NTSB Identification: ANC99FA073.
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Nonscheduled 14 CFR
Accident occurred Wednesday, June 09, 1999 in JUNEAU, AK
Probable Cause Approval Date: 08/03/2000
Aircraft: Eurocopter AS-350BA, registration: N6099S
Injuries: 7 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 air tour helicopter, with the pilot and six passengers, departed Juneau, Alaska, for a 50 minute flight over mountainous glaciers. About ten minutes after making a normal radio transmission, the helicopter was located by the pilot of a second company helicopter who was also conducting a tour. The accident helicopter impacted a nearly level, snow-covered glacier, and all occupants received fatal injuries. The leading edge of the impact crater was angled between 30 and 45 degrees below the horizon, and the face of the airspeed indicator gauge had a needle slap mark at 130 knots. The pilots of the only two helicopters near the accident site at the time of the accident, said the "flat light" made the featureless, snow-covered terrain difficult to discern from the indefinite, overcast ceiling. Photographs taken within one hour of the accident showed that the mountain pass the pilot was attempting to fly through was difficult to distinguish from the clouds, the glacier surface, and the surrounding snow-covered terrain. A postaccident inspection discovered no evidence of any preaccident mechanical anomalies. At the time of the accident, the pilot had accrued 7.9 hours in AS-350 helicopters, and a total of 37.5 hours in turbine helicopters, all with the accident company. This was the second day the pilot operated the AS-350 by himself. The pilot did not hold any instrument certificates, nor was he required to by the FAA. FAA Order 8400.10 requires Principal Operations Inspectors (POIs), and approved company check airmen, to have pilots demonstrate their ability to control a helicopter solely by reference to flight instruments during 14 CFR 135.293 competency checks for VFR-only helicopter operations. This requirement is not specified in 14 CFR Part 135. The FAA approved the company's training manual without this requirement being incorporated. The FAA did not ensure that the company check airman was aware of the checking requirements listed in FAA Order 8400.10. The pilot received no emergency instrument training from the company, nor did the company require him to demonstrate the ability to control the helicopter solely by reference to the installed flight instruments. The helicopter was required to, and did have, a gyroscopic pitch and bank indicator installed. The FAA's training minimums for new hire pilots is 16 hours of Indoctrination Training, and 16 hours of aircraft ground training. The FAA's national norm for these training programs are 24 hours each. POIs can approve the minimum hours based on the type and sophistication of the training methods. The approved training for the accident company was the minimum. The pilot's previous helicopter piloting experience (as a student, and as a flight instructor) was in Arizona and California. The pilot stated on his company resume that he had accrued 891 hours of helicopter flight experience at the time of his employment. The NTSB IIC, and the FAA, estimated the pilot actually had 612 helicopter flight hours when hired. The company had not received background checks for the pilot before the accident occurred, and was allowed by the Pilot Records Improvement Act to use a pilot for 90 days prior to receipt of background information. The pilot had expressed to a previous employer, and a previous instructor, that he was uncomfortable with company pressure to fly tours in bad weather.
The National Transportation Safety Board determines the probable cause(s) of this accident to be: 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. Full narrative available
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