Tuesday, May 8, 2012

Pilot Denny Fitch-- who helped land Flight 232 -- loses battle with cancer


As a trained pilot, Denny Fitch knew instinctively everyone aboard United Flight 232 could die in a matter of minutes.

“I was 46, I had the world ahead of me, I had a beautiful healthy family, and at 4 p.m., I was trying to stay alive,” he said in a documentary interview.

As the DC-10 thrashed, he took a second to think of his wife and three kids and what their last words had been that day back in 1989. “My wife said, ‘I love you, hurry home.’ And with that knowledge and that peace, I was ready to die that day if I had to.”

Fitch and 184 others survived, due in large part to his troubleshooting from the cockpit floor, pulling every aeronautical trick out of the book to control the plunging jet.

But the man hailed as a hero couldn’t stop the aggressive brain cancer he was diagnosed with in 2010.

The 69-year-old St. Charles resident died Monday with his family around him.
“Denny had a strong faith, and that helped him in the end,” his wife, Rosa, said Tuesday.

“He fought the disease as valiantly as he fought to save our lives in 1989,” said flight attendant Jan Brown of Schaumburg, who was on board the fateful trip.

Fitch was a United pilot and DC-10 flight instructor who happened to be a passenger aboard Flight 232 when it lost all hydraulic power July 19, 1989, flying from Denver to Chicago. The jet crash-landed into the Sioux City, Iowa, airport and veered into a cornfield, killing 111 people, but Fitch’s and the flight crew’s resourcefulness in bringing the aircraft down became legend in the aviation world.

“People studied it and used it to demonstrate the need for cockpit resource management,” said United pilot Mike Hamilton, who flew with Fitch. “It became a case study in how a crew could work together in an emergency.”

Fitch had his choice of two planes but chose the DC-10. “It was to be,” he told film director Errol Morris in a 2007 interview.

It was a quiet flight until a turbine blade came apart, sending shrapnel into the engine and disabling the hydraulic system, used for essential flight controls such as landings and takeoffs.

Fitch signaled to a flight attendant and told her he was a DC-10 instructor, “If there’s anything I can do to assist, I’m happy to do so,” he said.

He walked into a scene of cockpit chaos as pilots wrestled manually with failing controls. Fitch took charge of the throttles, desperately trying to ease the plane down. “I thought, ‘Dear God, I have 296 lives in my hands,’” he recalled.

Flight attendant Susan Callender tried to stay calm outwardly, but inside she panicked. “I was picturing headlines about death and thinking of my parents and how they’d feel,” she remembered. “I kept thinking. ‘Am I going to live? Am I going to die?’”

As the DC-10 streaked for the Sioux City airport, “I was hoping to pull the nose up and at the last minute arrest the sink rate so it wouldn’t hit the runway that hard, but there just wasn’t time,” Fitch said.

The cockpit broke off on impact, compacting the pilots and spinning out into the cornfield.

“Nobody had a right to walk away from that,” Fitch told the Daily Herald after the crash. He recalled crying for three days because of the casualties.
“He had survivor’s guilt after the crash because people died,” Rosa Fitch said. “It haunted him that he didn’t save everyone.”

But Fitch came out stronger from the crucible of the accident, becoming an international motivational speaker who inspired thousands and a consultant who worked with the National Aeronautics and Space Administration. He was commended by President George H.W. Bush and by the Senate.

“It gave him the platform and exposure to share his life lessons,” son Brian Fitch said. “By the end of his speeches, he had grown men crying.”

Fitch also turned his skills to volunteering with Lifeline, a service where pilots donate their time to transport critically ill patients to medical facilities. He became personally involved with some of his passengers, Rosa Fitch said.
“He was a big hugger,” she said. “Even if he didn’t know you, he’d put his arms around you.”

Now, in the midst of their grief, the family is celebrating Fitch’s life — just as he wanted.

“He was doing exactly what he wanted, didn’t want anyone to be sad when he was gone,” Brian Fitch said.

In his 2007 interview, Denny Fitch recalled how his mother made a joke about how he said, “plane” before saying “mommy” or “daddy.”

“I love it,” he said. “It’s what I was meant for. I’ve never gone to work, I’ve only gone to fly.”

Callender, who has since become a family friend, spread the news of Fitch’s death to United staff at a training event Tuesday. “It was a hard day of crying,” she said. “Everyone loved Denny; he was larger than life. And his laugh ... he had a deep hearty laugh.”

But she agreed his death should be a celebration.

“Having Denny on board was such a blessing,” she said. “I feel he was put there to play the role he did.”

Visitation is from noon to 8 p.m. Sunday at Yurs Funeral Home, 405 Main St., St. Charles. A funeral Mass is set for 10:30 a.m. Monday at Resurrection Church, 30W350 Army Trail Road, Wayne.
For more information, visit http://web.me.com/brianfitch/Denny_Fitch_Sr/Welcome.html.

Read more and photos:   http://www.dailyherald.com

Apalachicola Regional Airport (KAAF) without an FBO

Apalachicola Regional Municipal Airport is open for business.....sort-of. 

"The service provider the County had in the past is somebody called an FBO, a fixed base operator, who'd, he'd pump fuel, rent the T-hangars, he had some rental cars out there that he'd rent to people who flew in," said Alan Pierce, Franklin County Administrator.

The previous FBO's contract was up in February and his lease on the property ended May 4, 2012. He hadn't ordered fuel for the airport and supplies ran out about three weeks ago.

"The new FBO operator that we have chosen, we are negotiating a proposed lease and we have until Wednesday evening to finalize that. Otherwise we might go out and operate it ourselves," said Pierce.

People in Apalachicola say if this problem isn't resolved soon, the business owners are going to start feeling the effects.

Gary Settle is a realtor in Apalachicola who is also a pilot. He said many visitors and vacation home owners use the airport as their hub into the county.

"Not having that flow of people coming in and staying at hotels, and eating out and stuff can be tough for this local economy which has been hurting, and is just rebounding as now," said Settle.

For now, pilots have to fly to Tallahassee, Panama City, or Blountstown to fuel up.

"It's really kind-of-of inconvenient to have to take off and go somewhere else to fuel if you're going in a different direction, or if you need fuel," said Settle.

Watch Video: http://www.wctv.tv

Packed house greets Kalispell airport discussion

KALISPELL- Over 100 Flathead Valley residents packed the Kalispell City Council Chambers on Monday evening to voice their concerns again about the possible expansion of the city airport. So many people attended the hearing that monitors had to be set up in the lobby just to accommodate the overflow crowd and folks on both sides of the issue weighed in with comments. While the project was not up for a vote, an update on the master plan was given by Stelling Engineers. Those who spoke against the proposed expansion suggested Glacier International Airport was sufficient to handle additional traffic. But those who back the changes spoke about the boost to Kalispell's economy and improved safety to the city airport that the plan would bring. 

Watch Video: http://www.kpax.com

Pilatus PC-6 over Jumeirah Palm - Dubai



Father of New Zealand air crash victim calls for fundamental changes: NZ Aerospace Fletcher FU24-954, Skydive New Zealand, ZK-EUF. Accident occurred on September 4, 2010 at Fox Glacier Airstrip

Wednesday, 9 May 2012, 12:28 pm
Press Release: Amethyst Communications


Father of NZ air crash victim calls for fundamental changes to safety regulation

NEW ZEALAND PM URGED TO CONDUCT URGENT REVIEW OF AVIATION SAFETY AND REGULATION FOLLOWING AIR ACCIDENT REPORT PUBLISHED TODAY

FOUR TOURISTS KILLED IN “AVOIDABLE AND NEGLIGENT” ACCIDENT SAYS FATHER OF UK VICTIM

NEW ZEALAND CAA “MISSED THE OPPORTUNITY” AND OFFERED “NO ASSISTANCE OR OVERSIGHT” TO ENSURE THE AEROPLANE WAS FIT FOR PURPOSE

YOUNG TOURISTS IN NEW ZEALAND AT RISK AND SHOULD “THINK TWICE” ABOUT VISITING
Father of NZ air crash victim calls for fundamental changes to safety regulation


A British man is calling on the New Zealand Prime Minister to conduct an urgent and immediate review of aviation safety and regulation enforcement in the country following the publication of a highly critical air accident investigation report. Chris Coker, whose son died in New Zealand whilst trying skydiving, has written to New Zealand PM John Key today after publication of the air accident report into his son’s death. Mr Coker has told the Prime Minister that pending such a review “the public and tourists in New Zealand are highly vulnerable and are not safe, and the case for a change in the way adventure sports are regulated and such regulations enforced is now overwhelming”.

Mr Coker believes that until action is taken, there is compelling and worrying evidence that young people should “think twice” before pursuing any adventure activities in the country. This follows the publication of the air accident report, the findings of which he said “will alarm and worry every parent whose son or daughter travels to New Zealand on holiday”.

The official air accident report, published today, confirms that at least two of the tandem-master crew in the aircraft had been taking controlled drugs and one had taken cannabis shortly before the flight. The report is critical of the CAA in New Zealand, as well as others, and calls on the New Zealand government to introduce a rigorous control and testing drugs and alcohol regime.

Bradley Coker (24), from Farnborough, Hampshire, was killed along with three other young tourists on 4 September 2010 when the light aircraft taking them on a skydiving experience, crashed immediately after take-off at Fox Glacier, South Westland. All nine on board were killed, in what Chris Coker, Bradley’s father, calls “a completely avoidable and needless fatal accident”. It was New Zealand’s worst aviation accident for seven years.

An official report into the accident by New Zealand’s Transport Accident Investigation Commission published today, Wednesday 9 May 2012, finds the accident was caused by a series of negligent and reckless acts by those operating the aircraft in which the young people died and that the CAA “missed the opportunity to ensure the aeroplane was fit for purpose” and that “there was no assistance or oversight provided by the CAA” to ensure the aeroplane was safely introduced into service”.

In particular:
• The aircraft was overloaded and took off with more than its permitted take-off weight which was not checked prior to take off. We have discovered from the final report that the operator, Skydive NZ, had never performed this vital calculation since the day the aircraft was purchased, significantly modified and put into operation. The report says that the aeroplane was “excessively out of balance”. Furthermore, this was not policed by the New Zealand Regulator, the CAA which has admitted that “it did not check all the individual modifications” and that some “should not have been made to [this aircraft] without approval”;

• The passengers were not properly distributed on board the aircraft and the centre of gravity for the aircraft was around 55 per cent outside the allowable limit prescribed by the flight manual. None of the passengers in the aircraft were secured by a belt or other device and this is allowable under current NZ regulations. The report states that “ the weight and balance of the aeroplane … was the most significant factor contributing to the accident” and recommends that passengers should “preferably be restrained to prevent them moving rearward”. The poor distribution of passengers in the cabin was compounded by a lack of proper control within the cabin because:

• The report found that two of the aircraft’s crew in the cabin had taken controlled drugs in the hours before the flight. The crew in the cabin, known as “tandem masters” were paired with each of the tourists and harnessed to them in preparation for direct “control” of a tandem parachute descent. Even so, despite previous calls for compulsory random drug and alcohol testing, the CAA was “not convinced … that the costs would outweigh the benefits”. [page 43] The New Zealand Ministry of Transport has been looking into the issue of substance impairment since 2005 and in 2010 announced it would “investigate the feasibility of implementing a compulsory post-accident drugs testing regime” in 2011/2012. [page 24]

New Zealand law does not allow companies to be sued in the courts for negligence and has no criminal offence of corporate manslaughter. Compensation is decided by the New Zealand Accident Compensation Corporation, the sole and compulsory provider of accident insurance in New Zealand, which determined the death of Bradley Coker merited compensation for the family of £2,744. This compensation did not even cover the cost of the repatriation of Bradley’s body to the United Kingdom.

Oversight of activities associated with skydiving, including safety regulation, inspection and control, is largely delegated by the NZ Civil Aviation Authority (the CAA) to an industry governing body, something Mr Coker believes needs urgent change. In fact, the CAA had tried to inspect this company previously but no-one was in when inspectors called. In addition, the final report reveals that the CAA aviation safety advisers visits to Skydive NZ were “reported to have been of an informal nature”. [page 17] and that the CAA’s health and safety manager, who had audited four parachuting operators, “had no piloting or engineering experience and was not able to comment on operational safety and compliance”. [page 19]

The air accident report concludes: “Maintaining flight safety requires active participation and a co-ordinated approach by all sectors of the industry”. It found that:
• “the engineering company that modified [the aeroplane] did not follow the proper processes required by civil aviation rules and guidance”;

• “the aeroplane owner and their pilots did not comply with civil aviation rules and did not follow good, sound aviation practice”;

• “the CAA’s oversight and surveillance of commercial parachuting were not adequate to ensure that operators were functioning in a safe manner”;

• “an alcohol and drug testing regime needs to be initiated for persons performing activities critical to flight safety; and that

• “safety harnesses or restraints would help to prevent passengers sliding rearward and altering the centre of gravity of the aircraft”.

Writing to the Prime Minister, Mr Coker said:

“Nothing you can do will bring back my son Bradley, who was killed in the prime of his life whilst enjoying a holiday in your country, and no amount of compensation could make up for his death.

“Bradley’s death was completely avoidable and needless. The circumstances that led to his death are a shocking catalogue of behaviour that would be regarded as negligent in every civilised country in the world. This accident is, tragically, the latest in many similar events in your country and amply demonstrates the lack of proper regulation and control and the need for urgent and fundamental reform in the way this kind of activity in New Zealand is monitored, controlled and regulated.

“I urge you to act in the best interests of the thousands of young people who come to New Zealand every year to enjoy what you have to offer in such a beautiful country. Until you do act, the beauty of your country will continue to disguise a regulatory and legal culture that makes the public and visitors highly vulnerable and puts their lives in significant danger.

“When an accident happens in New Zealand, the law is not there to support you. There is not a single parent anywhere in the world who would look at the case of the death of our son and not find our treatment at the hands of the authorities and the legal system derisory.

“Until action is taken to ensure the regulation, inspection and control of adventure sports, particularly involving aircraft, is radically tightened, I feel it my duty to advise people thinking of visiting New Zealand for adventure sport to think twice.

“My whole family owes a duty to other families around the world to warn them of these dangers. I do not wish another parent to have my experience of a knock on the door at 5am telling you that your beloved son is dead.

“The whole world appreciates the focus that has been required of your Government to recover from the terrible events at Christchurch.

“But the year before the earthquake – in June 2010 – a national review in your country of the adventure tourism industry found that ‘regulatory safety standards applicable to commercial adventure aviation were designed for recreational (non-commercial) activity and did not provide sufficient assurance that commercial activities involving inherent risk are safely managed’. And yet there was no urgency on the part of the Government to effect the radical changes in regulation, monitoring and control that would have saved the lives of my son and his fellow tourists.

“A new civil aviation rule, effective from 1st May 2012, requires skydiving and other adventure aviation operators to hold a CAA Operator Certificate. This does not do anything to strengthen monitoring and control of the regulations, which might have saved Bradley's life. Every day that radical improvements in the enforcement of safety in New Zealand are delayed puts the lives of more tourists at very great risk.”

Elizabeth Coker, Bradley’s sister, and a UK lawyer, also said: “When your brother travels to a Commonwealth country such as New Zealand, you naturally expect the safety standards and legal standards to match those of the UK or your home country, and this is not the case. You cannot sue for negligence in New Zealand and there is no criminal offence of corporate manslaughter. In our view, this has had the effect of lowering safety standards in New Zealand. There is no ultimate sanction, either financial or criminal, on companies who ignore their duty to protect the public. This accident report backs our view that the legal system in New Zealand is weighted entirely against victims of accidents, and indeed the UK Foreign & Commonwealth Office website warns UK citizens of this in giving startling advice about travelling to New Zealand. I don’t think this is well known, but it deserves to be. Perhaps if my brother had known about it, he might not have taken the flight that ended his life. No-one would knowingly board an aircraft crewed by people who had taken controlled drugs. It defies every standard of decency and lawful behaviour in relation to the safety of others.”

The families of those killed in the crash have very recently received a touching letter from the people of Fox Glacier and Franz Josef. The community, who expressed their shock and continued sadness over the tragedy, plan to create a memorial seat in memory of those who died and held a collection to help relatives with legal and other costs. Each family received £400 from the local community, which has greatly touched the Coker family.

Gypsy Moth Aerial Spraying in Southwestern Wisconsin On May 9

Posted Tuesday, May 8, 2012

Press Release:

WHAT: Gypsy moth aerial spraying by the Wisconsin Department of Agriculture, Trade and Consumer Protection’s Gypsy Moth Slow the Spread Program

WHEN: Tentative May 9, weather permitting.

WHERE: Selected sites located in Grant, Iowa, Jackson, Lafayette and Vernon counties.

WHY: The spraying is necessary to control the spread of gypsy moth, a destructive and invasive pest that feeds on the leaves of oaks, maples, crabapple, birch and many other species of trees and shrubs.

PLAN DETAILS: 

All of the areas we’ll be spraying in Grant, Iowa, Lafayette and Vernon counties will be receiving their second and last treatment of Btk for the year. Upon completion of this, spraying will be completed for the year in Grant, Iowa and Lafayette counties. Then, we’ll return again at some point in late spring or early summer to Vernon County to spray at an additional site. As for Jackson County, most sites will be receiving their first application. One area will be receiving its second.

OTHER DETAILS:

Spraying can start as early as sunrise and will continue until the day’s spray plan is complete and as weather conditions allow. Spraying requires calm winds, high humidity and no precipitation.

The planes will fly low, just above the tree tops. It will be loud.

The planes will apply the biological insecticide Foray 48B, which is approved for use in certified organic production or food processing by the Organic Materials Review Institute. The spray will not affect organic certification. The insecticide contains Bacillus thuringiensis var. kurstaki or Btk. Btk is a naturally occurring soil bacterium that is poisonous to gypsy moth caterpillars when consumed. Btk breaks down in sunlight within a few days.

The insecticide is not toxic to people, bees, animals, birds and plants.

People who are uncomfortable or have allergies may wish to stay indoors or leave the area until the spraying is done. Pets or livestock may be frightened by the noise of the low-flying planes, so keep them indoors or keep a close eye on them.

Most sites will receive a second application of Btk about three to five days after the first application.

Skydive instructors took cannabis before fatal flight: NZ Aerospace Fletcher FU24-954, Skydive New Zealand, ZK-EUF. Accident occurred on September 4, 2010 at Fox Glacier Airstrip, New Zealand

Two instructors of the ‘excessively unbalanced’ skydiving plane that crashed and killed nine people near Fox Glacier in 2010 had taken cannabis, a report has revealed.

The Transport Accident Investigation Commission (TAIC) has released its final report into the crash of the Fletcher FU24, which killed four Skydive New Zealand instructors, four tourists on a skydiving trip and a pilot on September 4, 2010. 

 
The report found two of the tandem skydiving instructors tested positive to taking cannabis – with tests revealing one instructor smoked marijuana within three hours of the flight. 

TAIC says the presence of the drug, albeit at low levels, did not contribute to the accident but it was a concern as the Civil Aviation Authority (CAA) rules prohibited them from taking performance-impairing drugs. 

As a result, the Commission has recommended an alcohol and drug testing regime for those undertaking tasks that are critical to flight safety.

The report states the main reason for the crash was the aircraft being overloaded and exceeding maximum take-off weight. The passengers and crew were distributed unevenly towards the rear and the plane’s centre of gravity was out of its allowable limit by around 30 percent.

This may have caught the pilot unaware and the plane probably became airborne early and at too low a speed to control it from pitching ‘nose-up’.

The plane then reached a pitch angle at which the unrestrained parachutists were unable to stop themselves sliding backwards and this shift in weight toward the back of the plane would have made it even more unstable.

It continued to pitch upward until it was almost vertical, before the left wing dropped and the plane tilted vertically downward and crashed.

It was also revealed the owners of the aircraft used the incorrect amount of fuel reserves, removed the flight manual from the plane and did not devise their own operating procedures before using the plane for skydiving.
.
The report finds: 
.
• The engineering company that modified the plane from its original
agricultural role to a parachuting aircraft did not follow CAA rules.
.
• Two modifications were for a different aircraft, one belonged to a different design holder and a fourth was not referred to in the aircraft maintenance logbook, however TAIC said the engineering work was appropriately carried out.
.
• A flaw in the CAA regulatory system allowed the engineering company that modified the aircraft to have little or no CAA involvement.
.
• The CAA’s oversight and surveillance of commercial parachuting were not adequate to ensure that operators were functioning in a safe manner.
.
• The aeroplane owner and their pilots did not comply with CAA rules and did not follow good, sound aviation practice
.
• The CAA’s oversight and surveillance of commercial parachuting were not adequate to ensure that operators were functioning in a safe manner
.
• An alcohol and drug testing regime needs to be initiated for persons performing activities critical to flight safety; and that
.
• Safety harnesses or restraints would help to prevent passengers sliding rearward and altering the centre of gravity of the aircraft”.
.
The report calls for active participation and a co-ordinated approach by all sectors of the aviation industry to address the concerns.

http://www.3news.co.nz

Download full report .pdf

 

NZ Aerospace Fletcher FU24-954, Skydive New Zealand, ZK-EUF: Accident occurred on September 4, 2010 at Fox Glacier Airstrip, New Zealand

The Civil Aviation Authority (CAA) has been criticized following a plane crash that killed nine people at Fox Glacier 20 months ago.

Watch Video

Inquiry 10-009 Final Report
10-009 Executive summary

General

On 4 September 2010 the pilot of a Walter Fletcher aeroplane with 8 parachutists on board lost control during take-off from Fox Glacier aerodrome. The aeroplane crashed in a paddock adjacent to the runway, killing all 9 occupants.

The Walter Fletcher had been modified from an agricultural aeroplane into a parachute-drop aeroplane some 3 months before the accident. The modification to the aircraft had been poorly managed, and discrepancies in the aeroplane’s documentation had not been detected by the New Zealand Civil Aviation Authority (CAA), which had approved the change in category.
The new owner and operator of the aeroplane had not completed any weight and balance calculations on the aeroplane before it entered service, nor at any time before the accident. As a result the aeroplane was being flown outside its loading limits every time it carried a full load of 8 parachutists. On the accident flight the centre of gravity of the aeroplane was well rear of its aft limit and it became airborne at too low a speed to be controllable. The pilot was unable to regain control and the aeroplane continued to pitch up, then rolled left before striking the ground nearly vertically.

Recommendations
The Commission made 6 recommendations to the Director of Civil Aviation. Three related to the operation of parachute-drop aircraft, 2 related to the process for converting aircraft for another purpose and one related to seat restraints. A recommendation was made to the Secretary for Transport regarding the need for a drug and alcohol detection and deterrence regime for the various transport modes.

Key lessons
The investigation findings and recommendations provided reminders of the following practices that contribute to aviation safety:
  • no 2 aircraft of the same model are exactly the same, even if they look that way; therefore pilots must do weight and balance calculations for every individual aircraft
  • modifying aircraft is a safety-critical process that must be done in strict accordance with rules and guidelines and with appropriate regulatory oversight
  • good rules, regulations and recommended practices are key to ensuring safe commercial aviation operations
  • operators need to ensure that aircraft are being operated in accordance with prescribed rules and guidelines, and flown within their operating limitations
  • aircraft operations need to be accompanied by relevant and robust procedures
  • maintaining flight safety requires active participation and a co-ordinated approach by all sectors of the industry.
     


A Transport Accident Investigations Commission (TAIC) report into the crash was released today, repeating an earlier finding that the plane was out of balance and saying modifications made to it were poorly managed.

The Skydive New Zealand plane crashed soon after takeoff from Fox Glacier airstrip on September 4, 2010, killing four tourists, four skydive masters and a Queenstown pilot.

The report said the CAA allowed parachuting operators to flourish, despite knowing the industry was booming with 100,000 tandem jumps annually at the time of the accident, and should have ensured firms were operating in a safe manner.

CAA Director of Civil Aviation Graeme Harris said the report provided lessons for all pilots, and for the CAA.

TAIC found that the pilot had wrongly used weight and balance calculations for another Fletcher aircraft, he said.

It also said pilots must do weight and balance calculations for every individual aircraft, reminding pilots-in-command they were responsible for aircraft weight and balance, whether flying an airliner, private two-seater or microlight, he said.

"This is basic airmanship, taught to every student pilot. It is very sad that a critical element of pre-flight planning, which should be second nature to any pilot, appears to have been done so poorly. This is an accident that no pilot should ever forget," Harris said.

Since the accident the CAA had made significant changes. Soon after, it limited the number of skydivers who could be carried in Fletcher aircraft to six, and required that these passengers be individually weighed to ensure calculations were accurate.

The CAA now had much better tools with which to regulate the commercial skydiving sector. A new adventure aviation rule was introduced in November 2011, which set higher standards and allowed the authority to maintain significantly closer oversight of those activities.

Just before the accident, the CAA had also taken steps to more tightly control the kinds of modifications that could be made to an aircraft without direct CAA inspection.

Harris said although the pilot did not meet a basic element of good airmanship, the CAA at that time did not regulate the parachuting sector closely enough.

"In the intervening year and a half the regulatory landscape controlling these operations has been transformed. A great deal of work has been done to improve safety in this sector, and I am certain that it will."

PLANE OUT OF BALANCE

The September crash was blamed on the plane being out of balance, making the nose "pitch up".

The report said the aircraft had been modified from an agriculture plane into a parachute-drop plane three months before the accident, and the owner had not completed any weight and balance calculations before it entered service.
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As a result, the plane was being flown outside its loading limits every time it carried a full load of eight parachutists.

TAIC found the engineering company that modified the plane did not follow proper processes required by civil aviation rules, but due to a "flaw in the regulatory system" were able to use an internal inspector to oversee and sign off the work.

The commission said the Civil Aviation Authority adhered to normal practice when approving the changes, but should have had greater participation in the process to help ensure there were no safety implications.

"The level of parachuting activity in New Zealand warranted a stronger level of regulatory oversight than had been applied in recent years.

"The CAA's oversight and surveillance of commercial parachuting were not adequate to ensure that operators were functioning in a safe manner."

TAIC said the Fletcher FU24 aircraft was 0.122m off balance, becoming airborne at too low a speed to be controllable, which was a significant factor contributing to the crash.

The pilot was unable to regain control and the plane continued to pitch up, then rolled left before striking the ground nearly vertically.

TAIC said the owner and the pilots did not comply with "civil aviation rules and did not follow good, sound aviation practice" by failing to conduct weight and balance checks.

They also used the incorrect amount of fuel reserves, removed the flight manual from the plane, and did not draft their own standard operating procedures before using the plane.

The plane was 17kg over its maximum permissible weight that day, but was still 242kg lighter than the maximum all-up weight for which the aeroplane was certified in its previous agriculture role.

TAIC found the engineering company that worked on the aircraft had used two modifications that had been approved for a different aircraft type, one modification belonged to another design holder, and a fourth was not referred to in the aircraft maintenance logbook.

The flight manual was then not updated to reflect the changes.

TAIC made six recommendations to the director of Civil Aviation - three relating to the operation of parachute-drop aircraft, two relating to the process for converting aircraft for another purpose and one relating to seat restraints.

Key recommendations focused on weight and balance, airplane modification, introduction into service, and regulator oversight.

Safety restraints were needed to prevent parachutists from going too far to the plane's rear.

Two of the tandem masters had smoked cannabis, though TAIC said it did not contribute to the crash as they were not crew members of the plane.

The commission said an alcohol and drug testing regime needed to be implemented for people performing activities critical to flight safety.

The crash claimed the lives of Skydive New Zealand director Rod Miller, 55, of Greymouth, pilot Chaminda Senadhira, 33, of Queenstown, dive masters Adam Bennett, 47, from Australia but living in Motueka, Michael Suter, 32, from New Plymouth and Christopher McDonald, 62, of Mapua.

The four tourists, who had been touring the West Coast on a Kiwi Experience bus trip, were Patrick Byrne, 26, of Ireland, Glenn Bourke, 18, of Australia, Annita Kirsten, 23, of Germany, and Brad Coker, 24, of England.

Ryan Shaffer named manager at Greater Cumberland Regional Airport

By LIZ BEAVERS 
News-Tribune
`
WILEY FORD – A Fort Hill High graduate who first got interested in flying by spending time with his grandfather at the Mexico Farms airfield and who now works as a commercial pilot and flight instructor out of the Greater Cumberland Regional Airport has been named the new manager at the airport.

The Potomac Highlands Airport Authority, the bi-state entity which oversees the airport in Wiley Ford, announced Monday evening that Ryan P. Shaffer of Keyser was chosen from a field of over 20 applicants for the part-time position.

Contacted at home by telephone, Shaffer said he is excited about the opportunity to help move the airport forward.

“Being a flight instructor there, I see the opportunities that are there for the airport,” he said. “With a facility like we have there, and the runway project that's coming, there's a lot of opportunity for growth.”

Shaffer said he believes the airport can begin movement now toward bringing in more corporate business, as more and more businesses and industries in the area are made aware of what the facility has to offer.

“I honestly don't think a lot of people even realize it's there,” he said.

He also would like to see a commercial service eventually brought back to the airport – something which has not been available there since 2003.

In the meantime, Shaffer has his work cut out for him, as the hangars that were destroyed by fire earlier this year have been razed and construction on new ones will begin soon. A new restaurant is also coming to the airfield, and work is expected to begin soon on the long-awaited runway expansion project.

“It's definitely going to be busy, but I look forward to the task,” he said. “It's really exciting. It will be nice to bring some new opportunities to the area.”
Shaffer explained that he discovered his love of flight by spending time with his grandfather when he was a young boy.

“My grandfather was a World War II bombardier. He had two planes; one of them he built himself,” he recalls.

“I've just thought about it all my life and when I got a chance to get into it, I took it,” he said.

Shaffer has been the owner, commercial pilot, and flight instructor with Shaffer Aviation since 2009. In that capacity, has has trained students for primary certification through commercial certification.

Prior to that, he worked as an aircraft dispatcher and flight instructor, being responsible for dispatching all cross country flights of instrument-rated students, scheduling flights, and overseeing the safe operation of all company aircraft.

Prior to launching his aviation career, he worked as a journeyman electrician with S&S Electric and Queen City Electric.

“We are very happy to have a new manager and to be able to move the airport forward,” authority chairperson Cindy Pyles said.

Shaffer starts his new position on May 13.

Source:   http://www.newstribune.info

Council may adopt new standards at Ocala International Airport-Jim Taylor Field (KOCF), Ocala, Florida

Move could spur competition to provide services 

By Susan Latham Carr 

 OCALA - The Ocala City Council will decide at its Tuesday, May 15, meeting whether to adopt new, reduced minimum standards for the Ocala International Airport in hopes of making the facility more competitive.

During a workshop meeting Tuesday, Jeff Kohlman, owner of Aviation Management Consulting Group, discussed what the council should consider when changing or adopting minimum standards.

The standards outline the basic qualifications and requirements the city insists an operator of a commercial venture at the airport must meet.

For example, the current standards require that anyone who wishes to sell fuel at the airport must also provide maintenance and three services: flight training, aircraft rental and avionics. Those standards have been in effect since 1988, with a few revisions in 2000 and 2006.

What is being proposed is that anyone who wishes to sell fuel at the airport also must provide maintenance and one of the following services: flight training, aircraft rental, aircraft charter, avionics or aircraft sales.

The city’s current fixed base operator is Landmark Aviation, whose lease expires in about six years. Landmark is meeting the current standards.

The fuel rates being charged by Landmark, however, are considerably higher than neighboring airports, which causes pilots to refuel elsewhere. As of March 22, Landmark was charging $6.67 per gallon of Jet A fuel, compared to $4.95 in Williston, $5.84 in Leesburg and $6.35 in Gainesville.

According to Landmark’s lease, the city receives 3 cents for every gallon sold.

“I think the high fuel charges are a concern,” council president Suzy Heinbockel said.

Following the city’s request for proposals for a fixed base operator and the receipt of three, the council rejected all of them on Sept. 20, 2011.

Ocala Jet Center has since come back with another proposal to build a general aviation terminal and associated hangars, provide fuel and maintenance, and storage for larger airplanes on the west side of the airport.

“He will have to put a $500,000 investment just for the fuel farm,” Airport Manager Matthew Grow said about Ocala Jet.

Terry Crawford, chairman of the city’s Airport Advisory Board, told council members he had concern there was not enough fuel being sold to support two fixed base operators.

“I don’t mind the competition,” Crawford said after the meeting. “It’s difficult to support two.”

Crawford, who has been on the airport board more than 30 years, said Landmark provides a good level of service.

Grow said about 1 million gallons of fuel need to be sold in order to support two fixed base operators.

“We were there,” Grow said. “Business was there.”

In 2007, Landmark sold 1 million gallons of Jet A fuel. In 2011, the firm sold 568,000 gallons. So far this year, it has sold 191,000 gallons.

Asked if he thought the airport could support two fixed base operators, Grow said, “It depends on the business model.”

Heinbockel said the airport would be less likely to support two operators if they are required to duplicate services.

“If we give some flexibility to the second company, they could provide services that are not currently being provided,” Heinbockel said.

Grow said changing the minimum standards could facilitate additional business development at the airport.

Kohlman told council members that minimum standards are encouraged, but not required, by the Federal Aviation Administration. However, to be eligible for certain FAA funds, the city must meet certain assurances that ensure the airport is operated and maintained in a safe manner and is not unjustly discriminatory to anyone who wishes to provide aeronautical services to the public. He said the minimum standards should not be written to favor an existing operator or someone wishing to enter the market. He said that, generally, standards are reviewed about every five years and overhauled about every 10 years.

Although Mayor Kent Guinn said the city is looking to change the standards to allow for competition, Heinbockel said Grow has been urging the council to change the standards since January, 2005.

Landmark General Manager Tracine Anderson referred questions to corporate headquarters, which had not responded by deadline.

Source:  http://www.ocala.com

Massachusetts: Linden Ponds resident, 93, flies a helicopter and remembers his love of piloting

By Jessica Bartlett




Russell Jalbert, 93, has always had a love of airplanes.

Even just as a boy, Jalbert knew he wanted to fly, and when World War II came around, he knew exactly what he wanted to do.

He enlisted in Naval Aviation in 1941, and flew 18 types of airplanes until he left the Navy in 1945.

Decades later, the Linden Ponds resident's flying days are largely behind him, yet he still had an itch to fly one last time - this time, in a helicopter.

The World War II veteran took one more stab at the pastime he adored, flying at Plymouth Airport with Rick Smith, president of New England Helicopter Academy.

In an interview with The Boston Globe, he recounts the experience, and proves to everybody who had a doubt that you’re never too old to accomplish your dreams.

BG: How did your interest in this start?

RJ: It started in 1927, I was 9-years-old. My mother sent me down to the corner variety store and I got there and there were some men at a table and they were very excited. I found out that Charles Lindbergh had flown across the Atlantic - the first man in history to do that.

He instantly became my hero and I began making model airplanes and started reading all about it…and in those days there was a lot of variety, and people were trying to do new things with flying. Nine-years-old, I caught the bug.

I used to make airplanes out of balsa wood. It’s a very soft wood, easy to manipulate and you buy it in sheet. They are great for making model airplanes, so I made one of this kind of airplane and that kind of operation planes and passenger planes and all of that. I got to the point where making the airplanes out of balsa wood, I put a fuse on it, lit a match, and it caught on fire and crashed. And I thought that was great.

And I put myself in the Lindbergh seat. That was kind of my entry into the world of aircrafts...

BG: Now why did you always want to fly a helicopter?

RJ: When I was in the service in WWII, I flew airplanes and fell in love with the feeling of it. I flew all kinds of different aircrafts...

I left the service and became a commercial [flier]. I continued to fly on my own but I never flew in a helicopter. And it occurred to me - why not just get the feel of it? So I went out and found the helicopter academy down in Plymouth and took an introductory lesson. So I have that as one more experience.

BG: So this will make 19 total types of airplanes that you’ve flown. Is that unique to pilots to fly that many different kinds of aircrafts?

RJ: It’s just about 19 different kinds from the Piper Cub up to the monsters. One of the types of planes that very few people have flown are amphibians. And I’ve flown in fighter planes, passenger planes, all sorts of things in the sky.

It’s all summed up in a poem I found written by [John Magee], and it starts ‘Oh I have left the surley bounds of earth,’ and it expresses my emotions about flying and space. The poem ends that I ‘touched the face of god.’ It’s an emotional connection here…

I said … hey, maybe I can find a place around here that can teach you how to fly a helicopter, and sure enough I found the airport in Plymouth. And a phone call led to an interview and that led to an appointment and that lead to my experience.

BG: Now you haven’t flown for 10 years. How did it feel to get there, to step into a cockpit after all that time?

RJ: It was fun. I found it more difficult than I had expected, but I found out that it was mostly because of my old age, I don’t have the instant reflexes I used to have. But it was still …the feeling of having it go up and down instead of sideways, I got a kick out of it. I had a good instructor.

He sat me down first. I had a period of classroom instruction, and I knew a lot of the stuff. The aerodynamics are the same whether it’s a helicopter or a winged aircraft. Then he took me up in a two seater and he had one set of controls and I was on the other, and showed me how to do this and that…that was a lot of fun for me.

BG: How different is flying a helicopter than a regular airplane?

RJ: Very different. The differences in my age from the time I flew them also made the difference.

BG: Now that you’ve done this, what else is on your bucket list?


RJ: (Hearty laugh) I cant tell you how many people have asked me that question! I dream that the next step up would be a flight into space, but I’m not going to do that. I can live with that.

But my doctor says I’m in exceptionally good health for a man my age. I’m still 93, I can’t do what I did when I was 25 or 75/80.

[During this flight, though,] I could get around, I could jockey the helicopter into maneuvers that gave me some experience with the breadth of response from the helicopter.

That’s done and it was fun. It capped the interest I’ve had in aviation that I’ve had for so long. 

Source:  http://www.boston.com

Air India Stir: 10 Agitating Pilots Sacked, Union De-recognized

New Delhi/Mumbai, May 8 (PTI): In a crackdown, Air India today sacked ten agitating pilots, de-recognized their union and sealed its offices as around 160 of them failed to join duty, leading to cancellation of five international flights since midnight.

With Civil Aviation Minister Ajit Singh terming their agitation "illegal", airline sources said more severe action was to follow if the pilots did not get back to work by 1800 hours today.

Flights on Delhi-Toronto, Delhi-Chicago, Mumbai-Newark and Mumbai-Hongkong via Delhi sectors were cancelled "due to unavailability of pilots," an Air India spokesperson said.

With about 160 pilots not having joined duty, the services of at least ten pilots, including office bearers of the Indian Pilots Guild (IPG), which is leading the agitation, were terminated, the sources said.

While the IPG has been de-recognized, the sources said its offices in Mumbai and Delhi were sealed. A section of Air India pilots owing allegiance IPG are agitating over the rescheduling of Boeing 787 Dreamliner training and matters relating to their career progression.

The Civil Aviation Minister termed the strike as "illegal" and said the management of the national carrier would take appropriate action against those involved in the stir.

"They are reporting sick. They have not given any notice for any strike. So whatever the Air India management rules and regulations, action will be taken accordingly," Singh told reporters.

"The pilots have been told to return to work by today evening. And if they don't, the management will take stern action against them," the Air India spokesperson said. The airline management has also started sending doctors to the houses of pilots who were reporting sick, the sources said.

Meanwhile, the Nationalist Congress Party (NCP)-backed pilots' body has said that it is open to negotiations with the management. "We are open to negotiations at any given time," Indian Pilots Guild president and NCP leader Jitendra Awhad told PTI.

The Civil Aviation Minister said the pilots went on sick leave in the midst of their talks with the management of Air India which has led to cancellation of flights.

Noting that Air India is currently going through a turbulent period and crores of rupees of public money were being infused to run the carrier, Singh said this was not the right time for such protests.

Agreeing that every section of employees had grievances and there were ways to find a solution, the Minister said the "strike is illegal."

http://www.daijiworld.com

FAA seeking sanctions against Colorado Company in Arizona medical-helicopter crash: American Eurocopter LLC AS 350 B3, N509AM

PHOENIX — The Federal Aviation Administration is seeking sanctions against a Colorado company stemming from a deadly 2010 medical-helicopter crash in Arizona that killed the aircraft’s three-member crew.

FAA spokesman Ian Gregor tells The Associated Press that the federal agency wants to lodge a $50,625 fine against Colorado-based Air Methods, the parent company of LifeNet Arizona and the helicopter’s operator.

The development comes on the heels of a report by the National Transportation Safety Board that says the July 28, 2010, crash likely was caused by a contract mechanic’s mistake and a lack of proper inspection and testing of his work.

The helicopter left Marana, Ariz., and was en route to its home base in Douglas when it fell 600 feet in eight seconds, crashed into a backyard fence in Tucson and burst into flames about six minutes after leaving the ground.

http://www.washingtonpost.com

Red Bull acrobatic flight


Body Parts from the Four Crash Victims Recovered: Requested judicial cooperation from Dutch side --- Prosecutor Jacques Louvier. Piper PA-42-720 Cheyenne III, F-GXES, Transports Aériens Intercaraïbes - Guadeloupe

Prosecutor Jacques Louvier, Commandant of the Gendarmerie Stephen Brunet, and the team of investigators that specialize in airline crashes.


Marigot:--- The team of Gendarmes investigating the TAI Air Ambulance crash that took place early Saturday morning confirmed to reporters on Monday afternoon that they recovered body parts from all four of the victims. Prosecutor Jacques Louvier who was among the investigators at the press conference said the body parts now have to be analyzed and forensic testing has to be done to legally identify the four victims.

Louvier and the team of investigators said that since the whole bodies were not found they have to find relatives of the victims to do detailed DNA testing to identify the victims. Gendarmes who specialize in airline crashes that are currently on the island heading the investigation said that the testing and identification process will take time especially since one of the victims is from Cyprus. Investigation coordinator Fredrick Dozieres said that they would have to involve Interpol in order for them to get a close relative of the foreign victim so that he could be identified. The four victims have been identified as Bruno Le Jeune, Dr. Jean Michel Dudiot, Nurse Gerard Omer, and the cardiac patient Panayiotis Vrionides.

Prosecutor Louvier also announced on Monday that he submitted a request to the Dutch authorities requesting judicial cooperation from the Dutch side of the island so that the investigators could piece together exactly what happened and how the victims ended up on the French side of the island since the patient was hospitalized at the St. Maarten Medical Center.

Special aircraft investigator attached to the Gendarmerie Philippe Mola said that the divers already located the aircraft which is over 10 meters underwater. He said by the end of this week the investigators will be able to bring the wreckage to land so that they could continue their in-depth investigation into the cause of the accident. Mola said as an expert in aircraft crash investigations he could already say that there is no single cause of such an accident. Based on the damages he has seen thus far, it is clear that the aircraft had a huge impact when it crashed into the water. Mola said they have issued an order to all beach lovers and boat users not to venture in close proximity of the accident since they need every single piece of evidence that washed ashore.

The Gendarmes and special investigators that are busy conducting the three phase investigation is also calling on anyone who might have witnessed the fatal crash of the Piper Cheyenne III early Saturday morning to contact the Gendarmerie at telephone number 17 or 0590 52 30 00.

Spin Tunnel Test of the Diamond D-JET

 

May 4, 2012 by XFlowCFD 

The meshless technology of XFlow allows complex fluid-structure interactions such as this spin tunnel test of the D-JET from Diamond Aircraft.

The plane is fixed in translation and has three degrees of freedom in the three rotations: roll, pitch and yaw. After a short transient phase, the plane starts to stabilize its yaw rate when the reattachment of the flow on its left wing occurs leading to a smooth and realistic spinning motion.

The D-JET dynamic simulation analysis courtesy of Diamond Aircraft and Luc Van Bavel Design.

Ice Pilots' Arnie Schreder dies: Northern bush pilot died of small-cell lung cancer


Arnie Schreder – one of the stars of Ice Pilots NWT has died after a battle with cancer.

Schreder was a chief pilot at Yellowknife-based Buffalo Airways, and was a star of the show for three seasons. The reality program — which airs on History Television — follows bush pilots with Buffalo Airways, while flies Second World War-vintage airplanes year-round in Canada's North.

Schreder retired from Buffalo Airways in November 2010, during the show's second season, after he was diagnosed with lung cancer. He returned in the third season to fly one last job. He piloted a DC4 for a two-hour documentary that recreated the Second World War's dambusters raid. Schreder was able to hit a specially built dam just as Royal Air Force pilots did almost 70 years ago.

“Before we started shooting the series, Arnie was the first to warmly welcome us”, says series producer David Gullason. “He showed us around and invited me on a check-out ride for a new pilot on the C46. He was always warm, friendly and generous with everyone.”

Schreder trained hundreds of pilots over the years at Buffalo Airways.

He died of pneumonia after battling small-cell lung cancer. He was 69. You can leave a message on Ice Pilots NWT's Facebook page.

Eurocopter AS 350B3 Ecureuil, AirMethods (owned by BOKF Equipment Finance LLC), N509AM: Fatal accident occurred July 28, 2010 in Tucson, Arizona

National Transportation Safety Board - Aviation Accident Final Report: http://app.ntsb.gov/pdf 

Docket And Docket Items  -  National Transportation Safety Board: http://dms.ntsb.gov/pubdms

Aviation Accident Data Summary  -  National Transportation Safety Board:   http://app.ntsb.gov/pdf

NTSB Identification: WPR10FA371 
Nonscheduled 14 CFR Part 91: General Aviation
Accident occurred Wednesday, July 28, 2010 in Tucson, AZ
Probable Cause Approval Date: 05/03/2012
Aircraft: AMERICAN EUROCOPTER LLC AS 350 B3, registration: N509AM
Injuries: 3 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The single-engine helicopter was operating near its maximum gross weight and was on a repositioning flight back to its home base. About 6 minutes into the flight, cruising at 800 feet above ground level (agl), the helicopter experienced a complete loss of engine power. Witnesses observed the helicopter, which had been flying steadily in a southeast direction, suddenly descend rapidly into a densely populated residential area. Descent rates calculated from the last 10 seconds of radar data were consistent with an autorotation. The witnesses reported that, as the helicopter neared the ground, its descent became increasingly vertical. Examination of the accident site revealed that the helicopter was in a level attitude with little forward speed when it impacted a 5-foot-high concrete wall, which penetrated the fuselage and ruptured the fuel tank. A postimpact fire consumed the cabin and main fuselage of the helicopter.

An open roadway intersection was located about 300 feet beyond the accident site, in line with the helicopter’s flight path. It is likely that the pilot was attempting to make an autorotative approach to the open area; however, he was unable to reach it because he had to maneuver the helicopter over a row of 40-foot-tall power lines that crossed the helicopter’s flight path near the accident site. This maneuver depleted the rotor rpm, which, as reported by the witnesses, caused the helicopter’s descent to become near vertical before it impacted the concrete wall, which was across the street from the power lines.

The pilot had no training flights during the 317 days since his most recent 14 Code of Federal Regulations Part 135 check flight. The lack of recent autorotation training/practice, although not required, may have negatively impacted the pilot’s ability to maintain proficiency in engine failure emergency procedures and autorotations. However, because the engine failed suddenly at low altitude over a congested area, more recent training may not have changed the outcome.

External examination of the engine at the accident site revealed that the fuel inlet union that connected to the fuel injection manifold and provided fuel from the hyrdomechanical unit to the combustion section had become detached from the boss on the compressor case. The two attachment bolts and associated nuts were not present on the union flange nor were they located within the helicopter wreckage debris. Separation of the fuel inlet union from the fuel injection manifold interrupted the supply of fuel to the engine and resulted in a loss of engine power. Postaccident engine runs performed with an exemplar engine showed that, with loose attachment bolts and nuts, the union initially remained installed and fuel would not immediately leak. As the engine continued to operate, the loose nuts would progressively unscrew themselves from the bolts. With the bolts removed, the union would ultimately eject from the boss, and the engine would lose power due to fuel starvation.

The helicopter's engine had undergone maintenance over several days preceding the accident. The maintenance was related to fuel coking of the fuel injection manifold. The operator's mechanics removed the engine from the helicopter and separated the modules. Another engine with the identical problem was also undergoing the same maintenance procedure at the time. A repair station technician was contracted to complete the maintenance on both engines. The operator's mechanics and the repair station technician disassembled the accident engine and set it aside. They then performed the required maintenance on the other engine, before returning to complete the work on the accident engine. While working on the accident engine, the repair station technician disassembled module 3, replaced the fuel injection manifold, and then reassembled the engine. This work required that the fuel inlet union be removed and reinstalled. It is likely that the technician did not tighten the bolts and nuts securing the union with a torque wrench and only finger tightened them. The engine was reinstalled into the helicopter by the operator's maintenance personnel. The repair station technician was serving as both mechanic and inspector, and he inspected his own work. There were no procedures established by the operator or the repair station to ensure that the work performed by the technician was independently inspected. Further, although 14 Code of Federal Regulations 135.429, applicable to Part 135 operators using aircraft with 10 or more passenger seats, states, in part, “No person may perform a required inspection if that person performed the item of work required to be inspected,” there is no equivalent requirement for aircraft, such as the accident helicopter, with 9 or fewer passenger seats. An independent inspection of the work performed by the technician may have detected the improperly installed fuel inlet union.

In 2008, the Federal Aviation Administration (FAA) principal maintenance inspector (PMI) for the repair station removed the repair station's authorization to perform work at locations other than its primary fixed location. However, the Repair Station Manual was not updated to reflect this change, and the PMI did not follow up on the change, nor did he log the change in the FAA’s tracking system. The PMI was unaware that, in the year before the accident, the repair station had performed work for the operator at locations other than the repair station’s primary fixed location at least 19 times. The FAA's inadequate oversight of the repair station allowed the repair station to routinely perform maintenance at locations other than its primary fixed location even though this practice was not authorized.

The duty pilot performed a 7.5-minute abbreviated post maintenance check flight the evening before the accident. A full maintenance check flight conducted in accordance with the manufacturer's flight manual should, under normal conditions, take 30 to 45 minutes to complete. Had a full check flight been performed, it is likely that the union would have detached from the boss during the check flight. Because the helicopter would not have been operating near its maximum gross weight and the check flight would have been conducted over an open area, the pilot would have had greater opportunities for a successful autorotative landing.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The repair station technician did not properly install the fuel inlet union during reassembly of the engine; the operator’s maintenance personnel did not adequately inspect the technician's work; and the pilot who performed the post maintenance check flight did not follow the helicopter manufacturer's procedures. Also causal were the lack of requirements by the Federal Aviation Administration, the operator, and the repair station for an independent inspection of the work performed by the technician. A contributing factor was the inadequate oversight of the repair station by the Federal Aviation Administration, which resulted in the repair station performing recurring maintenance at the operator’s facilities without authorization.

HISTORY OF THE 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.

HELICOPTER 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 352 engine and aircraft hours, on July 27, 2010.

In the accident pilot’s off call to LifeCom he reported “2+55” (2 hours 55 minutes) of fuel, which equates to a fuel load of 90%. Mission fuel is usually 2 hours, and the flight to Douglas would have taken 55 minutes, therefore, the helicopter would have landed at Douglas with a mission fuel load of 2 hours. Weight and balance calculations were done by the pilot utilizing a spreadsheet program, available at each base and tailored for each specific helicopter. The actual weight and balance calculation performed by the pilot for the accident flight was not recorded at Marana and was not located in the wreckage (presumed destroyed). The spreadsheet program, designated AS350-B3-Dual Hyd, N509AM (Rev 4 – 3 Feb 09), listed the helicopter weight as 3,329 pounds, pilot weight as 210 pounds, medical crew weights as 210 pounds and 260 pounds, medical equipment weight as 310 pounds, and liquid oxygen (LOX) weight as 18 pounds. Total helicopter weight (without fuel) was 4,330 pounds. The spreadsheet then produces a table that computes fuel load and cargo capacity (loading table). The loading table lists the maximum fuel load as 90% (860 pounds), which will keep the helicopter slightly below gross weight and allows for no additional cargo/passengers. The total aircraft weight with this load was 5,190 pounds, and the moment arm was at 131.2 inches. The flight manual lists the maximum gross weight as 5,225 pounds.

According to the fueling receipt from Tucson Aeroservice Center, dated July 28, 2010, for aircraft N509AM, the quantity of fuel purchased was 105 gallons. The lineman that fueled the helicopter recalled the pilot requesting that 100 gallons of fuel be added to the helicopter, and that when he was done fueling, the fuel load was not 100%. The aircraft weight and balance record that was located in the helicopter flight manual and retrieved from the aircraft wreckage was dated December 12, 2009. The operational empty weight that was listed in the weight and balance document was 3,314 pounds and the longitudinal moment arm listed was 138 inches. Based on the crew weights, equipment loading, and the pilot’s 2+55 endurance calculation (the helicopter had a 90% (860 lbs) fuel load), would put the helicopter inside the weight and balance envelope at 5,182 lbs at takeoff.

The 15 lb difference between the helicopter empty weight documented in the weight and balance sheet and the spreadsheet program could not be completely explained by the operator. However, it was observed that the version of the spreadsheet used by the accident crew was dated February 3, 2009, and the most recent helicopter weight and balance documentation was dated December 12, 2009.

Helicopter Maintenance Review

Interviews conducted with the mechanics that had recently worked on the helicopter, and the pilot who flew the helicopter prior to the accident aircrew accepting the helicopter, revealed that the helicopter had been sent to Marana for maintenance related to an engine coking problem. According to a Turbomeca representative, fuel coking means that the injection manifold becomes coated with carbon deposits. As the engine temperature decreases, the tolerances usually decrease so that the engine will sometimes rotate with associated noise and the gas generator can seize when the engine cools down, preventing next starting. Fuel coking does not affect flight performance. The replacement of the fuel manifold is considered a level 3 maintenance action, and the Air Methods mechanics at Marana were authorized to perform up to level 2 maintenance. Helicopter Services of Nevada (HSN), who was authorized to perform level 3 maintenance, was contracted by Air Methods to perform the work at Marana.

Between July 24 and July 26, the engine was removed by Air Methods maintenance personnel, and the engine modules were separated. During this time, an additional engine with fuel coking also had to have the fuel manifold replaced. The accident engine was disassembled first, and the mechanics realized that they would need additional parts and tooling to complete the work. The accident engine was set aside and the second engine was disassembled and the fuel manifold replaced. As the Air Methods mechanics completed the work on the second engine, the HSN technician replaced the fuel manifold on the accident engine. During the work on the accident engine, module 3 was disassembled, the fuel injection manifold replaced, the engine reassembled by HSN technician, including the fuel inlet union. The engine was reinstalled into the helicopter by Air Methods maintenance personnel. The HSN technician inspected his own work, and as an HSN technician working away from its fixed location he had the authority to inspect his own work. The Air Methods mechanics stated that they did not specifically inspect the HSN technician’s work, however, they did inspect the engine after it was installed into the helicopter. Title 14 Code of Federal Regulations Part 135 does not require an independent inspection of maintenance.

In interviews with the Air Methods mechanics and HSN technician, they all reported feeling a sense of pressure to complete the maintenance and return the helicopters to service.

The Marana duty pilot performed a ground run of the helicopter, and after the ground run, the engine’s hydromechanical unit (HMU) was found to be leaking. The next day, July 27, the HMU leak was resolved and the pilot again performed a ground run. The pilot received permission from the Area Aviation Manager to put the base out of service while he performed the post maintenance check flight. Air Methods “AVL Hub Interface” system recorded that the maintenance test flight occurred on July 27, from 1743 to 1750 hours. According to the pilot the following flight checks were performed: droop check, rate of climb check, cruise power check, flight limit indicator check, flame out check, and autorotation. The pilot stated that the entire post maintenance check flight took 7.5 minutes. No records of the test flight results were retained.

The AS 350 B3 Flight Manual, Section 8.3.2, contains a matrix that illustrates what post maintenance checks need to be performed for various maintenance action or components replaced. For maintenance on an engine, FADEC, or module the following checks are to be performed after the ground run: hover flight, maximum continuous power climb, maximum take off power check, and maximum continuous power level flight. According to the American Eurocopter Chief Pilot, these checks usually take between 30 and 45 minutes to complete.

The Marana duty pilot stated that he had not received any training specific to post maintenance check flights and that any Air Methods pilot qualified in model can perform a maintenance check flight.

Helicopter Maintenance Records Review

The Maintenance Group Chairman reviewed the maintenance records for the helicopter. Immediately following the accident, Air Methods supplied electronic copies of the records. On August 12, 2010, an NTSB air safety investigator from the Denver Regional Office retrieved the hard copy records from the Air Methods facility. The Maintenance Group Chairman reviewed the records at the Denver Regional Office on August 24, 2010.

The helicopter began operating in the Air Methods fleet in December 2009. The last inspection was a 20-hour inspection that was completed on July 27, 2010, at a total time of 352 hours.

Review of the airworthiness directives (ADs) did not reveal any ADs that were not in compliance. Review of the maintenance records showed that on June 21, 2010, the engine cycles had exceeded the inspection requirements outlined in Airworthiness Directive 2009-09-03. The airworthiness directive was due at 600 hours or 500 cycles, whichever occurred first. At the time of the inspection, the engine had accrued 308.34 hours and 515.28 cycles. The company identified the oversight and complied with the airworthiness directive.

Review of the Air Methods maintenance records showed that on July 22, 2010, at 351.06 hours, the Air Methods "Aircraft Record of Maintenance" form noted "Aircraft won't crank," Air Methods Record of Maintenance Log Leaf #595941.

On July 23, at 352 hours, the engine was removed for repair due to "fuel coking."

On July 24, the form noted "Removed and replaced injection manifold referencing Arriel2 MTI [Maintenance Technical Instruction] No. X292M13032, update No. 4, January 30, 2008. Assembled referencing Arriel 2B1MM [Maintenance Manual] X292N54502, Revision No. 19, March 30, 2009. Work performed under WO [Work Order]#M517@FAA CRW KBMR477F, Helicopter Services of Nevada."

The work order and Turbomeca Technical Maintenance Report records completed by the Helicopter Services of Nevada technician were intermixed. According to HSN WO M-517, the cover page indicated the work order was pertinent to engine SN 46268; however, subsequent pages were applicable to engine SN 23366 and SN46268. Review of Helicopter Services of Nevada work order M-517 showed the following entries, all dated July 26:

"Disassembled engine 23366 to access M03 [module 3] S/N 20007. Removed fuel manifold 0292217030 S/N ANR 54450 and installed 0292217030 S/N 1956B references MTI No. X292MI3032."

"Reassembled engine 23366 to accommodate engine. Referencing Arriel 2B1. M.M. X292N54502 revision 19 March 30, 2009. Ground runs, oil pressure, and vibration good."

"HMU [Hydro-Mechanical Unit] is leaking from drain. Customer to replace TU43 seal. "

On HSN Work Order M-518, WO number M-517 was crossed out and M-518 was written in its place. The engine serial number noted on the document was 46268. The corrective action was indicated as follows:

"Disassembled engine 46268 to access MO 3, SN 9853. Removed fuel manifold PN 0292217030 SN ANR 2451 and installed 0292217030 SN 861B. Referencing MTI No. X292M13032 update No. 4, Jan 30, 2008."

On July 26, the Air Methods maintenance records stated "Reinstalled repaired engine SN46268 I/A/W Turbomeca Maintenance Manual, Chap 71 & 72. Ground run check OK. Front oil pressure check at 50 PSI. Rear oil pressure check at 19 PSI. Fuel Temp of 82 degrees, engine vibe check at 6 mms. The drive shaft balance check at .47 IPS." A later entry noted "HMU valve seal leaking."

On July 27, "Removed HMU SN 26003 from aircraft and replaced valve seal. Reinstalled HMU SN 26003 in aircraft I/A/W Turbomeca Arriel 2B1 Maintenance Manual Chap 73, PN 95601706620 valve seal, 1 EA, PN 9794410095 oring4ea, PN 9794710300 -ring, 1EA, PN 9682001605, O-ring 1EA, PN979441032, O-ring 1EA, PN 979441075, O-ring 1EA, PN 9794710200, O-ring 1EA, PN 9794710028 O-ring 1EA." During this maintenance, the mechanic completed AD 2007-10-07, the HMU Coupling Shaft Spline Inspection.

Also on July 27, the Air Methods 20-hour engine inspection was completed and the following entry was noted: "I certify that this aircraft has been inspected I/A/W Air Methods Turbomeca Arriel 2B1 engine 20 hour B61 inspection and was found to be in an airworthy condition at this time. Next compliance due by 372+7, A/C T.T. 372+7 ENG T.T. PWR Ck: 96.2 NG, 795 CT4, 71 TQ, 392 NR, ZP 5780, 24.8 OAT, T4 Margin -40 degrees, TQ Margin 2.5 degrees."

Injection Manifold Replacement

Replacement of the injection manifold is outlined in Turbomeca Maintenance Technical Instruction (MTI) X292M13032Rev4. The MTI instructs the technician to disassemble the engine and remove the injection manifold. It is then inspected. Once it is determined if components will be repaired or replaced, the injection manifold (or replacement) is reinstalled, and the engine reassembled. The full manufacturer's guidance, MTI X292M13032Rev4, is included as an attachment to this report.

In the MTI guidance, it states the following:

Removal of the jet union (Refer to Figure 501) (Detail C)
-Remove the nuts (72-43-00-01-304) (x2).
-Remove the screws (72-43-00-01-302) (x2).
-Remove the jet union (72-43-00-01-300).
-Remove and discard the special seal (72-43-00-01-340).
-Remove and discard the preformed packings (72-43-00-01-330) (x2).
Remove the screw (72-43-00-01-350) and discard the seal (72-43-00).
For reinstallation, it states the following:
Installation of the jet union (Refer to Figure 1006)
-Lubricate and install the preformed packings (72-43-00-01-330) (x2) on the jet union (72-43-00-01 -300).
-Install the special seal (72-43-00-01-340) on the flange of the intermediate casing (72-43-00-02-170).
-Install the jet union assembly (72-43-00-01-300) on the flange of the intermediate casing.
-Attach with the screws (72-43-00-01-302) (x2) and the nuts (72-43-00-01-304) (x2).
-Install the screw (72-43-00-01-350) with its seal (72-43-00-01-360) on the jet union
-(72-43-00-0 1 -300).
-Torque the nuts (72-43-00-01-304) (x2) and the screw (72-43-00-01-350) to 0.24 daN.m.
As installed, the jet union is visible when looking at the exterior of the engine. No torque striping is required.

Turbomeca authorizes reuse of hardware as noted in the maintenance manual.

According to the Eurocopter Maintenance Manual (71.00.03.401, Section 09-31, Page 01.00), when an engine is removed and installed, maintenance personnel need to refer to the flight manual, Section 8, in addition to engine documentation, the maintenance manual, and the standard practices manual. On Page 07.00 of this document, it states to perform a checkout ground run as per the Flight Manual Section 8.

In addition to those items listed in the maintenance manual, post maintenance operational check flights are required. In the Flight Manual, Section 8, it states that in addition to the flight report, VEMD [Vehicle and Engine Multifunction Display] ground run checks, a hover flight, maximum continuous power climb, maximum takeoff power check, and maximum continuous power level flight checks must be performed.

Engine Flame-Out: Audio Warnings, Visual Indications, & Pilot Emergency Procedure.

Section 3 of the AS 350 B3 Flight Manual provides information regarding helicopter emergencies, the warnings or alerts associated with a particular emergency, and the procedures to follow once the emergency has been identified. Continuous tone audio warnings are provided when the rotor (NR) is below 360 rpm (310 Hz tone), and when the maximum takeoff power limitation is exceeded (285 Hz tone). An intermittent tone is heard when NR is above 410 rpm (310 Hz). A gong is generated each time a red warning appears on the warning panel. Vy = 65kts – (1kt/1000 feet)

Section 3.2 contains Engine Flame-Out information. The procedures listed for an engine flame-out in cruise flight are as follows:

1. Collective pitch….. Reduce (to maintain NR in green arc)
2. IAS…………………..Vy
- If relight impossible or after tail rotor failure
3. Twist grip…………. IDLE detent
4. Maneuver the aircraft into the wind on final approach
- At height ˜ 70 ft (21 m)
5. Cyclic …………….. Flare
- At 20/25 ft (6/8 m) and at constant attitude
6. Collective pitch……. GRADUALLY INCREASE (to reduce the rate of descent and forward speed)
7. Cyclic…………… FORWARD (to apply a slightly nose-up landing attitude (<10°)
8. Pedal…………….. ADJUST (to cancel any sideslip tendency)
9. Collective pitch…… INCREASE
- After touch-down
10. Cyclic, collective, pedal ADJSUT (to control ground run)
- Once the aircraft has stopped
11. Collective pitch…… FULL DOWN
12. Rotor brake……… APPLY below 170 rotor rpm


Step 1 of the engine flame-out procedure refers to maintaining the NR (rotor rpm) in the green arc (375-405 rpm). The rotor rpm gauge is a dual gauge representing engine free turbine speed (NF) and rotor rpm (NR) displayed using LED bars along the arc of the gauge. The gauge itself is approximately 2 inches in diameter and, in the accident helicopter, installed in the lowest left portion of the pilot’s instrument panel. According to the airframe manufacturer, this is not a standard location for this instrument in the AS350B3.

The AS 35 B3 Flight Manual states in section 5.10 Glide Distance in Autorotation, that at 65 kts, NR=410 rpm, the glide ratio is 0.54 NM/1000 feet.

Additional information about autorotation performance is addressed in the Operations Group Chairman's Factual Report located in the official docket of this investigation.

WRECKAGE AND IMPACT INFORMATION

Airframe

The helicopter wreckage was upright, on a heading of 055 degrees magnetic, along the east verge of a north-south residential street. The center fuselage structure straddled a 5-foot-tall cement-block wall, with the nose resting on a garden shed. Both the shed and the wall were fragmented by the impact, with fire consuming the shed, its contents, and vegetation within a 15-foot radius of the fuselage. The top of a tree located 5-feet east of the helicopter nose had been severed at the 12-foot level. A 40-foot-tall set of power lines paralleled the street on the opposite verge, about 50-feet west of the main wreckage. No impact marks or damage were observed to the power lines, or any other adjacent tree or structure. Fragments of the fuel tank were found about 30 feet to the southwest, and the odor of jet fuel was present throughout the site.

The left foot pedal of the tail rotor control was found in the forward position, and it was deformed forward and down. The collective control was in the full down position, with the rotary throttle set to 'VOL' (flight position). The cyclic control exhibited buckling deformation to its shaft at the cabin floor, with the control pointing forward and to the right. The flight control linkages located beneath the cabin floor were deformed and impinged against the cross members. The remaining linkages aft of the cabin were consumed by fire through to the flight control servo actuators. The rotor brake and fuel shutoff valve control assemblies sustained thermal damaged, with both controls pointing to the forward position.

The aft 15-foot-long section of the tail boom remained in line with the fuselage, but was separated in the area of the exhaust heat shield. The tail boom junction frame and attachment members were consumed by fire. The horizontal stabilizer remained attached to the tail boom, with the left stabilizer bent upwards about 15 degrees midspan. The lower surfaces of the stabilizer and the tail boom section in the area of the doubler fittings sustained crush damage and dimpled indentations consistent with road surface contact. The upper vertical fin remained attached to the tail cone, which had separated from the tail boom just forward of the fin attachment fittings. The lower fin had separated at its root, and sustained vertical accordion crush damage through its entire length. The tail guard had separated from the fin and was found about 40 feet southwest of the tail. The underside of the guard exhibited dimpled indentations and gouges on its left edge, consistent in shape to contact with the road surface. A corresponding skid-length indentation was noted in the road surface adjacent to the tail cone, on a heading of 045 degrees.

The tail rotor gearbox remained intact and affixed to the tail boom structure. Oil was observed through the gearbox sight window, and rotation of the tail rotor yoke resulted in a corresponding rotation of the tail rotor drive shaft at the tail boom heat shield. Both blades remained firmly affixed at the rotor hub, were largely intact, and their associated pitch change links were noted connected to both the rotating plate, and blade control horns. The tail rotor push-pull tube was continuous from the rotor hub bell crank through to the tail boom heat shield. Forward of the heat shield, the remaining control tube and drive shaft were fire consumed through to the area of the steel forward drive shaft. The cylinder casing and control lines of the yaw pedal servo actuator were fire consumed; the associated servo rod end and input control bolts remained in place.

The main rotor blades had sustained varying degrees of fire damage and could not be identified by color. All three blade leading edges remained relatively intact, with the blades still connected through their full length to the hub blade attach pin. The Starflex hub, elastomer blocks, swash plate, and sleeves were partially consumed by fire, and located within the immediate vicinity the rotor mast assembly.

Engine

The engine and its associated gearbox remained attached and were located within the primary fuselage structure. The engine remained in-line with the fuselage, and had had come to rest on its left side.

External examination of the engine at the accident site revealed that the fuel inlet union, located on the lower right-hand side of the engine, was detached from the boss on the compressor case. The fuel supply line remained attached to the union and to the hydro-mechanical unit (HMU) via the adjusted valve. The intermediate gasket was located in the fuselage debris, directly below the union. The remaining wreckage and ground area were extensively examined utilizing a series of magnets and sifting grates, but did not reveal the presence of the two five-point bolts and self locking nuts for mounting the union to the compressor case flange.

There was no evidence found of any pre-existing failures of the helicopter airframe.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot on July 30, 2010, by the Tucson Police Department, Pima County, Arizona. The opinion of the Forensic Pathologist was that the cause of death was ascribed to multiple blunt force and thermal injuries.

Forensic toxicology was performed on specimens obtained during the autopsy of the pilot by the FAA Bioaeronautical Science Research Lab, CAMI, Oklahoma City, Oklahoma. The toxicology report stated no carbon monoxide detected in blood, no cyanide detected in blood, no ethanol detected in vitreous, and atropine was detected in blood and liver.

TESTS AND RESEARCH

Arriel 2B1Fuel Injection System

Fuel is delivered directly into the combustion chamber through use of a radial fuel supply, centrifugal fuel injection system. The injector assembly consists of a stationary distributor (manifold) and a rotating injection wheel located within the combustion chamber. The manifold contains a series of holes, which deliver fuel to the wheel. Holes within the injection wheel, which is mounted between the compressor and turbine shaft, act as fuel spraying jets. Pressure integrity between the wheel and the manifold is achieved by labyrinth seals, with rotation of the injection wheel resulting in the extraction of fuel through centrifugal force.

An internal supply line provides fuel to the manifold. The supply line routes from the manifold and along the outer combustor casing, where it protrudes through a boss on the compressor case. The exposed line protrudes in the form of a nipple through a flange on the case boss. An engine fuel inlet union, consisting of a mounting flange and seal, provide the interface between the internal fuel line nipple, and external fuel supply lines. The union is affixed to the compressor case flange with two five-point bolts (P/N: 72-43-00-01-304) and two self locking nuts (P/N: 72-43-00-01-302). Vacuum seal is provided by the use of a metallic intermediate gasket at the flange, and fuel seal is provided by two o-ring seals on the internal fuel supply line nipple. A leak test plug is provided in the body of the union to test the seal integrity of the interface. The union is connected to the external fuel supply line through a B-Nut fitting.

Fuel Inlet Union Tests
A group of engine test runs were performed on an exemplar Arriel 2B1 engine at the Turbomeca facility in Bordes, France. The tests were conducted under the supervision of investigators from the Bureau d'Enquêtes et d'Analyses (BEA). The purpose of the tests was to assess the engine's operating abilities with the fuel inlet union incorrectly affixed to the engine case flange.

The series of engine runs was performed in a test cell with the fuel inlet supply line union partially attached to the compressor case flange in the following configurations:

-Union inserted over inlet fuel nipple with no attachment nuts and bolts installed.
-Union partially inserted over inlet fuel nipple to first o-ring seal, with no attachment nuts and bolts installed.
-Union inserted, with attachment nuts and bolts installed, and hand-tightened only.
-Union inserted over inlet fuel nipple, utilizing only one attachment nut and bolt, tightened by hand.

The tests were performed at varying engine power levels, simulating startup and flight modes. The data revealed that with the union installed without its associated mounting nuts and bolts, it was possible to start and run the engine with no observable fuel leak. During the test with the union nuts and bolt tightened by hand, the engine ran for 3 minutes and 32 seconds before the nuts began to unscrew from the bolts.

The tests further revealed that with both nuts and bolts removed, the union would ultimately eject from the boss and nipple, resulting in an expulsion of about 0.5 liters of fuel, followed by a subsequent engine shutdown.

The group examined comparative dimensions for new and used union nuts and bolts. The results revealed that when tightened by hand, a new bolt would engage about two threads into the nut before friction was felt, resulting in an exposed bolt shank length of about 17 millimeters. By comparison, a used nut and bolt were similarly tightened, resulting in an exposed bolt shank length of about 13.5 millimeters. The threaded end of the used bolt was also observed to extend beyond the end of the nut by about half a thread. Comparative dimensions taken from an exemplar engine installation revealed that with the nuts and bolts installed and tightened to the specified torque on the union flange, approximately 1.5 threads were exposed beyond the nut, resulting in a bolt shank length of about 13 millimeters.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

Helicopter Services of Nevada (HSN) and FAA oversight of HSN

Helicopter Services of Nevada LLC was designated by the FAA as a domestic repair station under Title 14 CFR 145.53, repair station certificate number KBMR477F. In the limitations sections of the operations specifications, it stated that Helicopter Services of Nevada was authorized to "Perform levels 1, 2, and 3 maintenance functions in accordance with the manufacturer's maintenance program and maintenance instructions. To include removal and installation of power plant, rigging of fuel control unit and power turbine generators."

According to the FAA approved operations specifications effective at the time of the accident, in section A004. Summary of Special Authorizations and Limitations, it stated the following:

The certificate holder is not authorized and shall not:

Perform work, including continuous operations, at additional locations other than at a primary fixed location.

Perform work, excluding continuous operations, at additional locations other than at a primary fixed location.

On November 4, 2010, the operations specifications were changed and stated the following:

The certificate holder, in accordance with the reference paragraphs, is authorized to:

Perform work, excluding continuous operations, at additional locations other than at its primary Fixed Location.

According to FAA Order 8900.1, when providing surveillance of a 14 CFR part 145 repair station that performs aircraft maintenance away from its fixed location, the following circumstances apply:

Special Circumstances. When a special circumstance arises that allows work to be done away from the repair station on a temporary basis.

1) Temporary Basis—Short Term. When a special circumstance arises such as a blown tire, radio, or navigation equipment changes, etc.

2) Temporary Basis—Extended. When the repair or alteration requires the repair station to make repairs or alterations over an extended period, e.g., the aircraft is in for extended maintenance and an interior shop is requested to install a new interior at that location.

3) Recurring Basis. When it is necessary to perform such work on a recurring basis with operations specification (OpSpec) D100 authority.

The order notes, "The circumstances in subparagraphs A1) and A2) require the repair station to submit a request to the principal inspector (PI) for evaluation on a case by case basis, except for emergency short term work when the repair station has a procedure in its manual. In this case, the repair station only needs to notify the PI in accordance with the procedure."

The PMI reported that in 2008 he removed Helicopter Services of Nevada's authorization to perform work away from their permanent station on a continuous basis. He indicated that he also verbally requested that the Repair Station Manual be updated to reflect this change. However, the manual was not changed and the PMI did not follow up on the request, nor did he log it in an FAA tracking system. The PMI indicated that Helicopter Services of Nevada was authorized to perform maintenance on a temporary basis at additional locations, but was not authorized to perform maintenance at outside locations on a recurring basis. The PMI indicated that a recurring basis would be defined as performing the same maintenance at the same location for the same company three or more times per month. He was uncertain if Helicopter Services of Nevada exceeded this limit.

Review of Air Methods work orders from July 2009 to July 2010 for work performed by Helicopter Services of Nevada showed that 26 work orders had been created. Of those, 19 were performed at Air Methods' facilities, 2 were performed at Helicopter Services of Nevada facilities, and 5 locations were unknown.

According to the owner of Helicopter Services of Nevada, the removal of the authorization to “Perform work, excluding continuous operations, at additional locations other than at its primary Fixed Location” was a clerical error by the FAA. Additionally, the owner did not identify the change when signing page A004 of the Helicopter Services of Nevada operations specifications.

Helicopter Services of Nevada was designated as a Turbomeca Service Center. As a Service Center, they provided levels 1, 2, and 3, maintenance service, parts, and tools. The Turbomeca Service Center technicians complete a Turbomeca-designed checklist and engine build form when performing field maintenance. Turbomeca does not require its outside service centers to document their work with the forms, and they are allowed to develop their own forms to document the work. The Turbomeca forms are included as an attachment to this report. Helicopter Services of Nevada developed their own work order forms and checklists that were completed when work items were accomplished.

In interviews with the HSN mechanic, he reported that when an in-house inspection is performed, FAA 8130-3 form, the work order package form, as well as a final inspection are completed. He reported that when mechanics are working in the field, they do not complete an 8130-3 form, and do not do the thorough inspections and paperwork that occurs when engines come into the repair station due to the specific nature of the field work items requested.

Air Methods Operations

Air Methods is a commercial on-demand air taxi operator specializing in helicopter emergency medical services (HEMS). The company was established in 1980 in Colorado, and currently operates in 45 states. Air Methods received its Title 14 Code of Federal Regulations (CFR) Part 135 Operating Certificate, number QMLA253U, on March 1, 1992. Air Methods acquired LifeNet as part of its acquisition of Rocky Mountain Holdings, in 2002.

In accordance with 14 CFR Part 135.21, Air Methods kept current a General Operating Manual (GOM), which identified management policies and responsibilities, training/currency policies, and the procedures under which flights are to be conducted. The latest revision of the GOM was revision 4, dated November 11, 2009.

Section BA-8 of the GOM establishes the minimum cruising altitude employed by Air Methods flight crews, “At all times, with the exception of takeoff and landing, Air Methods’ pilots will operate at an altitude allowing, if a power unit fails, an emergency landing without undue hazard to persons or property on the surface. While en route, Air Methods’ helicopter pilots will maintain at least the following minimum altitudes: DAY: 300 feet AGL, NIGHT: 500 feet AGL. In all cases, aircraft will not be operated so as to pose a danger to persons or property on the surface.” Additionally, a letter of agreement (LOA) between Tucson Airport Traffic Control Tower, Tucson Terminal Radar Approach Control, and LifeNet stipulated that LifeNet helicopters could request a published helicopter route through the Tucson Class C airspace and would operate at 3,200 feet msl (500 feet agl) or below unless otherwise coordinated.

Air Methods Pilot Training

Chapter 3 of the Air Methods Pilot Training Program addresses the Recurrent Training Curriculum. The curriculum consists of 4 hours of ground training each for IFR and VFR operations, and recommends a minimum of 4 hours of flight training for IFR and 2 hours for VFR operations. However, an instructor can recommend a flight test before the completion of the recommended hours. The flight training is broken down into 4 modules. Each module addresses various normal, instrument, emergency procedures, and the fourth module addresses night operations. Autorotations are practiced in module 2, and hovering autorotations are practiced in module 3. Each module appears to be organized around 1 hour of flight time.

Annex 1, Flight Training Maneuvers, AS350, of the Air Methods Pilot Training Program delineates in detail all flight terms, definitions, and maneuver procedures for the Eurocopter AS350 helicopter. Section 1-33 and 1-34 describe the procedures to practice simulated engine failure resulting in straight-in and turning autorotations. All practice autorotations are to conclude with a power recovery terminating in a 3- to 5-foot hover.

Two of the operator’s check airmen stated that typically a Flight Proficiency Check (FAR 293 check) is preceded by a training flight. The training flight usually consists of standard commercial maneuvers, normal, shallow, and steep approaches, sloped landings, engine failures, hydraulics off flight, basic instruments, and an instrument approach. Three to five practice autorotations are performed towards the end of the training flight and terminate in a 3- to 5-foot hover power recovery. If a pilot is not performing up to standards they have the authority to provide extra training. Additionally, if a pilot feels they need extra training they can request additional training, which is coordinated through the appropriate chain of command and approved by the Chief Pilot or Aviation Training Manager. This policy is set forth in section B-6 of the Air Methods Operations Manual. Even though this policy is in effect, one of the check airmen interviewed said that it is very rare that pilots request additional training. He could only recall one instance and the training in question was IMC instrument recovery practice. Both check airmen stated that each pilot is provided two training flights a year; one just before the FAR 293 check flight and another approximately 6 months (semi-annual training) between check flights. One of the other pilots at the Douglas base stated that he had not received his semi-annual training flight this year (Air Methods training policy changed in February 2010, eliminating the semi-annual training policy).

One of the check airmen interviewed stated that Air Methods has two dedicated training helicopters that are moved from base to base and used to conduct training and check flights. A training flight usually lasts 1 -1.5 hours, and a check flight is usually 1 hour. About half the time a dedicated training helicopter is not available and the base has to reconfigure their helicopter to conduct training and check flights. Helicopter reconfiguration involves removing the patient litter, installing the copilot's seat and the second set of flight controls. The entire reconfiguration maintenance action takes about 4 hours to complete, and then another 4 hours to return the helicopter to mission configuration.

Federal Aviation Administration Information/Oversight

Oversight of Air Methods Corporation (QMLA) FAR Part 135 operating certificate is accomplished primarily by a certificate management team (CMT) based at the Denver Flight Standards District Office in Denver, Colorado. The current staffing is 27 CMT members as follows: There is one assigned Principal Operations inspector, one Principal Maintenance inspector, and one Principal Avionics inspector who are assisted by 8 operations inspectors, 7 maintenance inspectors, and 3 avionics inspectors. (There is also an additional Principal Maintenance Inspector and Principal Avionics Inspector assigned to provide oversight of the company's FAR Part 145 repair stations.) The CMT is comprised of an Operations and an Airworthiness unit. Each unit has an assigned operations and airworthiness supervisor respectively. Each unit receives administrative support by 1 each assigned administrative assistant. A complete review of FAA oversight is contained in the Operations Group Chairman's Factual Report located in the official docket of this investigation.




 





PHOENIX - A medical-helicopter crash in Tucson that killed three people likely was caused by a mechanic's mistake and the lack of an inspection and testing of his work, according to a recently released federal report.

The report by the National Transportation Safety Board, released last week, said the AS350 B3 Eurocopter had undergone maintenance over several days before the July 28, 2010, crash .

The report, the results of which were first reported by The Arizona Daily Star on Tuesday, says a contract mechanic likely only finger-tightened bolts, instead of using a torque wrench, when he was putting the engine back together. Maintenance personnel did not adequately inspect his work and the pilot who performed a post-maintenance check didn't follow the manufacturer's procedures, the report said.

The LifeNet helicopter left Marana and was en route to its home base in Douglas when it fell 600 feet in eight seconds, crashed into a backyard fence and burst into flames about six minutes after leaving the ground.

The crash was in a densely populated area of Tucson but no one on the ground was injured.

Killed were pilot Alexander Kelley, 61, flight nurse Parker Summons, 41, both of Tucson, and paramedic Brenda French, 28, of Safford.

The report does not specify whether Kelley was the pilot who improperly performed the post-maintenance check, or whether a different pilot performed it.

The check was supposed to take 30 to 45 minutes, but the pilot's check took just seven and a half minutes, the report said.

If a full check was done, the report said the problem that caused the crash likely would have been detected.

In addition, the contract mechanic who put the helicopter's engine back together "was serving as both mechanic and inspector, and he inspected his own work."

Craig Yale, vice president of corporate development for LifeNet Arizona's parent company -- Colorado-based Air Methods -- said Tuesday that LifeNet made important changes not long after the crash.

Those changes include requiring the company's own staff to inspect the work of any contracted mechanics, and requiring pilots to do full-length maintenance checks.

"This (crash) was several things compounded and some very good people lost their lives," Yale said. "We're going to continue to do everything we can to make sure this doesn't happen again."

He said before the Tucson crash, LifeNet assumed that third-party companies would double-check their own work, but that didn't happen.

"Our lesson learned from this is double check everything, even when the work is done by an outside contractor," he said.

The NTSB report also says that Kelley, who had 14,000 hours of flight experience, had no training flights for nearly a year before the crash.

Although Kelley was not required to undergo additional training during that time, the report said it "may have negatively impacted the pilot's ability to maintain proficiency."

"However, because the engine failed suddenly at low altitude over a congested area, more recent training may not have changed the outcome," the report said.

The report said Kelley likely was trying to get the chopper to an open intersection about 300 feet away from the crash site, but was unable to reach it because he had to maneuver over a row of 40-foot power lines -- a maneuver that depleted the engine and caused the helicopter's near-vertical plummet.