N509AM

HISTORY OF FLIGHT

On July 28, 2010, at 1342 mountain standard time, an American Eurocopter AS 350 B3, N509AM, descended rapidly and collided with terrain in an urban area of Tucson, Arizona. The helicopter was operated by Air Methods Corporation, as LifeNet 12, on a repositioning flight, under the provisions of Title 14 Code of Federal Regulations Part 91. The commercial pilot and two medical flight crew members were fatally injured. The helicopter was substantially damaged, and consumed by a post impact fire. Visual meteorological conditions prevailed, and a company flight plan had been filed. The repositioning flight originated at the Marana Regional Airport, Tucson, at 1332, and the intended destination was the Air Methods base in Douglas, Arizona.

Witnesses reported observing the helicopter flying steadily in a southeast direction when it started to descend rapidly. Witnesses also stated that the helicopter made some unusual ‘whump, whump’ sounds, and rapid intermittent popping sounds, which were followed by unusual quietness as the helicopter descended. As the helicopter turned and got closer to the ground its flight trajectory became increasingly vertical. The helicopter impacted a 5-foot-high concrete wall and was consumed by a post impact fire.

The accident helicopter (N509AM) was positioned at the Marana Regional Airport on July 24 to undergo engine maintenance related to a fuel coking problem. The helicopter’s engine was removed, and the fuel manifold was removed and replaced. This process involved removing all the external engine piping and harnesses, separating the engine modules, removing and replacing the fuel manifold, and reassembling the engine. The engine was reinstalled on the evening of Tuesday, July 27, and the Marana base pilot and base mechanic performed a 7.5-minute post maintenance check flight.

At 1132 on Wednesday, July 28, 2010, the Douglas aircrew arrived at Marana in the area’s spare helicopter, N106LN. The crew swapped out the medical equipment from N106LN to the accident helicopter, N509AM. At 1329, the pilot called Life Com and reported that LifeNet 12 (N509AM) had departed Marana with 3 people, 2 hours 55 minutes of fuel, and an estimated time en route to Douglas of 55 minutes.

Radar data provided by the Federal Aviation Administration (FAA) recorded the first radar return of LifeNet 12, transponder code 0461, at 1334:33, 2,600 feet mean sea level (msl), slightly southeast of Marana. The terrain elevation between Marana and Tucson is approximately 2,300 feet msl. The track proceeded on a course of 112 degrees magnetic for 17 miles directly to the accident location. The helicopter gradually climbed to 3,200 feet by 1339:19, and continued to maintain altitude between 3,000 and 3,200 feet msl until 1341:23. The final two radar returns were 1341:28 at 2,600 feet msl, and 1341:33 at 2,400 feet msl, and were located in the vicinity of the accident site.

LifeNet 12 initially checked in with Tucson TRACON about 1333,“ Tucson Approach, LifeNet 12 on 23, correction, 2400.” Tucson TRACON acknowledged LifeNet 12 and asked what the request was. LifeNet 12 responded, “….we just came off of Marana, we’re gonna be heading southeast bound low level though your area back to Douglas VFR.” Tucson TRACON responded,“LifeNet 12, Tucson Approach, roger, you are radar contact 4 miles southeast of Marana Airport. Tucson altimeter is 30.01.” LifeNet 12 replied, ”30.01 LifeNet 12 thanks.”

No other communications with LifeNet 12 were recorded. At 1341:38, the Tucson TRACON controller noticed that LifeNet 12 had dropped off the radar display and attempted to contact LifeNet 12 unsuccessfully numerous times.

The radar data, consisting of latitude, longitude, and mode C altitude, was used to determine the helicopter’s ground speed, altitude changes, rate of climb changes, and headings. The ground speed averaged between 120 and 130 knots between the first radar return and the final radar return. The altitude increased from 250 feet agl to 750 feet agl in the first 3.5 minutes of the flight and stabilized between 750 and 850 feet for the next 2.5 minutes. Then the altitude decreased at 200 feet per minute (fpm) for 10 seconds, leveled off for 10 seconds at 750 feet, then descended rapidly (approximate rate of descent was 2,300 fpm) for the final 10 seconds of data. The ground speed decreased from 132 knots towards 70 knots over the last 20 seconds of data. The heading was consistent along 112 degrees magnetic heading for the initial 6.6 minutes of data and then changed to 132 degrees during the final 20 seconds of data. The helicopter entered its final descent from approximately 800 feet agl about 30 seconds before the final radar return. The final 10 seconds of data is consistent with an autorotative descent. The distance traveled over the ground by the helicopter during the last 30 seconds of radar data was approximately 1.3 miles, and approximately 0.25 miles over the final 10 seconds.

In the vicinity of the accident location, there was an open roadway intersection that was free of obstacles. This open area was about 570 feet from the final radar return, and about 300 feet from the point of ground impact, in line with the final flight path trajectory of the helicopter.

External examination of the engine at the accident site revealed that the fuel inlet union was detached from the boss on the compressor case. The fuel supply line remained attached to the union and the hydro-mechanical unit (HMU) via the adjusted valve. The intermediate gasket was located in the fuselage debris, directly below the union.

PERSONNEL INFORMATION

Pilot

The pilot, age 61, held a commercial pilot certificate with ratings for airplane single engine land, rotorcraft-helicopter, instrument-airplane and helicopter, issued on November 11, 2008. He held a second-class medical certificate with the limitation that he wear corrective lenses for intermediate vision, issued on January 5, 2010. Prior to being employed by Air Methods, the pilot flew for the US Army, and US Border Patrol. According to colleagues, he retired from the Border Patrol in 2002. In 2002, the pilot was hired by Rocky Mountain Helicopters and was retained after Air Methods acquired the company. During his time in the US Border Patrol, all the pilots received two check flights year. During these check flights they would fly with an instructor pilot, and practiced full landing autorotations.

Pilot information provided by Air Methods dated June 25, 2008, documented the pilot’s total flight time at 13,900 hours, 9,465 rotary-wing hours, 4,500 single engine fixed wing hours, and 100 hours of total instrument time. The pilot’s duty log maintained by Air Methods documented that he accumulated 86.9 hours between January 1 and July 28, 2010, and 7.5 hours within the 30 days prior to the accident. Pilot training records provided by Air Methods documents that he received AS 350 pilot transition training from Aerospatiale, and was qualified as pilot-in-command on February 10, 1989. He received ground and flight training for the AS 350 B3 in August 2002. The pilot received his most recent annual FAR 135.293 and FAR 135.299 Airman Competency/Proficiency Check on Sept 14, 2009. All areas of the examination were graded as ‘S’ (satisfactory) and no discrepancies were noted. Instrument procedures were not practiced; however, an ILS approach arrival was performed, and use of an autopilot was check marked ‘not authorized.’ Power failure, autorotation to a power recovery, and hovering autorotations were performed. The listed aircraft the pilot was authorized to operate were the AS 350 B2, AS 350 B3 2B, and AS 350 B3 2B1.

A review of the pilot’s training records for the previous 4 years was conducted. During the 50 months prior to the accident, the pilot had completed 6.9 hours of training flights and approximately 4.4 hours of proficiency check flights totaling 11.3 hours. The pilot completed one semi-annual training flight and three recurrent training flights during those 50 months, and had no training flights where he would have practiced autorotations between his most recent FAR 135.293 check flight and the day of the accident, a span of 317 days. All the training events were graded as “meets FAA pilot training standards (PTS)” and power recovery autorotations were practiced on each training flight and each competency/proficiency check.

Helicopter Services of Nevada (HSN) Mechanic

The mechanic who replaced the fuel manifold was employed as a technician for Helicopter Services of Nevada (HSN). He is an A&P, and had been employed at HSN since September 2009 as the Director of Maintenance for Turbomeca Engines. Prior to coming to HSN, he worked for 23 years at Turbomeca.

In his position at HSN he oversaw four mechanics, and was responsible for arranging work for his employees. Under contract with Turbomeca, the technicians for Helicopter Services of Nevada perform repairs and Level 3 maintenance. They also perform maintenance at their facility in Boulder City. The majority of their work is in the field through the contract with Turbomeca. The mechanic had accomplished his initial Level 3 Turbomeca training in 1998.

AIRCRAFT INFORMATION

The helicopter was a Eurocopter AS 350 B3, serial number 4698, and was manufactured in 2009. The FAA Airworthiness certificate was issued September 9, 2009. FAA registration records show that Air Methods acquired the helicopter December 23, 2009. It was configured for medical transport of a single patient on a gurney. The gurney was located on the left side of the helicopter and extended over the left side of the cockpit into the left side of the cabin. The crew consists of a single pilot, a flight nurse, and paramedic. A review of the helicopter’s maintenance records revealed that it had 352 total hours at the time of the accident, and the most recent maintenance inspection was the Air Methods’ 20-hour B61 engine inspection at 35...