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N4948V accident description

Alaska map... Alaska list
Crash location Unknown
Nearest city Juneau, AK
58.301944°N, 134.419722°W
Tail number N4948V
Accident date 30 May 1998
Aircraft type Cessna 172RG
Additional details: None

NTSB Factual Report

HISTORY OF FLIGHT

On May 30, 1998, at 1611 Alaska daylight time, an Aerospatiale AS-350-B2 helicopter, N187EH, and a Cessna 172RG airplane, N4948V, collided in midair, approximately four miles southeast of downtown Juneau, Alaska. The helicopter sustained substantial damage to the right-side doors and fuselage. The commercial pilot and four passengers were not injured. The remaining helicopter passenger sustained serious injuries. The helicopter made an emergency landing at a mine site about 1/2 mile north of the collision point. The airplane impacted the water in the Gastineau Channel, about one mile west of the collision point, and was destroyed. The airplane's private pilot, seated in the left seat, and the commercial pilot/flight instructor, who was seated in the right-front seat, both sustained fatal injuries. Visual meteorological conditions prevailed at the time of the accident. A company flight plan was on file for the helicopter, and a VFR flight plan had been filed by the airplane pilot.

The helicopter flight was being conducted under 14 CFR Part 135 as an air tour flight, transporting cruise ship passengers to the Juneau ice fields. The helicopter was operated by ERA Aviation, Inc., of Anchorage, Alaska. The flight departed the ERA heliport, 10 miles west of the collision point, as the third ship in a flight of three. The first two helicopters departed at 1602 and 1603. The accident helicopter was delayed on the pad while the pilot adjusted a passenger's seat belt, and departed at 1606.

The airplane flight was conducted under 14 CFR Part 91 as a U.S. Government civil flight. The airplane was owned by Take Flight Alaska, Inc., of Anchorage, and was rented and operated by the Federal Aviation Administration, Alaskan Region, in Anchorage. The accident flight was the second flight of the day for the airplane occupants. The flight departed Sitka, Alaska, for Petersburg, Alaska, at 1343. Then departed Petersburg at 1525, for the Juneau International Airport, Juneau, Alaska. The airplane's pilot contacted the FAA Juneau Flight Service Station (AFSS) on 122.2 MHz at 1608, said that N4948V was 15 miles down Gastineau Channel, and closed the VFR flight plan. No other transmissions were received from the airplane.

The helicopter pilot stated to the NTSB investigator-in-charge (IIC) during an interview on May 31, that he had just crossed Gastineau Channel from Treadwell on a magnetic heading of about 040 degrees at 2,000 feet above sea level (msl), and was beginning a climb, when the helicopter was impacted from the right side. The pilot stated that the passenger's audio narration tape ended just as the helicopter crossed the channel, and he had just asked how his passengers were doing.

None of the helicopter occupants said they saw the airplane prior to the collision. The passenger seated in the right-rear seat told the IIC that he was looking 30 degrees to the right of the helicopter's nose at the moment of impact. He said "I saw a flash of something white and angular, to the right, which I thought was a large bird."

The helicopter pilot indicated that at the time of collision, the helicopter was thrown onto its left side, pitched about 70 to 80 degrees nose down, and his feet were knocked off the pedals. He said that he regained control of the helicopter, immediately began an emergency descent to land, and transmitted that "187 is going down" on 123.05 MHz, 118.7 MHz, and on the company FM radio frequency. The pilot related that he entered an autorotative descent, recognized that the helicopter was controllable, and completed a power-on landing.

After landing, he noted that the passenger seated in the right-rear seat was injured, and that there was debris, including a wingtip light, in the aft cabin. He told the NTSB IIC that it was at that point he realized his helicopter had collided with an airplane.

Witnesses on the ground heard a loud noise, looked up, then saw the airplane on a westerly heading, and the helicopter on a northerly heading, flying away from each other. The airplane was described as momentarily remaining level, appearing to lose a piece of wing, then spiraling vertically into the water.

An air taxi pilot told the IIC that as he was exiting the Gastineau Channel northeast bound up the Taku Inlet about 1605, he saw a white Cessna enter the Gastineau Channel westbound. He said he did not hear any transmissions from this airplane on 123.05 MHz.

INJURIES TO PERSONS

The two occupants of the Cessna 172RG sustained fatal injuries. Both were attached to their seats by seatbelts and shoulder harnesses. The pilot was seated in the left pilot seat, and the pilot-rated passenger was in the right pilot seat.

The passenger seated in the right-rear seat of the helicopter sustained a closed fracture to his right lower leg. The remaining five occupants of the helicopter were not injured.

DAMAGE TO AIRCRAFT

The helicopter sustained substantial impact damage to the right side of the cabin and fuselage, damage to antennas mounted under the tail boom, and surface scratches to the lower vertical stabilizer and both tail rotor blades.

The airplane was destroyed by a combination of collision and water impact forces.

PERSONNEL INFORMATION

Helicopter

The pilot of the helicopter has a commercial helicopter pilot certificate, and a private pilot certificate for single-engine land airplanes. He holds instrument ratings in both helicopters and single-engine airplanes. In addition, he was rated as a flight instructor in helicopters. He had a first class medical certificate issued on July 18, 1997, with no limitations. The pilot is 75 inches tall, with a sitting height of 33 1/2 inches from the seat pan to his eyes.

The helicopter pilot was hired by the company on April 19, 1997, and originally assigned to the Anchorage, Alaska base. He was authorized to fly AS-350, BH-212, and BH-412 helicopters for the company. The helicopter pilot's last flight review was his annual 14 CFR Part 135.293 and 135.299 competency and line checks. These were performed by a company check airman on March 20, 1998, in an AS-350-B2 helicopter.

At the time of the accident, the helicopter pilot had accumulated about 2,350 total flight hours, 2,250 in helicopters, and 403 hours in the AS-350. In the 90 and 30 days prior to the accident, he had flown 35 and 23 hours, respectively. On the day of the accident, the pilot had flown 2.5 hours on four previous air tours in the accident helicopter. The accident flight was his fifth flight of the day. This was the second season that he flew tours for the company in the Juneau area. He had acquired 17 hours flying in the Juneau area this season, all within the previous 7 days.

The pilot told the NTSB IIC during an interview on June 10, that he normally sleeps five to six hours per night, from midnight until 0600. He said that the night prior to the accident he attended a concert, and slept his normal amount. On the day of the accident, he preflighted his helicopter, and then slept another hour before he began his flights. He also indicated his sleep patterns were normal the previous two nights.

Airplane

The pilot of the airplane held a private pilot certificate with privileges for single-engine land airplanes which was issued on April 19, 1977. In addition, he held a certificate as an FAA control tower operator. According to the pilot's personal flight logbook which was found in the airplane, he had accumulated 433 hours of flight experience at the time of the accident. The last entry in this logbook was the previous flight on May 30, 1998. The pilot's logbook indicated that he had flown 20 hours in the previous 90 days, all accumulated in the previous 30 days.

The pilot held a third class medical certificate issued on June 13, 1996, with the limitation that he have glasses available for near vision. His medical certificate, and Alaska driver's license, indicated his height to be 72 inches. His estimated sitting height, from seat pan to eyes, was 33 1/2 inches.

A review of the pilot's logbook, which was found in the airplane, had entries from Sept 23, 1969, to the day of the accident. No entries indicated any flights had been conducted in the Juneau, or southeast Alaska, area.

The pilot was employed by the FAA as a budget coordinator for the National Airspace Implementation Center, located at the FAA Alaskan Region headquarters in Anchorage. Each summer the pilot would travel to all facilities he was responsible for to assess future budgetary requirements. The operation of the airplane was for transportation in support of the pilot's job. A review of FAA purchase order records revealed that the accident airplane's rental and fuel purchases on this trip had been paid with U.S. Government SF-44 "purchase order-invoice-vouchers."

The sole passenger in the airplane held a commercial pilot certificate issued on August 30, 1991, with ratings for single-engine land and sea airplanes, multiengine airplanes, and instruments. She also held a flight instructor certificate with privileges for single-engine airplanes, with an instrument rating. She held a first class medical certificate issued on February 20, 1998, with the restriction that she wear corrective lenses. Her uncorrected distant vision was 20/200, corrected to 20/20. She possessed a Statement of Demonstrated Ability (SODA) for visual acuity, issued on February 9, 1977. Her height was 64 inches.

According to her logbook, the passenger had accumulated 1,795 hours of flight experience. In the previous 90 and 30 days, she had flown 32 and 28 hours, respectively. A review of her pilot logbook, which was found in the accident airplane, showed that she had logged pilot-in-command and flight instructor time for all previous flights on this trip. No record was found of previous flight experience in the Juneau, or southeast Alaska, area.

The passenger was employed by Lockheed-Martin, Inc., as a support contractor assigned to the FAA Alaskan Region. Her place of employment was at the FAA Alaskan Region headquarters, where she was a communications specialist. According to her supervisor, she was assigned to the trip as a support specialist for assessing budget and technical needs, and was not assigned as a flight crewmember.

AIRCRAFT INFORMATION

Helicopter

The helicopter was equipped with white, high-intensity strobe lights located on top of the fuselage aft of the main rotor mast and on the tips of both horizontal stabilizers. Red, rotating beacons were located under the fuselage and on the top of the vertical stabilizer. Navigation lights were located on the tail and ends of the horizontal stabilizers. Two pulsating landing lights were located under the fuselage and projected forward through an arc of 180 degrees. All light bulbs on the accident helicopter were inspected after the accident; all were intact and operative.

The helicopter's color scheme was white and red. The upper surface of the helicopter main rotor blades were painted in an alternating white and black, high-visibility paint scheme.

Item 1 on the AS-350 pilot ENGINE START/SYSTEMS CHECK checklist used by ERA is: "Anti Coll. Lt. ... ON." Item 7 on the BEFORE TAKEOFF checklist is: "Landing / Pulse Lights ... AS REQUIRED." The company procedure is that all lights must be on and functioning prior to departure. Immediately prior to takeoff the company lineman ensures the lights are on and all operating. If any lights are not operational, the company requires the flight to be delayed to replace them.

Airplane

The FAA Alaskan Region had rented the airplane for business use by the pilot as a means of transportation for the duration of this trip.

The airplane was equipped with a landing light and a taxi light, both located in the nose of the airplane facing forward. The airplane had a high-visibility, white strobe light mounted on each wingtip, standard red/green/white navigation position lights, and a red, anti-collision rotating beacon on top of the vertical stabilizer.

The airplane's color scheme was white, with burnt orange stripes and highlights.

METEOROLOGICAL INFORMATION

The closest weather observation station is located at the Juneau International Airport, located 13 miles west of the accident site. At 1613 a special observation indicated winds from 280 degrees at 14 knots, broken ceilings of 4,000 feet, and 10 miles visibility. A review of photographs taken from the helicopter passengers' cameras show gray, overcast clouds, and ridgetops at 4,000 feet msl visible. Visibility in the photographs from the Juneau-Douglas bridge in downtown Juneau was beyond the eastern entrance of Gastineau Channel to Williams Mountain, a distance of 14 nautical miles.

The pilot of the helicopter told the NTSB IIC on May 31, that the tops of the ridges were visible, and that because of the overcast there was no direct sunlight, and good visibility.

AIDS TO NAVIGATION

No radar coverage exists in the area of the accident.

COMMUNICATIONS

Postaccident investigation on June 22, 1998, of the Allied-Signal, King KX-155 Navigation-Communications radios, revealed the following frequencies captured in the nonvolatile memory chips:

Com-1 Active: 118.7 MHz Standby:121.9 MHz Nav-1 Active: 116.5 MHz Standby:113.8 MHz

Com-2 Active: 122.2 MHz Standby:126.4 MHz Nav-2 Active: 116.5 MHz Standby:113.8 MHz

The closest geographic frequencies which match those selected are as follows:

Communication:

118.7 MHz Juneau Air Traffic Control Tower 121.9 MHz Juneau Ground Control 122.2 MHz Juneau Radio (Flight Service Station) 126.4 MHz Juneau ATIS

Navigation:

116.5 MHz Level Island VOR (20 miles southeast of Petersburg, Alaska) 113.8 MHz Biorka VOR (13 miles west of Sitka, Alaska)

At 1521, the pilot of the airplane contacted the Sitka FSS, and transmitted "Sitka radio, this is Cutlass 4948V on 122.35 at Petersburg. We'll be off here at ah (15)25, would you please activate my flight plan to Juneau, please."

Three minutes prior to the collision, at 1608, the pilot of the airplane contacted Juneau AFSS on 122.2 MHz and transmitted "(yeah) we're about 15 miles ah down Gastineau Channel would you cancel our flight plan please." The Juneau AFSS radio frequency depicted on the VFR sectional chart for the Juneau downtown RCO area is 122.15.

The Common Traffic Advisory Frequency (CTAF) for the Juneau Harbor Seaplane Base is 123.05. This is also the frequency depicted in the "Alaska Aviation Information 1998" booklet which provided local traffic information, and in the Juneau Area local air taxi operator's Letter Of Agreement (LOA) for traffic transiting the harbor area. This frequency was not selected in any of the frequency bins of the accident airplane.

The first helicopter in the flight of three made departure and traffic calls for all the helicopters on 118.7 MHz (tower), and then on 123.05 MHz (Juneau Harbor CTAF). The accident helicopter pilot told the NTSB IIC during an interview on May 31, that because he was delayed three minutes, and behind the first two helicopters in the flight, he made all of his own traffic calls as well when departing the helicopter pad, when crossing the Juneau-Douglas bridge, and when crossing Gastineau Channel at Treadwell. He said that when he was crossing Gastineau Channel, the first two helicopters had already crossed over a ridge and were no longer in sight.

According to the FAA coordinator, the accident helicopter pilot told him on May 30, that he did not make his own radio transmissions prior to the collision. He indicated that the first helicopter in the flight made calls for all three helicopters.

Immediately after the collision, the pilot of the helicopter transmitted "going down in Sheep Creek, at the mine." He told the NTSB investigator-in-charge (IIC) that he did not receive any response. The other two helicopters in his flight overheard his distress call on the company frequency, as did dispatchers at the company heliport.

Once he landed, he notified his company that they were safely on the ground, and the company immediately dispatched another helicopter to assist him. This was relayed to the other helicopters in his flight, and they continued on their respe

NTSB Probable Cause

The failure of both command pilots to maintain an adequate lookout to see and avoid each other's aircraft. Factors associated with the accident were the other pilot's failure to follow published advisory procedures to monitor/issue position reports on the appropriate radio frequency, and his lack of familiarity with the geographic area.

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