N655GS

HISTORY OF FLIGHT

On September 29, 2005, about 2113 Pacific daylight time (PDT), an Agusta A109A II helicopter, N655GS, impacted the ocean waters of Puget Sound near Edmonds, Washington. The air ambulance helicopter was destroyed and the three occupants, an airline transport pilot and two flight nurses, were killed. The helicopter was operated by CJ Systems Aviation Group of West Mifflin, Pennsylvania, under contract to Airlift Northwest of Seattle, Washington. The helicopter was on a 14 CFR Part 91 positioning flight when the accident occurred. The flight departed from Harborview Medical Center in Seattle about 2104 with an intended destination of Arlington Municipal Airport (AWO) in Arlington, Washington. Earlier in the evening, the helicopter had flown a patient from a hospital in Arlington to Harborview. The accident occurred as the helicopter was returning to its base at AWO. Visual meteorological conditions prevailed for the helicopter's departure from Harborview, and instrument meteorological conditions prevailed at the accident site. A company visual flight rules (VFR) flight plan was filed.

Radar data provided by the Federal Aviation Administration (FAA) shows the helicopter departing Harborview, proceeding northbound over the water, following the coastline at an altitude of approximately 800 feet msl. As the radar track reaches an area near Edmonds called Brown's Bay, the helicopter enters a left turn towards the west, away from the shoreline. The last radar return was recorded at 2112:33 and places the helicopter at N 47:51.250 and W 122:21.520.

No eye witnesses to the accident were located. A number of ear witnesses heard a low flying helicopter and then an "explosion" or loud boom. About 2122, the communications center for Northwest Airlift attempted to contact the helicopter by radio as there was another mission for the helicopter. The communications center received no response from the helicopter.

A search was started, and the United States Coast Guard found debris floating in the water at N 47:51.190 and W 122:21.010 about 0130 on September 30, 2005. The body of one flight nurse was found with the floating debris.

On October 7 to 10, 2005, an extensive search and recovery effort was conducted by the United States Navy employing specialized undersea search and recovery equipment. A debris field was located on the ocean floor at a depth of about 525 feet, centered at N 47:51.018 and W 122:21.901, about 2,100 feet southwest of the last radar return. During this effort, the pilot's body was located and recovered.

PERSONNEL INFORMATION

The pilot held an airline transport pilot certificate with a helicopter rating and commercial privileges in single engine land airplanes with an instrument airplane rating. His most recent first class medical certificate was issued on March 26, 2005, with the limitations: "Holder must wear corrective lenses for distant vision and have available for near and intermediate. Not valid for any class after March 31, 2006."

The pilot had been employed as an air ambulance helicopter pilot in the Puget Sound area since 1988. He was hired by CJ Systems on May 1, 2000, when CJ Systems became the helicopter vendor to Airlift Northwest. He was previously employed in the same capacity, as an Agusta A109A pilot, by Hospital Air Transport, Inc., Airlift Northwest's previous helicopter vendor. He completed his most recent twelve month 14 CFR Part 135 checks (135.293(a), 135.293(b), and 135.299) on November 11, 2004. His most recent six month 14 CFR Part 135 instrument flight rules (IFR) proficiency check (135.297) was completed on May 20, 2005.

According to information provided by CJ Systems, the pilot had accumulated a total flight time of 8,190 hours of which 7,990 hours were in helicopters with 4,192 hours in the Agusta A109A. He had accumulated 2,396 hours of night flight time and 672 hours of instrument flight time. In the previous 90 and 30 days, he had accumulated 38 and 12 hours, respectively.

On January 20, 2002, the pilot was involved in an accident that occurred during a repositioning flight in an Agusta A109A II near Baring, Washington. According to the NTSB Factual Report on the accident, on the previous day, the pilot had aborted a flight due to adverse weather conditions (dark night, snow, rain and fog), and the helicopter was parked over night in an open field. The following morning, the pilot boarded the helicopter with the intention of returning it to the AWO base. Shortly after takeoff, there was a sequential loss of power in both engines, and the helicopter landed hard following an autorotation. The helicopter sustained substantial damage, and the pilot, the sole occupant, sustained serious injuries. Both engines were test run following the accident with no indication of any mechanical problems. The NTSB determined that the probable cause of the accident was "the sequential non-mechanical total loss of power in both engines 1 and 2 for undetermined reasons and the pilot's failure to maintain adequate rotor RPM to prevent a hard landing. Contributing factors were the tripped "RPM WARN" circuit breaker which disabled the engine failure and low rotor warning lights and aural warnings." Following the accident, the pilot was out of work recovering from his injuries for approximately 20 months. He returned to work in September 2003.

The duty schedule for the pilots at the AWO base was 7 days on, working 12 hour shifts, followed by 7 days off. The pilots worked day shift for 7 days, had 7 days off, and then worked night shift for 7 days. The day shift was from 6:15 am to 6:15 pm, and the night shift was from 6:15 pm to 6:15 am. The accident flight occurred on the second day of the pilot's week working the night shift. On the first day of his work week, he made one 0.6-hour flight with 3 landings. The accident flight was his first flight on the second day of his work week.

AIRCRAFT INFORMATION

The 1984 model Agusta A109A II helicopter, S/N 7299, was powered by two 420-horsepower Rolls Royce Allison 250-C20B turbo-shaft engines, S/N CAE 834357 (#1) and CAE 834829 (#2), driving a four bladed main rotor system and a two bladed tail rotor. The helicopter was equipped and certified for IFR flight. Installed equipment included a Garmin GNS-430 GPS/Com/Nav and a factory installed autopilot.

The helicopter was being maintained by the operator in accordance with an FAA Approved Inspection Program. Examination of the helicopter's maintenance records revealed that it received a 150 hour/12 month airframe inspection on September 7, 2005, at an airframe total time of 3,740.1 hours. On this date, both engines received 150 hour inspections with engine #1 at a total time of 8,832.6 and engine #2 at a total time of 6,178.0 hours. The helicopter's most recent inspection, a 25 hour/30 day inspection, was done on September 19, 2005, at an airframe total time of 3,766.5 hours, engine #1 total time of 8,859.0 hours, and engine #2 total time of 6,204.4 hours. When the accident occurred, the helicopter had been flown approximately 29 hours since this inspection.

Review of the daily maintenance report sheets for the helicopter from August 1, 2005, to the date of the accident revealed no listings of any uncorrected maintenance discrepancies.

According to the day shift pilot who flew the helicopter for 1.5 hours on the day of the accident and 1.5 hours on the day before the accident, he experienced no anomalies with the aircraft. The dayshift pilot mentioned that the autopilot was slow to react to some turbulence he encountered, so he turned it off and hand flew the helicopter. He stated that this was "typical, nothing unusual" for the autopilot.

METEOROLOGICAL INFORMATION

The National Weather Service (NWS) Surface Analysis Chart for 2000 PDT depicted a low pressure system to the north of the accident site over British Columbia, with a cold front extending southwestward from the low over northwestern Washington and into the Pacific Ocean. The accident site was located immediately ahead of the cold front. The NWS Weather Depiction Chart for 2000 PDT depicted an area of IFR conditions over western Washington and Oregon. The accident site was located in the area of IFR conditions. The NWS Radar Summary Chart for 2118 PDT depicted a large area of light-to-moderate intensity rain showers over western Washington moving eastward at 51 knots.

The closest weather reporting facility to the accident site was at Snohomish County Airport - Paine Field (PAE), Everett, Washington, located 5 miles northeast of the accident site at an elevation of 606 feet msl. The airport had an automated surface observation system (ASOS) and was augmented by certified NWS weather observers. The following conditions were reported:

PAE weather observation at 1853 PDT, wind from 190 degrees at 15 knots gusting to 25 knots, visibility unrestricted at 10 miles, ceiling overcast at 800 feet, temperature 16 degrees Celsius (C), dew point temperature 14 degrees C, altimeter 29.81 inches of Mercury (Hg).

PAE weather observation at 1953 PDT, wind from 190 degrees at 16 knots, visibility unrestricted at 10 miles, ceiling overcast at 800 feet, temperature 16 degrees C, dew point 14 degrees C, altimeter 29.81 inches of Hg.

PAE weather observation at 2053 PDT, wind from 200 degrees at 9 knots, visibility 6 miles in mist, ceiling overcast at 600 feet, temperature 16 degrees C, dew point 14 degrees C, altimeter 29.82 inches of Hg. Remarks, in part: ceiling 500 variable 900 feet.

PAE special weather observation at 2117 PDT, wind from 220 degrees at 6 knots, visibility 4 miles in light rain and mist, ceiling broken at 400 feet, overcast at 1,100 feet, temperature 15 degrees C, dew point 14 degrees C, altimeter 29.82 inches of Hg. Remarks, in part: ceiling 200 variable 800 feet.

PAE special weather observation at 2124 PDT, automated, wind from 240 degrees...