold (ALT)

The cyclic stick also contains controls for the AFCS. The SAS/AP CUT button disengages the SAS (3-axis backup SAS) and disengages the AFCS. The BEEP TRIM control modifies the attitude reference in ATT mode and modifies IAS, ALT, ALT.A, HDG, GA or VS reference when the respective mode is engaged. The AP MD DCPL button cancels all upper modes and reverts to ATT mode.

For upper mode engagement of the AFCS, the airspeed has to be above 60 knots. At airspeeds below 26 knots, any previously engaged upper mode will be automatically disengaged.

To engage the AP1/AP2 control a pilot must press the respective AP push button. The illumination "OFF" would then extinguish (the default mode after powering up the helicopter is AP off). To disengage the AP, a pilot must press the respective AP push button which then becomes illuminated "OFF." Additionally, pressing the SAS/AP CUT push button on the cyclic stick results in disengagement of all stabilization systems, and the pilot must fly "hands-on" at that point.

The ALT function of the AFCS maintains the current barometric altitude. To activate this function the pilot must press the ALT push button which then becomes illuminated "ON." The reference will be synchronized to the barometric altitude at the time of engagement. To disengage the ALT function, a pilot has three options. He/she can press the ALT push button on the APMS, and the illumination "ON" will then extinguish. The pilot can also press the AP MD DCPL push button on the cyclic stick. The autopilot will then revert to ATT mode. Or, the pilot can engage the GA, IAS, ALT.A, VS, or GS mode. To temporarily override the ALT function, the pilot can apply fore or aft motion of the cyclic. Additionally, if the pilot applies fore or aft motion of the BEEP TRIM switch on the cyclic stick, the altitude reference will slow at 1500 ft/min. The reference is indicated by a green bug on the PFD ALT scale, and on the AFCS strip of PFD, a green ALT label is displayed in the area of engaged mode axis.

The weather reported at FMY, at 0053, included winds from 060 degrees at 4 knots, 10 miles visibility, clear skies, temperature 25 degrees C, dew point 23 degrees C, and altimeter setting 30.07 inches mercury.

All three crewmembers reported the weather was "clear" at the time of the accident, and the visibility was "good."

The helicopter impacted the Intercoastal waterway, about 1/2 mile east of North Captiva Island, off of Pine Island. It was recovered from 6-8 feet of water about midnight on August 17, 2009, and transported to a secure facility.

A Federal Aviation Administration (FAA) inspector examined the helicopter after it was recovered. According to the inspector, flight control continuity was established and no anomalies were noted with the helicopter's engines.

The tailboom separated from the helicopter fuselage during the accident. Additionally, substantial damage was noted to the fuselage and main rotor blades.

After the helicopter impacted the water, it flipped over, and crewmembers estimated it filled with water within 5 seconds. They estimated the helicopter was in about 6-7 feet of water, about 200 yards off shore when it came to rest.

The first flight paramedic was seated in the rear of the helicopter, on the left side, facing aft. After the impact, he reached for the door handle and was able to open it and egress from the helicopter.

The second flight paramedic was seated on the right side of the helicopter, facing forward. After the impact, he reached for the door handle on his side of the helicopter. He was able to slide the door about 5 inches before it became stuck. He then egressed through a 12-inch gap between his door and the pilot's door.

The pilot was seated in the front, right seat of the helicopter. After the impact, she was also able to open her door and exit from it.

All three crewmembers were wearing their seat belts and shoulder harnesses, as well as helmets. Additionally, they had completed water survival (egress) training about three months prior to the accident flight. The crewmembers estimated they surfaced within 10 seconds of impact. They climbed onto the belly of the helicopter and used whistles and flashlights to attract the attention of the fire department.

The three crewmembers were not wearing life preservers during the accident flight; however, they were carried on the helicopter. After the impact, the crewmembers discussed going back into the helicopter to retrieve the life preservers; however, they agreed the helicopter was relatively stable and they were rescued after a short time.

As a result of the accident, the company now requires pilots and flight paramedics to wear a life preserver from takeoff to landing on every flight.

The following components from the accident helicopter were sent to the National Transportation Safety Board (NTSB) Vehicle Recorder Laboratory for further examination: L-3 Targa Data Recorder with PCMCIA Data card installed, Garmin model GNS-430 GPS/NAV/Com, Garmin model GNS-530 GPS/NAV/Com, Technisonic TDFM-6158 Com Unit, ECT Industries Boitier Helicopter Monitoring Type 704 unit.

According to the Specialist's Factual Report, all of the components contained significant corrosion due to their immersion in salt water during the accident. The L-3 Targa Data Recorder was capable of recording several hours of flight and engine data to the removable PCMCIA memory card. The Garmin units were capable of recording the last two (primary/standby) radio and navigation frequencies in battery backed up volatile memory. They did not store any GPS track data. The Technisonic Comm Unit did not store any useful data in internal memory. The ECT Industries Boitier Helicopter Monitoring unit did not contain any internal memory.

No data was recovered from either of the Garmin units. The internal batteries that held the memory alive were completely depleted due to the salt water immersion.

The L-3 Targa unit did contain flight data on the PCMCIA card. The recorded data was consistent with data that was recorded when the aircraft was initially delivered from the factory. According to the operator, they have no program in place to routinely remove the memory card from the Targa device and recover the data. It appeared the PCMCIA card "filled up" and subsequently stopped recording any new data.

Simulator Evaluation

On December 17, 2009, a simulator evaluation was conducted at the Eurocopter facility in Grand Prairie, Texas, under the supervision of the NTSB. The accident flight was recreated in an EC-145 simulator and four possible scenarios for the accident were identified.

The first scenario was that the helicopter must have an airspeed higher than 60 knots to activate the autopilot modes. If the helicopter was slower that 60 knots, the autopilot would not have engaged.

The second scenario was that the pilot may have pushed the altitude acquire button twice, thinking she hadn't already pushed it the first time. If the altitude acquire button is pushed twice, it will disengage the altitude acquire mode and the helicopter will not level off at the selected altitude.

These first two scenarios were determined to be unlikely as the accident scenario since the pilot observed an amber ALT light, which indicated the autopilot was engaged.

The third scenario was that the pilot may have engaged the vertical speed mode instead of the altitude hold mode. This would cause the helicopter to default to level at 65 feet and 60 knots. If not enough power (collective pitch) is maintained, the mode will disengage.

This scenario was possible, but not likely, since the pilot reported that she engaged the altitude acquisition (ALT.A) mode of the autopilot.

The fourth scenario was that the pilot selected altitude acquire (ALT.A) to 500 feet, which is what she reported. As commanded by ALT.A., the aircraft reached 500 feet, but the power setting (collective pitch), which must be manually controlled by the pilot, was not enough to maintain altitude at 60 kts. The aircraft then would have descended if the pilot did not add power (increase collective pitch) until the aircraft finally descended to the water.

While flying in the ALT mode, the green indication on the primary flight display (ALT) turns amber in case the minimum speed protection is activated. This occurs at 65 knots. From that point on, the aircraft will descend at 60 knots, and once an excessive deviation is detected, the amber indication blinking amber chevrons will appear. Neither the minimum speed protection nor the detection of an excessive deviation will deactivate an upper mode (autopilot does not disengage). The pilot must compensate for the lack of available power by raising the collective lever and increasing power, to allow the autopilot to automatically capture the preselected altitude. If the pilot does not increase power, the aircraft will descend through the selected altitude.

Organizational Information

Lee County MEDSTAR was the critical care transport service, air and ground, which operated within the division of Lee County Public Safety-Emergency Medical Service (LCEMS). MEDSTAR was responsible for on-scene responses and inter-facility transfers for Lee County and Southwest Florida. Lee County EMS covered more than 1,000 square miles, including seventy five (75) barrier islands scattered along the Southwest Florida gulf coast.

The air component of MEDSTAR was staffed with two critical care flight paramedics and an EMT/pilot. The ground component of MEDSTAR was staffed with two critical care paramedics and augments the air component.

At the time of the accident, MEDSTAR owned a Eurocopter BO-105 helicopter (N5217J), in addition to the accident helicopter. They employed six pilots including the chief pilot and director of operations.

Pilots typically worked 12 hour shifts, 7 days on followed by 7 days off. The shifts would alternate from day shifts (0700 to 1900) for one week, followed by night shifts (1900 to 0700) the next week.

Public Use

Although Lee County MEDSTAR was a county-owned and operated program, they held a Part 135 operating certificate. According to the Manager of Aircraft Operations, they operated primarily as a Part 135 commercial operator, and only operated under Part 91 (Public Use) if a State of Emergency was declared.

FAA oversight was conducted through the local Flight Standards District Office.

Dispatch

According to the dispatcher who handled the accident flight, she received the request for a helicopter transport from the Upper Captiva Fire Department. She dispatched the accident helicopter and monitored its route of flight on the "outerlink" GPS map system. She also maintained radio communication with the pilot while the flight was enroute. The dispatcher heard the pilot report "one minute out," and thought the helicopter icon was in the appropriate place on the GPS map. She then noticed that the helicopter had stopped moving on the GPS map. The dispatcher assumed it was a server problem, since on occasion the system stopped tracking intermittently. She subsequently rebooted the system hoping to see the helicopter had landed.

About 10 minutes later, the fire department called and "asked where Medstar was." This was the dispatcher's first indication that the helicopter had not arrived at its destination landing zone (LZ).

A review of the dispatch log revealed the following timeline:

"0015 - Medstar 1 advised ETA to LZ 1 minute

0015 - Noticed Outerlink was no longer following. Attempted reboot.

0025 - Upper Captiva called to check on Medstar1 from the LZ.

0028 - Upper Captiva started crews to the boat to check a light seen from shore

0044 - Medstar1 crew members aboard UCFD boat."

The Outerlink system reported the last GPS hit at 1214:05 EDT, at an airspeed of 88 mph, a heading of 270 degrees, and an altitude of 176 feet.

According to the Lee County Helicopter Operations General Operations Manual (GOM), the pilot was responsible for the following during a flight:

• "Contact Emergency Operations Center (EOC) as soon as practical after takeoff and update any information as required or requested

• Verify by radio with EOC that electronic flight following is operating correctly and/or make position reports of Lat/Long by radio to EOC every fifteen minutes

• Advise EOC of flight plan changes as soon as possible and when transitioning to ATC flight following"

The GOM further stated dispatcher duties included the following:

• "Record for each flight as a minimum, that information contained in a VFR flight plan as listed in FAR 91.153

• Monitor each flight until completion

• Record fifteen minute position reports as appropriate

• Advise pilot when electronic flight following is inoperative"

Flight Following

The Lee County EMS Medstar Polices stated in part, "Lee Control is mandated by State regulations to track and record flight data for every flight made by a Lee County EMS helicopter.

• Medstar is tracked via OUTERLINK until the flight terminates back at RSW.

• Regardless of the functionality of OUTERLINK, verbal communications with Medstar is required every 10-15 minutes for local flights and every 15 minutes for out-of-county flights. It is the responsibility of the crew to initiate this communication.

• With regards to out-of-county transports, a Medstar crew member shall make landline contact with Lee County upon arrival at the facility and again when departing that facility.

Manual tracking becomes necessary whenever the OUTERLINK system is out of service. Lee Control will notify the pilot when the OUTERLINK system is down and also when it becomes operable again."