Accident Agusta A109E Power N507CF,
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ASN Wikibase Occurrence # 167956
 
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Date:Thursday 17 July 2014
Time:01:42
Type:Silhouette image of generic A109 model; specific model in this crash may look slightly different    
Agusta A109E Power
Owner/operator:Tristate Careflight Llc
Registration: N507CF
MSN: 11067
Year of manufacture:2000
Total airframe hrs:3703 hours
Engine model:P&W Canada PW206C
Fatalities:Fatalities: 3 / Occupants: 3
Aircraft damage: Destroyed
Category:Accident
Location:North of Newkirk, Guadalupe County, NM -   United States of America
Phase: En route
Nature:Ferry/positioning
Departure airport:Santa Fe, NM (SAF)
Destination airport:Tucumcari, NM
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
After the commercial pilot received an emergency medical services helicopter flight request, he quickly (in about 20 seconds) assessed the weather conditions and accepted the flight. No records were found indicating that the pilot obtained an official weather briefing before departing on the flight, and the investigation could not determine which weather resources the pilot used to assess the weather. About 8 minutes later, the pilot called the company's operations center to report that the flight was departing; this was the last communication received from the pilot. The helicopter was operating in an area that was known by company pilots, including the accident pilot, to have the potential for low visibility, even though there were no airport weather reporting facilities or Doppler radar coverage in the area.

A review of GPS data showed that, while en route to pick up the patient, the helicopter performed a slight descending 360° turn before continuing toward the hospital. Weather overlays with the GPS track indicated that the helicopter made the 360° turn about the same time that an outflow boundary wave, which could have increased the potential for windshear and strong updrafts and downdrafts and reduced ceilings and visibility. Following the 360° turn, the helicopter proceeded toward the destination. About 14 minutes later, the helicopter turned right and began flying toward a major highway. It is likely that, due to the reduced visibility in the area, the pilot was flying toward the highway to follow the lights toward the city. The helicopter then turned further right and began to climb. As the helicopter entered another outflow boundary wave, it turned left. The left turn tightened, and the helicopter began to rapidly descend into terrain. The helicopter impacted a mesa in a near-level attitude.

A review of a company communication recording showed that, about 17 minutes after the estimated accident time, the operations center attempted to contact the flight crew and was unsuccessful. The company sent three company helicopters to the accident helicopter's last known position; one helicopter pilot flew near the helicopter's site but was unable to see anything, and the two other pilots could not proceed close to the accident site due to clouds and low visibility. The wreckage was subsequently located by local law enforcement. A postaccident examination of the helicopter and engine did not reveal any anomalies that would have prevented normal operation.

Due to mid- and low-level cloud cover, it is likely that no lunar or celestial lighting was available for amplification by the pilot's night vision goggles (NVG). Since the helicopter was not equipped with an infrared spotlight, only cultural light would have been available for NVG amplification. However, the helicopter was operating in a remote, sparsely populated area with minimal cultural light. Although the pilot's recurrent training included recovery procedures from inadvertent entry into instrument meteorological conditions (IMC), and his training records showed that he satisfactorily completed this item on his most recent training flight about 8 months before the accident, the circumstances of the accident are consistent with the pilot's inadvertent visual flight into IMC, which resulted in a loss of helicopter control.


Probable Cause: The pilot's inadvertent visual flight into instrument meteorological conditions, which resulted in a loss of helicopter control.

Accident investigation:
cover
  
Investigating agency: NTSB
Report number: CEN14FA369
Status: Investigation completed
Duration:
Download report: Final report

Sources:

NTSB
FAA register: http://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?NNumbertxt=507CF

Location

Revision history:

Date/timeContributorUpdates
17-Jul-2014 14:05 gerard57 Added
17-Jul-2014 14:54 gerard57 Updated [Operator, Total occupants, Departure airport, Destination airport, Source, Narrative]
17-Jul-2014 20:17 gerard57 Updated [Operator, Total fatalities, Other fatalities, Source, Narrative]
18-Jul-2014 00:02 Geno Updated [Time, Aircraft type, Registration, Cn, Departure airport, Destination airport, Source, Narrative]
18-Jul-2014 19:39 Black Typhoon Updated [Aircraft type]
23-Jul-2014 17:10 TB Updated [Aircraft type, Location]
23-Jul-2014 19:20 Alpine Flight Updated [Aircraft type]
11-Aug-2014 23:24 Geno Updated [Time, Nature, Departure airport, Source, Narrative]
30-Jun-2016 06:03 Aerossurance Updated [Location, Nature, Narrative]
21-Dec-2016 19:28 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
30-Nov-2017 18:53 ASN Update Bot Updated [Operator, Other fatalities, Nature, Departure airport, Source, Narrative]

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