NTSB Factual Report

HISTORY OF FLIGHT

On June 9, 1999, at 1050 Alaska daylight time, a skid/ski equipped Eurocopter AS-350BA helicopter, N6099S, was destroyed when it impacted the Herbert Glacier, about 3,400 feet above sea level (msl), approximately 20 miles north of Juneau, Alaska, at 58 degrees 34.958 minutes north latitude, 134 degrees 33.602 minutes west longtitude. The commercial certificated pilot and the six passengers on board were fatally injured. The helicopter was owned and operated by Coastal Helicopters, Inc., of Juneau, Alaska, under 14 CFR Part 135 as an on-demand air tour flight. The flight departed Juneau at 1008 for the Herbert Glacier. Visual meteorological conditions prevailed in Juneau at the time of the accident, and a company VFR flight plan was in effect.

The accident helicopter landed about the 1,000 feet msl level of the Herbert Glacier about 1025, as a routine part of the tour. The helicopter was near a second company helicopter which had also landed on the glacier. The accident flight took off again about 1035 to continue the tour. The pilot of the second company helicopter indicated he was about 5 minutes behind the accident helicopter, and did not have the accident flight in sight during the second half of the tour.

The pilot of the second company helicopter, and the pilot of a third helicopter (operated by a different company) who was on the Mendenhall Glacier side of the pass between the Herbert and Mendenhall glaciers, told the NTSB investigator-in-charge (IIC) that about 1045 they heard the accident pilot transmit "Coastal 99S is upper Herbert for the Mendenhall, right side." Both pilots said the radio transmission sounded normal. The pilot of the second helicopter, flying up the Herbert Glacier behind the accident helicopter, found the wreckage about 1055. Both pilots said the snow-covered glacier was featureless, the overcast ceiling was difficult to discern from the snow, and described the lighting as "flat." Both pilots said the overcast layer was a few hundred feet above the elevation of the 4,100 feet msl pass between the two glaciers, but neither could discern the exact ceiling.

INJURIES TO PERSONS

All seven persons on board the helicopter were fatally injured. The State of Alaska Medical Examiner's report noted decelerative injuries to all occupants.

DAMAGE TO AIRCRAFT

The helicopter was destroyed by impact forces.

PERSONNEL INFORMATION

The pilot was a New Zealand citizen, legally working in the United States. He held no New Zealand airplane or helicopter certificates.

The pilot held a U.S. commercial helicopter pilot certificate issued on June 29, 1998. The pilot did not hold any U.S. ratings for airplanes. His helicopter flight instructor certificate was issued on September 19, 1998. He did not hold an instrument rating. All pilot rating examinations were administered by FAA Designated Pilot Examiners (DPE). There were no records indicating the pilot had received instrument training in the United States, or in New Zealand. His most recent U.S. second class medical certificate was issued on March 15, 1999, with no restrictions.

The New Zealand Civil Aviation Authority (CAA), and the New Zealand Transportation Accident Investigation Commission (TAIC), reviewed the pilot's New Zealand aviation, education, and medical records. This review found the following:

The pilot had been a part owner of two microlight aircraft in New Zealand. The other owner/partner estimated the pilot had accrued about 500 hours in microlights. During April 1996, the pilot completed a microlight check with a flight instructor. He was issued an Advanced Microlight pilot certification by the Recreational Aircraft Association of New Zealand (RAANZ), on October 27, 1997, for three-axis control (group B) aircraft. There is no CAA license required for microlight flying, but there is a legal requirement for pilots to hold a microlight certificate to fly microlight aircraft in New Zealand. The progression of certificates issued by the RAANZ is novice, intermediate, and advanced.

Interviews conducted by the FAA indicated the pilot had difficulty reading and writing English. Quantum Helicopters, Inc., in Chandler, Arizona, provided commercial helicopter flight training to the pilot. Quantum's chief pilot stated that the accident pilot began training for his helicopter flight instructor certificate, but the company terminated his training, citing a failure to meet the standards set forth in FAR 61.183: "To be eligible for a flight instructor certificate a person must - (b) Read, write, and converse fluently in English." The pilot then completed training for his flight instructor certificate with Group-3 Aviation, Inc., of Van Nuys, California, on September 18, 1998. He passed an examination for the certificate on September 19, 1998.

Interviews conducted by the FAA and NTSB IIC with other employers and flight schools did not indicate obvious language difficulties. The other persons interviewed consistently commented that upon review, none remembered the pilot performing detailed written work in person. Comments indicated that when given written work assignments, they were normally returned the following day, in good order. Group-3 Aviation commented that when the pilot arrived for training, he already had extensively prepared lesson plans with him, and generating new ones was not required.

The pilot was hired as a flight instructor by Aero Helicopters, Inc., in Scottsdale, Arizona, the same company which had provided his initial training for the private pilot certificate. He worked for Aero Helicopters, Inc., from September 20 to November 30, 1998. Between December 1, 1998 and May 8, 1999, the pilot worked as a flight instructor for Guidance Helicopters, Inc., in Prescott, Arizona.

The pilot was hired by Coastal Helicopters, Inc., on May 8, 1999. He was based and lived in Juneau. He completed initial ground training on May 11, 1999. On May 11, 1999, the pilot was administered a pilot-in-command, 14 CFR 135.293 and 135.299 proficiency and line check in a BHT-206 by the company president, who is also the director of operations, and FAA authorized company check airman. On June 7, the pilot successfully completed pilot-in-command checks in the AS-350.

The pilot had no turbine engine powered aircraft experience as a pilot prior to his employment at Coastal Helicopters, Inc. His previous helicopter piloting experience was in Robinson R-22, and Schweizer-300C helicopters. During his employment at Coastal Helicopters, Inc., he accrued a total of 37.5 hours of flight experience. He received a total of 5.7 hours of dual flight instruction in the BHT-206, and 5.7 hours of dual flight instruction in the AS-350. His total experience (including dual flight instruction) in the AS-350 at the time of the accident was 7.9 hours.

Flight and Duty Time

On the day of the accident, the pilot's estimated total helicopter experience was 650 hours. According to prior employer and flight school records compiled by the FAA, the pilot had accumulated 487 hours of verifiable flight experience in helicopters. An additional 125 hours of helicopter experience was estimated to have been accrued while employed by Aero Helicopters, Inc., from September 19 to November 30, 1999 (flight records are missing for this time period). The pilot's total estimated helicopter experience at the time of employment by Coastal Helicopters Inc., on May 5, 1999, was 612 hours.

In the 24 hours prior to the accident, the pilot had flown 2.2 hours. He completed his flights about 1700 on June 8, the day prior to the accident, and was off duty for 14 hours prior to reporting to work the morning of the accident.

The pilot flew each of the nine days prior to the accident. He had flown 13.8 hours in the previous 7 days, and 36.4 hours in the previous 30 days.

Helicopter Experience Claimed By The Pilot

According to New Zealand CAA records, FAA medical records, and employment applications submitted by the pilot, the following progression of flight time was presented by the pilot:

Date(s) Flight Experience Source

August 22, 1995 82 hours(microlight),10(other) New Zealand CAA records April 24, 1998 47 hours(helo) to date private pilot application June 25, 1998 157 hours(helo) to date commercial pilot application September 18, 1998 203 hours(helo) to date flight instructor application March 11, 1999 804 hours(helo) resume submitted to Coastal Helicopters March 15, 1999 800 hours(helo) second class medical application May 11, 1999 891 hours(helo) Crew Information Sheet-Coastal Helicopters

Helicopter Experience Verified By FAA

The following flight hours were determined by the FAA to have been accrued by the pilot between September 1998 and May 5, 1999:

Sept 19-Nov 30, 98 125 hours estimate by Aero Helicopters, Inc. Dec 1, 98 - May 5, 99 283.6 hours(helo) Guidance Helicopters, Inc. pay records

According to the FAA inspector who verified the pilot's flight experience, when the pilot's employer at Aero Helicopters, Inc., was asked for a summary of his flight time, he was told the records were not available. The employer stated that he had not discarded the records, and he believed the pilot removed them when he terminated his employment. Aero Helicopters, Inc., estimated that as a flight instructor, the accident pilot would have averaged 50 hours per month of flight time. The estimated experience gained while employed at Aero Helicopters, Inc., was 125 hours.

Ultralight Vehicle Experience

In a letter he sent to Coastal Helicopters, Inc., on March 9, 1999, the pilot stated: "I started as a fixed wing pilot flying tailwheel aircraft... . I have 800 helicopter hours and am averaging 80-100 hours per month at present plus have 600 hours of tailwheel fixed wing." Research revealed that he had accumulated about 500 hours in microlight (ultralight) aircraft in New Zealand.

14 CFR Part 103, Ultralight Vehicles, contains the following regulatory statements:

"103.1 ...an ultralight vehicle is a vehicle that... (c) Does not have any U.S. or foreign airworthiness certificate..." "103.7...ultralight vehicles...are not required to meet the airworthiness certification standards specified for aircraft....(b) ...operators of ultralight vehicles are not required to meet any aeronautical knowledge, age, or experience requirements...or to have airman or medical certificates..."

FAA Order 8700.1 (General Aviation Inspector's Handbook), Volume 2, Chapter 1, page 1-46 and 1-47, paragraph 9B states, in its entirety:

"B. Logging Time. Unless the vehicle is type certificated as an aircraft in a category listed in FAR 61.5(b)(1) or as an experimental aircraft, or otherwise holds an airworthiness certificate, flight time acquired in such a vehicle may not be used to meet requirements of FAR 61 for a certificate or rating or to meet the recency of experience requirements."

The NTSB IIC, the FAA, and the New Zealand CAA, requested the pilot's logbook from his family. The family responded that the pilot's logbook and all flight records were cremated with his remains.

AIRCRAFT INFORMATION

The helicopter was an American Eurocopter AS-350BA. It was equipped with a Turbomeca Arriel-1B turboshaft engine. The helicopter was configured to carry one pilot and six passengers.

The helicopter was maintained on the manufacturer's inspection program, under an Approved Aircraft Inspection Program (AAIP). This program contains inspections performed approximately every 100 hours. The helicopter and engine were manufactured in January 1995, and both had accumulated 1,827 hours in service at the time of the accident. 62 hours had elapsed since the most recent 100 hour inspection. A review of maintenance records revealed no evidence of preexisting anomalies at the time of the accident.

The allowable maximum weight of the helicopter was 4,630 pounds. The NTSB IIC estimated the weight at the time of the accident to be 4,366 pounds.

Required Equipment

All equipment required by 14 CFR Part 91.205, 207, 209, and 135.149, 159, and 161, was installed on all company helicopters.

The company was authorized to operate the helicopter in day and night VFR conditions. 14 CFR Part 135.159, Equipment Requirements: Carrying Passengers Under VFR At Night, states, in part: "No person may operate an aircraft carrying passengers under VFR at night...unless it is equipped with- (a) A gyroscopic rate-of-turn indicator... (b) A slip skid indicator (c) A gyroscopic bank-and-pitch indicator. (d) A gyroscopic direction indicator..."

METEOROLOGICAL INFORMATION

The nearest official weather reporting station to the accident site is located at the Juneau International Airport, 20 nautical miles south of the accident site. The airport elevation is 19 feet above sea level (msl).

Numerous pilots from different companies were interviewed by the NTSB IIC. All confirmed that weather conditions on the various glaciers flowing from the Juneau Ice Field often vary significantly from that reported at the Juneau airport. The weather conditions tend to be local in nature due to mountainous terrain, wind, and temperature variations associated with the large mass of ice.

The pilot of the second company helicopter on the Herbert Glacier who found the wreckage stated "the light was flat and very difficult to distinguish terrain from the overcast....a milky blur."

Numerous photographs were taken by rescue personnel, and the Alaska State Troopers, about one hour after the accident. A review of these photographs by the NTSB IIC showed the pass between the Herbert Glacier and the Mendenhall Glacier obscured, with no discernible horizon, when looking at the pass from the accident site. The view looking down the Herbert Glacier from the accident site depicted an overcast ceiling which sloped up with the terrain, gradually lowering toward the upper elevations.

Weather observations for the Juneau International Airport, for the time periods of each flight the pilot took while employed by the company revealed the following:

The weather observation at the Juneau airport, at 0952 on the day of the accident, was 1,700 feet broken; 2,500 feet overcast; visibility 10 miles; temperature 52 degrees Fahrenheit; dew point 46 degrees Fahrenheit, winds 220 degrees at 6 knots.

The weather observation at the Juneau airport, at 1053 on the day of the accident, was 1,600 feet scattered; 2,100 feet overcast; visibility 10 miles; temperature 52 degrees Fahrenheit; dew point 46 degrees Fahrenheit, winds 210 degrees at 5 knots. This was the lowest weather reported at the Juneau airport during any time period in which the pilot flew since he was hired.

The reported weather at the airport during the pilot's training and check flights in the BHT-206 was 8,000 feet ceilings and 10 miles visibility. The lowest reported weather during AS-350 training was 2,500 feet scattered; 3,500 feet overcast; 10 miles visibility in light rain. The weather during the pilot's check flight in the AS-350 was clear, with unlimited visibility.

According to company records, the pilot had flown to and from the Herbert Glacier on 31 occasions prior to the accident flight. He had flown from the Herbert Glacier to the Mendenhall Glacier via the Upper Herbert Glacier Pass, on 11 flights, on 5 different days. According to the company president, the preferred tour route would be to fly up the Herbert Glacier, cross the upper pass to the Mendenhall Glacier, and then down the Mendenhall Glacier to the Juneau airport. The company president indicated the reason the pilot would fly up the Herbert Glacier, and return via the same route, would be due to low ceilings which closed the pass to the Mendenhall.

The Juneau International Airport weather on the five previous days the pilot had flown through the upper Herbert Glacier pass to the Mendenhall Glacier, was:

May 21 3,000 feet scattered, 4,200 feet overcast, 10 miles visibility June 4 2,500 feet scattered, 7,000 feet overcast, 10 miles visibility June 6 14,000 feet scattered, 10 miles visibility June 7 clear June 8 5,500 feet broken, 10 miles visibility

COMMUNICATIONS

NTSB Probable Cause

The pilot's continued VFR flight into adverse weather, spatial disorientation, and failure to maintain aircraft control. Factors associated with the accident were pressure by the company to continue flights in marginal weather, and the "flat" lighting leading to whiteout conditions. Additional factors were the pilot's lack of instrument experience, lack of total experience, inadequate certification and approval of the operator by the FAA, and the FAA's inadequate surveillance of the emergency instrument procedures in use by the company.