Friday, March 2, 2018

Bell 47G-5, N4427F: Fatal accident occurred June 20, 2015 -and- Accident occurred September 03, 2010 near Salinas Municipal Airport (KSNS), Monterey County, California

Frank William Gomes, Jr., passed away on June 20, 2015, doing what he loved, being an Ag pilot. He was born May 28, 1948 in Hollister, California where, at an early age, he began his lifetime career in agriculture.


The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; San Jose, California

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

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Gomes Farm Air Service Inc: http://registry.faa.govN4427F

Location: Salinas, CA
Accident Number: WPR15LA193
Date & Time: 06/20/2015, 0715 PDT
Registration: N4427F
Aircraft: BELL 47G 5
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 137: Agricultural 

Analysis 

The non-instrument-rated pilot was conducting aerial application flights in the helicopter and had completed several work orders at various locations before the accident flight. Two coworkers refilled the fertilizer tank on the helicopter and saw it depart from the loading area. About the time that the helicopter was expected to return, a thick fog came in, and the visibility dropped to about 15 to 20 ft. When the helicopter did not return, one of the coworkers searched for the helicopter and found the accident site. Examination of the wreckage did not reveal evidence of any pre-impact mechanical failures. It is likely that the pilot lost visual contact with the ground due to the fog and subsequently experienced spatial disorientation and lost control of the helicopter. This pilot had a similar accident in the helicopter about 5 years earlier, which suggests that he had a habit of taking risks with the weather.

Toxicology testing of the pilot was positive for hydrocodone, dihydrocodeine, acetaminophen, and hydromorphone. The hydrocodone level in the pilot's peripheral blood was 0.718 ug/ml, which was more than 10 times the usual upper therapeutic limit of 0.05 ug/ml. Hydrocodone and its metabolites do not undergo significant postmortem redistribution. Therefore, the measured levels of hydrocodone most likely represent the pilot's antemortem levels. If the pilot had been a novice user, this level would likely have been toxic and caused severe symptoms. However, with regular opioid use, brain physiology changes, leading to tolerance for both the desired analgesic effects and the sedative effects. As a result, incremental dosing increases are required to achieve the same effects, and long-term, chronic users may need the drug to feel and act "normally." The levels present in the pilot indicate that he was chronically taking high doses of hydrocodone. It is likely that the pilot was impaired by opioids at the time of the accident.

In the high workload situation of piloting a helicopter in low altitude flight, even a small degree of impairment from the pilot's use of a high-dose of opioid would have contributed to the likelihood of an accident. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The non-instrument-rated pilot's visual flight rules flight into instrument meteorological conditions, which resulted in his spatial disorientation and loss of helicopter control. Contributing to the accident was the pilot's impairment by high-dose opioid use. 

Findings

Personnel issues
Qualification/certification - Pilot (Cause)
Decision making/judgment - Pilot (Cause)
Spatial disorientation - Pilot (Cause)
Aircraft control - Pilot (Cause)
Illicit drug - Pilot (Factor)

Environmental issues
Fog - Effect on operation (Cause)
Fence/fence post - Contributed to outcome

Factual Information

History of Flight

Maneuvering-low-alt flying
Loss of control in flight (Defining event)
Collision with terr/obj (non-CFIT)

On June 20, 2015, about 0715 Pacific daylight time, a Bell 47G-5 helicopter, N4427F, impacted a fence and terrain while maneuvering about 5 miles southwest of the Salinas Municipal Airport (SNS), Salinas, California. The commercial pilot was fatally injured, and the helicopter sustained substantial damage. The helicopter was registered to and operated by Gomes Farm Air Service, Inc., under the provisions of Title 14 Code of Federal Regulations Part 137. Instrument meteorological conditions prevailed, and no flight plan was filed. The local aerial application flight originated from a loading area near the accident site about 0650.

According to a tachograph card found in the wreckage, the pilot had completed six different work orders at various locations on the morning of the accident.

Two witnesses, who worked for the operator, refilled the fertilizer tank on the helicopter and saw it depart from the loading area. According to the witnesses, about the time that the helicopter was expected to return, a thick fog came in, and the visibility dropped to about 15 to 20 ft. The witnesses became concerned when the helicopter failed to return for its scheduled rinse load. One of them searched for the helicopter and found the accident site nearby. 



Pilot Information

Certificate: Commercial; Private
Age: 67
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used: 4-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 02/10/2014
Occupational Pilot: Yes
Last Flight Review or Equivalent: 11/29/2014
Flight Time:  17500 hours (Total, all aircraft) 

The pilot, age 67, held a commercial pilot certificate with airplane single-engine land and rotorcraft-helicopter ratings. He did not hold an instrument rating. Federal Aviation Administration (FAA) records indicated that the pilot's most recent third-class airman medical certificate was issued on February 10, 2014, with the limitation that the pilot "must wear corrective lenses." According to the pilot's application for this medical, he had accumulated a total of 17,500 hours of flight time of which 200 hours were within the last 6 months.

Aircraft and Owner/Operator Information

Aircraft Manufacturer: BELL
Registration: N4427F
Model/Series: 47G 5
Aircraft Category: Helicopter
Year of Manufacture: 1970
Amateur Built: No
Airworthiness Certificate: Restricted
Serial Number: 7971
Landing Gear Type: High Skid;
Seats: 2
Date/Type of Last Inspection: 02/06/2015, Annual
Certified Max Gross Wt.: 2257 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:  8275.4 Hours at time of accident
Engine Manufacturer: Lycoming
ELT:
Engine Model/Series: VO 435 B1A
Registered Owner: GOMES FARM AIR SERVICE INC
Rated Power: 265 hp
Operator: GOMES FARM AIR SERVICE INC
Operating Certificate(s) Held:  Agricultural Aircraft (137)

The helicopter, a Bell 47G-5, serial number 7971, was manufactured in 1970 and was issued a restricted category airworthiness certificate on May 17, 2012. The helicopter's type certificate data sheet indicated that it seated two and had a maximum gross weight of 2,257 pounds. The helicopter was configured for agriculture and pest control operations. The most recent annual inspection was conducted on February 6, 2015, at a total airframe time of 8,275 hours. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: KOAR, 144 ft msl
Observation Time: 1353 UTC
Distance from Accident Site: 3 Nautical Miles
Direction from Accident Site: 297°
Lowest Cloud Condition:
Temperature/Dew Point: 12°C / 9°C
Lowest Ceiling:
Visibility:  7 Miles
Wind Speed/Gusts, Direction: Calm
Visibility (RVR):
Altimeter Setting: 29.92 inches Hg
Visibility (RVV):
Precipitation and Obscuration: Heavy - Fog; No Precipitation
Departure Point: Salinas, CA
Type of Flight Plan Filed: None
Destination: Salinas, CA
Type of Clearance: None
Departure Time:  PDT
Type of Airspace: Class G 

At 0653, the SNS weather reporting facility, located about 5 miles east of the accident site, reported wind calm, visibility 7 statute miles, sky condition clear, temperature 12°C, dew point 9°C, and an altimeter setting of 29.92 inches of mercury.

At 0653, the recorded weather at Monterey Regional Airport, Monterey, California, about 9 miles southwest of the accident site, was wind 290° at 3 knots, visibility 1 statute mile, mist, overcast at 200 ft, temperature 12°C, dew point 11°C, and an altimeter setting of 29.93 inches of mercury. 



Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude:  36.658889, -121.707500 

An FAA inspector examined and documented the wreckage on-scene. The helicopter came to rest on a road near a lettuce field. An opening was torn in a wired fence that ran parallel to the road about 40 ft northeast of the main wreckage. Powerlines running in an east-west direction about 50 ft south of the accident site were undamaged. During the examination, the inspector did not identify any anomalies or malfunctions with the helicopter. 

Medical And Pathological Information

The Monterey County Sheriff-Coroner's Office, Salinas, California, performed an autopsy of the pilot. The autopsy report listed blunt force injuries as the cause of death. The autopsy also identified an enlarged heart and significant coronary artery disease with 50-75% stenosis of two coronary arteries.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing of the pilot and identified 0.718 ug/ml of hydrocodone and 0.098 ug/ml of dihydrocodeine in blood and 224 ug/ml of acetaminophen, 4.61 ug/ml of dihydrocodeine, 36.917 ug/ml of hydrocodone, and 12.99 ug/ml of hydromorphone in urine.

Hydrocodone is a prescription opioid identified as a Schedule II controlled substance by the Drug Enforcement Administration. It is most commonly sold in combination with acetaminophen, often with the names Vicodin and Lortab. It carries several warnings, including, "hydrocodone, like all narcotics, may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery," and "alcohol and other CNS (central nervous system) depressants may produce an additive CNS depression, when taken with this combination product, and should be avoided."

Dihydrocodeine and hydromorphone are each opioid analgesics, but they are also metabolites of hydrocodone. Hydrocodone's usual therapeutic levels are between 0.010 and 0.050 ug/ml. Dihydrocodeine's usual therapeutic levels are between 0.050 and 0.150 ug/ml.

The pilot had reported no chronic medical conditions and no chronic medication use to the FAA. At the time of the autopsy, a small plastic baggie containing 5 tablets labeled M367 was found in the pilot's pocket. The autopsy report identified these tablets as a combination of 325 mg of acetaminophen and 10 mg of hydrocodone.

Additional Information


The pilot was involved in a helicopter accident on September 3, 2010, where he received serious injuries, and the Bell 47G helicopter was substantially damaged (NTSB accident number WPR10LA446). The NTSB determined that the probable cause of the accident was the pilot's visual flight rules flight into instrument meteorological conditions, which resulted in his spatial disorientation and loss of helicopter control. 

NTSB Identification: WPR15LA193 
14 CFR Part 137: Agricultural
Accident occurred Saturday, June 20, 2015 in Salinas, CA
Aircraft: BELL 47G 5, registration: N4427F
Injuries: 1 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this a
ircraft accident report.

On June 20, 2015, at 0715 Pacific daylight time (PDT), a Bell 47G 5 helicopter, N4427F, was substantially damaged when it impacted a fence and terrain while maneuvering about 5 miles southwest of the Salinas Municipal Airport, Salinas, California. The helicopter was registered to, and operated by, Gomes Farm Air Service, Inc., under provisions of Title 14 Code of Federal Regulations Part 137. The commercial pilot, the sole occupant of the helicopter, was fatally injured. Instrument meteorological conditions prevailed, and no flight plan was filed. The local aerial application flight originated from a loading area near the accident site about 0650.

Ground crewmen who worked for the operator had just refilled the fertilizer tank on the helicopter prior to its last departure. When the helicopter did not return for its scheduled rinse load the crewmen drove out to the field to be sprayed and observed that the helicopter had crashed on a road near a field. Neither ground crewmen witnessed the crash but stated that the fog was thick and visibility was between 10 and 20 feet at the time of the accident.

A postaccident examination of the helicopter was conducted by the Federal Aviation Administration, on June 20, 2015. The examination revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

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

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Location: Salinas, CA
Accident Number: WPR10LA446
Date & Time: 09/03/2010, 0600 PDT
Registration: N4427F
Aircraft: BELL 47G
Aircraft Damage: Substantial
Defining Event: VFR encounter with IMC
Injuries: 1 Serious
Flight Conducted Under: Part 91: General Aviation - Positioning

Analysis

After taking off on a visual flight rules flight in instrument meterological conditions, with a reported 2 1/2 miles visibility with mist and overcast clouds at 100 feet, the pilot proceeded westbound about 50 feet above ground level (agl) then, while approaching an interstate highway, climbed to 100 feet agl in order to avoid power lines. During the climb, the helicopter entered the fog. The pilot stated that after entering the fog he turned on the landing light, which blinded him and caused him to become disoriented as he attempted to make a 180-degree turn back to the airport. The pilot added that he subsequently lost control of the helicopter and impacted a highway guardrail with the tail section of the helicopter. The helicopter then came to rest inverted and partially in the southbound lane of the highway. The pilot reported no helicopter mechanical failures or malfunctions. A truck driver who witnessed the accident reported that the forward visibility was about 250 feet at the time of the accident.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's visual flight rules flight into instrument meteorological conditions, which resulted in his spatial disorientation and loss of helicopter control.

Findings

Personnel issues
Decision making/judgment - Pilot (Cause)
Spatial disorientation - Pilot (Cause)
Aircraft control - Pilot (Cause)

Environmental issues
Low visibility - Contributed to outcome

Factual Information

On September 3, 2010, about 0600 Pacific daylight time, a Bell 47G-5 helicopter, N4427F, was substantially damaged following impact with terrain near Salinas, California. The commercial pilot, the sole occupant, was seriously injured. Gomes Farm Air Service of Salinas, was operating the helicopter under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed at the time of the accident, and a flight plan was not filed. The repositioning flight had departed the Salinas Municipal Airport (SNS) about 0550, with its destination being an off-airport work site about 3 miles west of SNS.

According to a Federal Aviation Administration (FAA) aviation safety inspector who conducted a telephone interview with the pilot shortly after the accident, the pilot stated that he was flying about 50 feet above the ground and was concerned about the power lines that were hidden by the fog. The pilot reported that he then climbed up to about 80 feet above ground level (agl), which put him in the fog, and when he turned on the landing light in an attempt to illuminate the ground references and identify the power lines,  it caused a temporary blinding condition that caused him to become disoriented. The pilot stated that he then attempted a 180-degree turn toward the airport, which resulted in a loss of control and impact with the highway pavement. The pilot reported no mechanical problems with the helicopter.

In a written report submitted to the National Transportation Safety Board investigator-in-charge (IIC) several days after the accident, the pilot reported that abeam the airport’s control tower at an altitude of about 75 feet mean sea level (msl) and after turning west toward the interstate highway that borders the airport on the west, he could clearly see a [sugar plant] about 2 miles away. The pilot stated that after reaching the interstate highway he climbed to 100 feet msl and remained clear of clouds, with visibility “2 miles plus.” The pilot revealed that when the helicopter was over the interstate highway’s  median strip between the north and southbound lanes, visibility began to deteriorate. The pilot reported that at this time he decided to turn around and return to the airport, as well as to descend in an attempt to re-establish visual contact [with ground references]. The pilot stated that during the descent and course reversal the tail section of the helicopter collided with a guard rail on the highway. The helicopter subsequently impacted the highway pavement and came to rest inverted partially in a southbound lane. The helicopter sustained substantial damage to its airframe. 

A truck driver who was traveling southbound on the interstate highway reported seeing the helicopter approaching her position from the right side; it was moving from side to side. The witness stated that the helicopter subsequently impacted the terrain and rolled over, coming to rest partially inverted. The witness added that the forward visibility at the time of the accident was about 250 feet, and it was also very foggy.

At 0546, a special observation was reported by the SNS Automated Surface Observing System  (ASOS), which revealed wind calm, visibility 2 ½ miles, mist, overcast clouds at 100 feet, temperature 13 degrees Celsius, dew point 12 degrees Celsius, and an altimeter setting of 29.96 inches of Mercury.

At 0553, the SNS ASOS reported wind calm, visibility 2 ½ miles, mist, overcast clouds at 100 feet, temperature 13 degrees Celsius, dew point 12 degrees Celsius, and an altimeter setting of 29.97 inches of Mercury. 

History of Flight

Enroute
VFR encounter with IMC (Defining event)
Loss of visual reference
Loss of control in flight

Uncontrolled descent
Collision with terr/obj (non-CFIT) 

Pilot Information

Certificate: Commercial
Age: 62, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used: Seatbelt
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 02/16/2010
Occupational Pilot: Yes
Last Flight Review or Equivalent: 11/18/2008
Flight Time:  15928 hours (Total, all aircraft), 15928 hours (Pilot In Command, all aircraft), 120 hours (Last 90 days, all aircraft), 50 hours (Last 30 days, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: BELL
Registration: N4427F
Model/Series: 47G 5
Aircraft Category: Helicopter
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Restricted
Serial Number: 7971
Landing Gear Type: Skid
Seats: 2
Date/Type of Last Inspection: 07/30/2010, Continuous Airworthiness
Certified Max Gross Wt.: 2850 lbs
Time Since Last Inspection: 0 Hours
Engines: 1 Reciprocating
Airframe Total Time: 7936 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: Installed, not activated
Engine Model/Series: VO435
Registered Owner: Gomes Farm Air Service Inc.
Rated Power: 260 hp
Operator: Frank Gomes
Operating Certificate(s) Held:
Operator Does Business As:
Operator Designator Code: LSJG 

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: SNS, 27 ft msl
Observation Time: 0553 PDT
Distance from Accident Site: 2 Nautical Miles
Direction from Accident Site: 180°
Lowest Cloud Condition: Unknown
Temperature/Dew Point: 13°C / 12°C
Lowest Ceiling: Overcast / 100 ft agl
Visibility:  2 Miles
Wind Speed/Gusts, Direction: Calm
Visibility (RVR):
Altimeter Setting: 29.97 inches Hg
Visibility (RVV):
Precipitation and Obscuration: Mist; No Obscuration
Departure Point: Salinas, CA (SNS)
Type of Flight Plan Filed: None
Destination: Salinas, CA (SNS)
Type of Clearance: Special VFR
Departure Time: 0550 PDT
Type of Airspace:

Airport Information

Airport: Salinas Municipal Airport (SNS)
Runway Surface Type:
Airport Elevation: 85 ft
Runway Surface Condition:
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Serious
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Serious
Latitude, Longitude: 36.662222, -121.623889 (est) 

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