N335AE

Destroyed
Fatal

BELL HELICOPTER TEXTRON 206L 1S/N: 45659

Accident Details

Date
Saturday, October 4, 2014
NTSB Number
CEN15FA003
Location
Wichita Falls, TX
Event ID
20141004X60516
Coordinates
33.540000, -98.300003
Aircraft Damage
Destroyed
Highest Injury
Fatal
Fatalities
3
Serious Injuries
1
Minor Injuries
0
Uninjured
0
Total Aboard
4

Probable Cause and Findings

The pilot’s failure to maintain yaw control when he applied power to execute a go-around at a low airspeed in dark, night conditions, which resulted in a rapid, uncommanded right yaw due to a loss of tail rotor effectiveness.

Aircraft Information

Registration
N335AE
Make
BELL HELICOPTER TEXTRON
Serial Number
45659
Engine Type
Turbo-shaft
Year Built
1981
Model / ICAO
206L 1B06T
Aircraft Type
Rotorcraft
No. of Engines
2

Registered Owner (Historical)

Name
AIR EVAC EMS INC
Address
1001 BOARDWALK SPRINGS PL STE 250
Status
Deregistered
City
O FALLON
State / Zip Code
MO 63368-4100
Country
United States

Analysis

HISTORY OF FLIGHT

On October 4, 2014, about 0155 central daylight time, N335AE, a Bell 206L1+ helicopter, was destroyed by post-impact fire after it impacted terrain while on approach to the United Regional Hospital helipad, in Wichita Falls, Texas. The commercial pilot was seriously injured and the flight nurse, paramedic, and patient died. The helicopter was registered to and operated by Air Evac EMS, Inc, O'Fallon, Missouri. A company visual flight rules flight plan was filed for the patient transfer flight that departed Jackson County Hospital, near Waurika, Oklahoma, about 0133. Visual meteorological conditions prevailed for the air medical flight conducted under the provisions of 14 Code of Federal Regulations Part 135.

A witness, who was a photojournalist for NBC News 3 in Wichita Falls, TX, was driving southbound on the central freeway and was passing over Maurine Street when he first saw the helicopter. He said it appeared to be flying toward the "north" and its spotlight was turned on. As the witness continued to drive south toward downtown Wichita Falls, he realized the helicopter was hovering over 10th and Grace Streets and he thought it was odd that the helicopter had not landed yet and maybe he was waiting for someone to clear off the helipad. The witness said the helicopter was hovering at a height that was equal to the height of the top of the hospital, about 100-120 feet. The witness said that when he reached 9th Street, he saw the helicopter begin to spin to the right and move from its position over 10th and Grace Streets south toward the helipad. He said the helicopter entered the spin slowly and began to descend as soon as it started to spin. Initially, the witness thought the helicopter was going to land, but it continued to spin and descend. The helicopter then disappeared from his view behind a building. Shortly after it disappeared from his view, the witness saw sparks. He called 911 and drove the scene. Once he arrived on-scene the police and first responders were already there.

According to the pilot, he and his Duncan, Oklahoma, based medical crew had just returned from a flight to Oklahoma City, Oklahoma, when he received a call from company dispatch to pick-up a patient in Waurika and transport him to United Regional Hospital in Wichita Falls. The pilot accepted the flight, but told dispatch that they needed 15 minutes on the ground to prepare for the flight since they had just landed.

The pilot stated that he, along with the paramedic and flight nurse, re-boarded the helicopter, performed the necessary checklists, called dispatch and filed a flight plan. The flight to Waurika was uneventful. After landing, the pilot stayed in the helicopter for about 20 minutes with the engine running while the patient was prepped and loaded. The pilot and medical crew then departed for Wichita Falls. The weather was clear and the wind was three knots or less. The pilot said he used night-vision-goggles (NVGs) while en route, but flipped them up as he approached the hospital due to intense ground lighting. Upon arriving in Wichita Falls, the pilot said he performed a "high recon" of United Regional Hospital's helipad and called out his intentions to land. He performed the pre-landing checklists, and started the approach to the helipad from the northwest at an altitude of 700 feet above ground level (agl). Both of the hospital's lighted windsocks were "limp" but were positioned so they were pointing toward the northwest. The pilot, who said he had landed at this helipad on numerous occasions, said the approach was normal until he got closer to the helipad. He said he felt fast "about 12-15 knots" and a "little high," so he decided to abort the approach. At this point, with about ¼ to ½ -inch of left anti-torque pedal applied, he added power, "tipped the nose over to get airspeed," and "pulled collective." The pilot said that as soon as he brought the collective up, the helicopter entered a rapid right spin. He described the spin as "violent" and that it was the fastest he had ever "spun" in a helicopter. The pilot told the crew to hold on and that he was "going to try and fly out of it." The pilot said he tried hard to get control of the helicopter by applying cyclic and initially "some" left anti-torque pedal "but nothing happened." The pilot said he added more left anti-torque pedal, but not full left anti-torque pedal as the helicopter continued to spin and he was still unable to regain control. He also said the engine had plenty of power and was operating fine. The pilot recalled the helicopter spinning at least five times before impacting the ground inverted. He said smoke quickly filled the inside of the helicopter, so he unbuckled his seatbelt assembly, took off his helmet, punched out the windshield and exited the burning helicopter.

The pilot also said that he did not hear any unusual noises prior to the "tail coming out from underneath them" and he did not recall hearing any warning horns or seeing any warning/caution lights. When asked what he thought caused the helicopter to spin to the right so quickly, he replied, "I don't know."

The helicopter was equipped with a handheld Garmin GPS 396 and Sky Trac ISAT-100 flight-tracking software. The SkyTrac system recorded position every 5 seconds versus the GPS that recorded position every 60 seconds. Data was successfully downloaded from each unit. The data between the two units was fairly consistent and revealed that after the helicopter departed Waurika, it flew on a south-westerly heading until it crossed Highway 447 in Wichita Falls. It then flew on a westerly heading until it reached Highway 287, where it then turned on a north westerly heading. As it proceeded to the northwest, the helicopter flew past United Regional Hospital to the east before it made a left, 180 degree turn about 1 to 1.5 miles north of the hospital. The helicopter then proceeded directly to the helipad on a south-easterly heading. A review of the last 43 seconds of the recorded Sky Trac data revealed that as the helicopter approached the helipad, it descended from an altitude of 202 feet to 152 feet and decelerated from a ground-speed of about 9 knots to about 5 knots before it turned to the right. Over the next 10 seconds, the helicopter traveled back toward the northwest as it descended to an altitude of 54 feet and increased to a ground-speed of about 17 knots before the data ended at 0155:14. The location of the last recorded data point was consistent with where the helicopter impacted the ground.

A portion of the accident flight and impact were captured on one of the hospital's surveillance cameras. A review of the surveillance tape revealed the helicopter approached the helipad from the north with the spotlight turned on (the pilot said that he used the spotlight during the approach). The helicopter then climbed and went out of frame before it reappeared in a descending right hand turn then hit the ground. The time of impact was recorded at 0154:56. About 6 seconds later, there was a large explosion.

Another Air Evac flight crew (pilot, paramedic, and a flight nurse) was based at United Regional Hospital, and were in their quarters near the helipad when the hospital-based pilot heard the helicopter. The crew was preparing to assist the inbound crew with the patient transfer. The hospital-based pilot stated that when he opened the door to their quarters, he heard the helicopter arriving from the north. As the helicopter got closer, he heard "a change in rotor noise" followed by the sound of a "snap then bang then silence." The hospital-based pilot yelled to his crew that the helicopter may have crashed. All three immediately responded to the accident site where they found the helicopter upside down, facing west, and on-fire. The hospital-based pilot said the flight nurse, who was seated in the rear right seat, was lying about 6-feet away from the helicopter. She was on fire and most of her Nomex flight suit had burned away. The hospital-based pilot also saw the paramedic, who was seated in the rear, left seat, crawling out of the wreckage and the pilot was crawling out of the front of the wreckage. Due to the intense fire, there was no way to assist the patient.

The hospital-based paramedic stated that he was asleep when he was alerted of the inbound flight. He heard the helicopter approaching "then nothing." The lights in their crew-quarters then flickered for about 10 seconds. The hospital-based pilot then came in and said the helicopter had crashed. The hospital-based paramedic said that when he got to the accident site, the flight nurse was lying on her back on the sidewalk. The paramedic was on fire and about 10 feet away from the helicopter in the street. A bystander was using his shirt to put out the flames on the paramedic. The hospital-based paramedic then ran over to the injured paramedic. He said the paramedic was alert and was aware that he was involved in an accident. The hospital-based paramedic said he picked the injured paramedic up, placed him on a gurney and took him to the emergency room. He did not talk to the flight nurse or pilot.

The hospital-based flight nurse stated he was in bed, but had not fallen asleep. He heard the hospital-based pilot say that a company helicopter was inbound and he could hear it approaching the helipad. The flight nurse said he was putting on his jumpsuit when he heard the helicopter "power-up" followed by silence then the sound of a "crash." He and the two others immediately responded to the accident site. When the hospital-based flight nurse arrived on scene, he saw the flight nurse and thought she was deceased until she started screaming for help. The pilot was crawling through the front windshield and his foot was stuck. There was a "winding noise" coming from the helicopter so he helped him get out and away from the burning helicopter. He asked the pilot if he was ok, and he responded, "I don'...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CEN15FA003