RA-25464 – Mil MI-8MTV-1 – 1999-03-15 NTSB Accident Report

NATIONAL TRANSPORTATION SAFETY BOARD

AIRCRAFT ACCIDENT REPORT

IMPACT WITH MOUNTAINOUS TERRAIN, AT NIGHT

INTERNATIONAL CHARTER INC. OF OREGON, Mi-8MTV-1, RA-25464, 38 MILES NORTH OF PORT-AU-PRINCE, MARCH 14, 1999; IAD99RA036

1. FACTUAL INFORMATION

1.1 History of Flight

On March 14, 1999, about 1945, a Mil Mi-8MTV-1, registration RA-25464, operated by International Charter Inc., of Oregon (ICI), impacted mountainous terrain, 15 miles west-southwest of Hinche, Haiti (Unless otherwise noted, all times are local, eastern standard time, est.). The flight had a dual mission of emergency medical evacuation (medevac) pickup, and the transport of maintenance and security personnel to assist a sister helicopter, RA-25463 (RA-63). All 13 persons on board RA-64 sustained fatal injuries. ICI, in contract with Vladivostok Air (V/A), provided two Mi-8 helicopters in Haiti, and flight and maintenance personnel. The operator was brought to Haiti by letter of agreement between the U.S. Embassy and the Haitian government, to replace CH-47 Chinook helicopters in a transport mission. ICI held FAA certificate number 17CA0811, effective January 8, 1998, and was certified to operate as an "air carrier and conduct common carriage operations," in accordance with 14 CFR Part 135 (ICI Operator's Certificate, Attachment 1). The Mi-8s were certified in Russia for flight and maintenance in accordance with Russian Civil Aviation Regulation no. 15.07.91r-17.07.91. RA-64 held Airworthiness Certificate no. DB-645, dated March 26, 1998, and was registered in Russia under Certificate of Registration no. 3231, dated April 20, 1998 RA-25464 (Certificates of Registration and Airworthiness, Russian Federation, Attachment 2). The flightcrew was comprised of two pilots and a flight engineer (Russian citizens). An ICI corporate officer, who was a U.S. citizen, served as the aviation officer, stationed in the cabin. The passengers consisted of three Russian maintenance personnel (to performance maintenance on RA-63) and six Argentine Gendarmeria security personnel, serving in the United Nations civil police mission to Haiti (MIPONUH). RA-64 was verbally tasked by the tasking officer of the UN mission to Haiti for the emergency medevac. Flight orders for a Canadian utility helicopter squadron, which ICI replaced, were on file at ICI base operations. A specific flight plan was not filed for the accident flight (The operator provided Attachment 3, regarding the flight plan. The attachment outlines a radio check with operations base to "Open my flight plan").

The ICI base radio operator stated that during the afternoon of March 14, he received a call from the tasking officer, who said that a written task order would follow by FAX. The mission was to fly an Mi-8 to Labadee, near Cap Haitien, about 85 miles north of the ICI facility at MTPP (MIPONUH AIR REQUEST, TASK/MISREP form, Attachment 4. The landing field at Labadee was a soccer field. There were no navigation aids at Labadee. The nearest airport was at Cap Haitien). The ICI on-call crew was notified and an ICI corporate officer took the position of in-cabin air officer. At 1735, RA-63 departed MTPP and at 1801 called base and reported landing assured at Labadee (ICI Radio Log, transcription and rewriting of transcription, 2 pages, Attachment 5).

The chief air traffic controller at MTPP later stated that the tower operator staffed the tower until 2200 local. The 1700 and last recorded meteorological observation for MTPP was "visibility unlimited, few clouds broken at 3,000 feet, cumulonimbus, few clouds at 8,000 feet, and few clouds at 23,000 feet, temperature 29 degrees Celsius, dew point 22 degrees, QNH (barometric pressure) 1012.4, cumulonimbus north (Tower hourly weather log, Attachment 6. CAA, Haiti, stated that the meteorological observer departed the tower after the 1700 observation). The captain of RA-63 later stated that he flew to Labadee, flying northeast, and near the city of Hinche turned to the northwest, in order to take advantage of valleys and lower en route terrain. He stated that he noted clouds in the mountains but was not particularly concerned regarding weather for his return flight from Labadee.

The medevac was a woman from Finland who had been struck by a boat and seriously injured. Upon RA-63 landing at a soccer field at Labadee, she was brought into the aircraft cabin. Prior to takeoff, the air officer, standing outside the helicopter, noted that the exhaust cowling for one of the engines was missing. The flight did not depart, and a call was made to ICI operations to state that the injured woman was still in need of transport and the aircraft was down in the landing zone for maintenance. According to the ICI base radio dispatcher, a company officer who had been in ICI operations throughout the afternoon, soon conferred in person at ICI with the MIPONUH tasking officer. Shortly thereafter, three V/A mechanics gathered with their tools to fly on board RA-64 to assist RA-63. Also, six Argentine Gendarmeria arrived to also fly on board RA-64, in order to provide overnight security for RA-63. A typed log, submitted by Port-au-Prince Tower, records that at "001520 [Zulu] RA464" initially contacted Tower for departure (Port-au-Prince "Pilot Controller Communications," Attachment 7. "001520" is 0015:20 Zulu/Greenwich Mean Time or 1915: local). RA-64 lifted-off with maintenance and security personnel on board. The ICI company officer was stationed in the cabin as the air officer. The ICI radio dispatcher recorded that at 1935 the flight radioed base that they were passing over Point November (five miles north of the ICI facility), outbound, and estimated landing at Labadee at 2000. The flight again contacted ICI base, about 4 minutes prior to impact (See CVR transcript, Attachment 8, two copies: complete in Russian and partial English translation).

The RA-64 cockpit voice recorder (CVR) was recovered from the crash site and read-out at the Interstate Aviation Committee investigative laboratories in Moscow. The CVR conversation revealed that the flightcrew was aware that they were in mountainous terrain, attempting to maintain visual contact with the terrain, and turning and climbing prior to impact. ICI and V/A personnel stated that flightcrew were equipped-with and could have been wearing night vision goggles (NVGs. An investigator, early on-site, reports that he saw a "set of two rings" attached to the front of one of the flightcrew helmets. Flightcrew NVGs were not seen by other investigators or recovered from the wreckage.). As evidenced in the CVR transcript, the captain was at the controls, and immediately prior to impact, one flightcrew member stated, "Altitude 100 [meters radio altimeter], Altitude 70, Altitude." There was no moon that night (Quarters of the moon, by month, 1999; Attachment 9).

A UN police advisory (CIVPOL) detachment at Gonaives, Haiti, submitted a log that stated that at 1940 they started a search, after receiving a radio transmission from RA-64 that said they were changing the itinerary because of bad weather conditions. The CIVPOL stated they later could not reestablish radio contact with the helicopter (This conversation is not on the CVR. The air officer in the cabin had a separate FM transmitter/receiver. The CIVPOL detachment at Gonaives did not contact ICI or other known agency, on the evening of March 14, regarding the radio conversation).

About 2000, not having heard from RA-64, the ICI base dispatcher attempted to contact the flight by radio, without success. At 2035, the ICI air officer for RA-63 called by telephone to the base dispatcher. They agreed to keep trying to contact RA-64, but did not yet call the U.S. Coast Guard facility at MTPP (Statements of Josh Cotes and Lara Brekken, ICI employees, Attachment 10). At 2200, the ICI radioman called the company president in Oregon, and stated that he wished to call the USCG, which he did. At 2320, a USCG HH-60J Jayhawk departed north from MTPP, in a search attempt for RA-64 (Statements of HH-60J search and rescue pilots: RAF Flight Lt. Miller and USCG Lt. Bullock, Attachment 11. Additional witness statements, Attachment 12.). The route north was obscured by clouds and the HH-60J flew northeast towards the city of Hinche and the lower terrain in that vicinity. The USCG crew, wearing night vision goggles, found the mountainous areas obscured by clouds and were not able to search above 3,500 feet mean sea level (msl). After dawn, the USCG renewed the helicopter search for RA-64. Shortly after noon, March 15, a USCG HH-65 crew observed a crowd of people on a mountain slope, and then observed burned wreckage. The wreckage was found at an elevation of 4,200 feet msl, in a wreckage path approximately 90 meters in length, on an impact course of approximately 170 degrees.

Examination found no evidence of any system problem with the aircraft prior to impact. A person who lived about five miles to the south of the accident site stated in interview that he observed the aircraft pass overhead with smoke coming down from the fuselage and then fire. There was no evidence of pre-impact fire found in wreckage examination. The turbine engines evidenced normal power at the time of impact. On-site examination was followed by instrument examination at the Interstate Aviation Committee Headquarters, Moscow. Wreckage examination evidenced that at the time of impact the helicopter was in a slight climb. Instrument examination revealed that the helicopter was in a 35 degree right bank at the time of impact. The impact was approximately 30 meters below the top of a ridge, beyond which mountain peaks and ridge lines gradually descended towards the south.

The accident occurred at nighttime in instrument meteorological conditions (IMC), at 72 degrees 10 minutes West, 19 degrees 03 minutes North. (Coordinates 07.98246 by 21.08081)

1.2 Injuries to Persons

Injuries Flightcrew Cabincrew Passengers

Fatal 3 1 9 Other 0 0 0 Total 3 1 9

1.3 Damage to Aircraft

The aircraft was destroyed at impact.

1.4 Other Property Damage

The impact occurred in rural mountainous terrain. There was no private property damage.

1.5 Personnel Information

1.5.1 Captain

The captain, age 49, was hired by V/A in 1973. He held a Russian Class One Pilot certificate. At the time of the accident, he had accumulated 11,800 total flying hours. He logged 10,800 hours in the Mi-8 helicopter, including 9,730 hours as captain, and 163 night flying hours. His medical certificate was issued on July 23, 1998, with no restrictions.

He was certified in accordance with Russian civil air regulations to perform as a pilot under the following meteorological conditions:

Day time: Visual Flight Rules (VFR), Special VFR: 150 meters cloud base, by 1,500 meters visibility, by wind speed of 25 meters per second.

Night time: Special VFR: 450 meters cloud base, by 4,000 meters visibility, by 25 meters per second wind speed.

Day time: Instrument Flight Rules (IFR): 150 meters cloud base, by 2,000 meters visibility, by 25 meters per second wind speed.

The captain held a helicopter instructor pilot rating and was certified to pilot international flights. His last proficiency flight check in the Mi-8 was in Russia, February 3, 1999, under day/IFR, and night/special-VFR conditions. He also passed a proficiency check as a navigator, December 12, 1998. His most recent IFR approaches were in actual instrument meteorological conditions (IMC), 3-each: January 31, 1999, and during the February 3, 1999, proficiency flight check. He also received three hours of flight simulator instrument training February 2, 1999, as required within each 90-day period by Russian CAA regulations, and received three hours of supervised in-cockpit/on-the-ground emergency procedures review with the V/A chief pilot, during crew-rotation training in Haiti, February 8, 1999. All flight and simulator checks were passed and qualifications re-approved.

1.5.2 Copilot

The copilot, age 39, was hired by V/A in 1978. He held a Russian Class Two Pilot certificate. At the time of the accident, he had accumulated 6,220 total flying hours. Since March 14, 1988, he logged 3,125 hours in the Mi-8 helicopter as copilot. His medical certificate was issued on October 13, 1998, with no restrictions.

The copilot's most recent proficiency check in flying technique was on February 3, 1999. He also passed a proficiency check as a helicopter navigator on September 9, 1998.

1.5.3 Flight Engineer

The flight engineer, age 40, was hired by V/A in 1977. He held a Russian Flight Engineer Class Two certificate. At the time of the accident, he had accumulated 4,570 total flying hours. He logged 2,050 hours in the Mil-8 helicopter as flight engineer. His medical certificate was issued on September 29, 1998, with no restrictions.

His most recent flight engineer proficiency check was February 11, 1999, in Haiti.

1.5.4 Duty Period

The captain of RA-63 stated that the accident flightcrew were on scheduled duty March 11 through March 13, 1999. The average crew rest (sleep) period was 9 hours and lasted from 2200 hours until 0700 hours. No other flights were flown by the accident flightcrew during the 3-day duty period, and they did not leave the ICI base operations and housing area at MTPP during the duty period.

1.6 Airplane Information

Mi-8MTV-1, RA-25464, was manufactured at Mil Helicopter Company, Kazan Air Plant, Russia, February 28, 1991, as serial no. 95608. The helicopter was configured to carry a flightcrew of three (two pilots and a flight engineer) and 22 passengers. At the time of the accident, the airframe had accumulated 2,993 flight hours. It had a maximum gross weight of 13,000 kilograms (kg) (about 28,660 pounds), and maximum load capacity of 4,000 kg (about 8,818 pounds). It was capable of carrying 2,100 kg (about 4,630 pounds) of fuel, total, in two fuel cells.

1.6.1 Airplane Engines

The helicopter was powered by two TV-3-117VM helicopter turbine engines, manufactured at the Zaporozie Air Plant, Ukraine. The left engine (no. 1), serial no. 7087881200002, was manufactured March 3, 1992. It had 1,194 total flight hours, 498 hours since overhaul on June 28, 1997, and 20 hours since last inspection, February 3, 1999. The right engine (no. 2), serial no. 7087882000012, was manufactured April 17, 1990. It had 1,994 total flight hours, 498 hours since overhaul, February 6, 1997, and 20 hours since last inspection, February 3, 1999.

1.7 Meteorological Information

There were no recorded weather observations made by tower after 1700. The ICI radio dispatcher, in interview, stated that seeing no lights on at the tower, he thought it closed about the time of the departure of RA-64. The chief ATC controller stated that the tower was open until 2200. CAA, Haiti, stated that the meteorologist departed the tower after the last recorded weather observation, at 1700 (see Attachment 6). The nearest weather observation to the crash site was obtained by the USCG HH-60J search and rescue flightcrew, that departed MTPP at 2330, March 14, and reported that they were unable to search in the above 3,500 feet msl, because of cloud obscuration in the mountains (See Attachment 11). The barometric pressure at the accident site is unknown. The pressure provided to the accident flight by MTPP tower, recorded on the CVR at the time of takeoff was "1014" (millibars, or 30.03 inches of mercury).

1.8 Aids to Navigation

MTPP Air Traffic Control (ATC) is scheduled-open daily until 2200. The Mi-8's did not practice instrument approaches and landings in Haiti, and communicated with MTPP to obtain takeoff and landing winds, temperatures, and barometric pressures. ICI base operations supplemented weather information by computer-downloading satellite data.

MTPP was equipped with a very high frequency omni directional radio range / distance measuring equipment (VOR/DME) for international arrivals and departures. The airport did not have an ATC radar facility. The Mi-8s did not have VOR receivers, and for radio-navigation were equipped with non-directional beacon (NDB) receivers. An NDB navigation transmitter was located on the airport at Cap Haitien. The Cap Haitien Airport closed daily at 1800, and the NDB navigation equipment and runway lighting terminated when the airport closed.

The ICI Project Manager in Haiti stated that on two occasions Mi-8 flightcrews were told on ATC frequency not to use the frequency. The chief ATC controller at MTPP said that such a request would not have happened.

1.9 Communications

There were no known problems with communications. Upon takeoff, RA-64 communicated with MTPP on tower VHF frequency, and the ICI base operations radio dispatcher ("Tiger Base") on FM radio. En route, including about four minutes prior to impact, RA-64 again communicated with Tiger Base (See CVR transcript, Attachment 8).

1.10 Airport Information

MTPP is an international airport, with regularly scheduled daily arrivals and departures of American Airlines, Air Canada, Air France and other international flights. At the time of the accident, the airport was not radar-equipped and not U.S. Federal Aviation Administration (FAA) certified.

1.11 Flight Recorders

The CVR and flight data recorder (FDR) on board the helicopter, were manufactured in Russia, and had the respective model and serial numbers of P-503 UZ, no. 192005; and SARPP-12DM. Both recorders were recovered from the crash site and examined at the Interstate Aviation Committee Headquarters, Moscow. Thirty-one minutes of clear voice recordings were obtained from the CVR, up until the time of impact (see Attachment 8). Due to heat and impact damage, no useful information was obtained from the FDR.

1.12 Wreckage and Impact Information

The aircraft impacted rising terrain, about 4,200 feet MSL. The wreckage path carried for approximately 90 meters in rising terrain.

Initial impact was identified by a near-level impact mark of a main rotor blade, striking the slope to the right of the helicopter. A section of tail rotor blade came to rest in this area, and a section of main rotor blade dug into the hillside a few feet beyond the point of initial main rotor blade impact. The tail gearbox and head carried forward approximately 10 meters on a heading of approximately 170 degrees, coming to rest imbedded partially in mud, just below the main transmission and rotor head. Sections of the cockpit, including broken directional control pedals and instruments, as well as the pilots' bodies also came to rest after initial blade impact but before the final resting point of the main gearbox. Both engines came to rest immediately before the main gearbox. The tailboom came to rest to the left of the main gearbox, as well as both clam shell doors. The cabin floor came to rest to the left of the main gearbox, near the tailboom and evidenced partial burning, in a post impact ground fire. The left main mount and wheel were still attached to the lower fuselage below the attached partial cabin floor, and was burned substantially. The nose wheel came to rest below the burned clam shell door and was not burned, nor was the right mainmount which carried on a course of 160 degrees beyond the final resting point of the main wreckage, including main gearbox and main rotor head (See RCMP forensic section wreckage chart with photographs, Attachment 13, and photographs of wreckage, Attachment 14).

There was extensive ground fire in the vicinity of the main gearbox. All fire, including external engine fire damage, resulted from impact. There was no physical evidence of fire damage or failure to any aircraft system prior to impact.

Both ICI and V/A personnel reported that night vision goggles were on-board the accident helicopter and could have been in use. On the CVR, one flightcrew member referred to putting on a "helmet." Night vision goggles were not recovered from the wreckage.

1.12.1 Engines

Both engines evidenced normal operation at the time of impact. The stator vanes for both engines were found in the normal operation position, and the temperature indicators for both engines were found frozen about 740 degrees C.

1.12.2 Instruments

The altimeters, two metric and one in feet, the radar altimeter, in meters, and a turn and bank indicator appeared frozen from impact. They were shipped to Interstate Aviation Committee Headquarters, Moscow, for laboratory analysis (see section 1.16).

1.13 Medical and Pathological Information

Because of the condition of the bodies when recovered, the medical examiner in Haiti did not take toxicological fluid samples. All crewmembers suffered extreme impact trauma, and some sustained fire damage. Autopsies were not performed.

1.14 Fire

There was a substantial, post-impact fire, centered about the area of greatest mass in the main wreckage, at the main gearbox and surrounding structure. A witness statement of pre-impact fire was not verified by wreckage evidence. There was no fire prior to impact.

1.15 Survival Aspects

The impact was not survivable.

1.16 Tests and Research

All three barometric altimeters (two in meters, and one in feet - footometer), and both gyro horizon (attitude indicator) instruments were recovered from the wreckage and examined in laboratory conditions at the Interstate Aviation Committee Headquarters, Moscow, in April 1999. The examinations found that the two metric altimeters indicated 1350 and 1360 meters, with barometric settings corresponding to 755.5 and 756 millimeters of mercury (mm Hg.), respectively. The footometer did not provided recoverable information. The two gyro horizons provided angle of bank information of 30 to 45 degrees right bank, and 35 degrees right bank, respectively. The pitch attitude indication for both indicators was 25 degrees, nose down. The chief laboratory examiner stated that he believed there was a lag in loss of electrical power to the instruments, following impact, resulting in the extreme nose-down indications, and that the indicated aircraft angle of bank at the time of impact was 35 degrees, right bank (See "The results of the [instrument] analysis," report in Russian and 1-page summary in English.).

1.17 Organizational and Management Information

The operator, ICI (a U.S. corporation), in contract with V/A (a Russian corporation, owner of the helicopter, and employer of flightcrew and maintenance personnel), came to Haiti in order to perform logistic support / transportation missions, and to replace in the mission CH-47 Chinook helicopters that had departed the country. ICI was introduced by letter of agreement between the U.S. State Department and the Republic d'Haiti.

An ICI corporate officer served as the air officer on RA-64. The ICI base manager was on leave, outside of Haiti at the time of the accident. He and the ICI Senior Vice President, upon hearing of the accident, flew to Port-au-Prince.

Subsequent to the accident, V/A installed VOR/ILS navigation receivers in their helicopters. ICI / V/A helicopters in Haiti, subsequently communicate with ATC, on operating frequency, and practice instrument approaches in Haiti (the VOR/ILS approach at MTPP, and the VOR approach at Cap Haitien Airport).

1.18 Additional Information

None.