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History of Flight
On November 8, 1994, at 2020 central standard time (all times are in central standard time), N2620, a Sikorsky S-76A helicopter (s/n 76-0211), operated by Mobil Administrative Services Company, Inc. (MASCI), crashed 2 miles offshore from Cameron, Louisiana. The helicopter was destroyed, the single passenger drowned, and the two pilots on board sustained minor injuries. The flight had departed the Baltic-1 oil rig (position N27-56.12, W93-57.12), 118 nautical miles offshore in the High Island 572-C block of the Gulf of Mexico, at 1930, and was returning to MASCI's Cameron, Louisiana base. The flight was conducted under the provisions of 14 CFR Part 91, and was to be the crews' final flight of the day. A company flight plan was filed, and instrument meteorological conditions prevailed at the time of the accident.
At 2011:18 the ERA Helicopters weather observer transmitted to N2620 that the altimeter setting "was uh, zero zero zero at five, I'm sorry that was six o'clock, not five." At 2011:59 the captain asked the copilot "he said 30.05 at six o'clock?," who replied "yeah." The altimeter setting recorded for Lake Charles at 1950, and provided to the flight by Lake Charles Approach at 2018:21 was 30.02. (No discrepancies were found with the calibration of the barometric equipment at the ERA Cameron facility.)
At 2017:04 the captain stated "... we're gonna need to slow it down because we are going to go IFR." The copilot replied "alright, you talk me through the mileages now." The captain stated "I got everything taken care of. You're, you're doing good." The crew stated to the Investigator-In-Charge (IIC) that the captain was setting up the navaids and cockpit instruments for the approach, and the copilot was visually confirming the captain's actions during this conversation.
The captain stated that after telling the copilot that he had the lights of the village in sight, he remembered seeing 300 feet on the radar altimeter, called Lake Charles Approach to cancel his IFR clearance, and then looked down at the center console to change radio frequencies. He reported no unusual sensations or noises, and then "it felt like I closed my eyes and ran into a wall." He described being upside down under water, completely pitch black, and having no idea where he was.
The copilot stated that the first indication he had that anything was abnormal was when he realized he was upside down, under water. He stated that he began to struggle, then realized he was still strapped to his seat. He forced himself to calm down, and remembered from his training, that if strapped in his seat he knew where he was, and that the exit door must be to his left.
He reached for the door, felt the outside of the helicopter (all windows on the left side of the helicopter had broken out at impact), unbuckled his seatbelt and shoulder straps, and pulled himself clear of the helicopter. After he surfaced, he climbed onto the belly of the inverted helicopter. He stated that since no other persons appeared, he believed he was the only one who was able to escape.
The captain described attempting to open his (the right) door; he did not use the emergency exit handle or unlock the door, which did not open. He unbuckled his seat belt and shoulder harness, and stated he immediately became disoriented, and then began to panic as he ran out of air. He then remembered that he carried a portable breathing air bottle (HEED - Helicopter Emergency Egress Device) in his survival vest. He removed it, began to breathe, and then continued to try to find a way out of the submerged helicopter.
He estimated that he had remained disoriented for at least 2 minutes, when the air in the HEED was exhausted. His vest became tangled inside the helicopter, so he removed it and continued trying to escape. He stated that as the air supply in his lungs was exhausted, he took a series of normal breaths, except that he inhaled water.
While still lost inside the aircraft, he ran into an illuminated emergency exit light positioned on the ceiling of the passenger cabin, swam toward it, and then his head broke the surface of the water. He stated he had no idea where he was until he saw the light, which he knew was on the cabin ceiling. He did not know how he got out of the helicopter. The pilot estimated that he was underwater for 4 minutes, and this was confirmed by the copilot.
The emergency exit lights installed on the accident helicopter consisted of a single red light bar which read " <-EXIT-> ." This bar was positioned above the non-opening window between the cabin door and the pilots door, with an arrow pointing forward and aft. The windows on the left side of the helicopter were all missing, and no other exit paths were available.
During the inbound flight, the crew maintained radio communications and flight following with MASCI and ERA in accordance with MASCI's procedures. Approximately 2007 hours and 50 miles from Lake Charles, the flight contacted Lake Charles Approach Control, requested an IFR clearance to conduct the VOR- DME COPTER 010 approach to Cameron, and were issued a discreet transponder code. At 2017 the flight transmitted "I don't know if you ever picked us up...we're 28 DME...is it ok to go ahead and shoot this uh, uh, Copter One approach?" This was 2 miles from the final approach fix.
Lake Charles Approach replied, "...I just picked you up, right when you called...you appear to be just comin' on the final approach fix." N2620 responded "yes sir we are...we're 27 DME indicated." Lake Charles responded "...2620 roger, I'll monitor you to uh, you can cancel IFR and uh, and uh, we'll just go from there... radar contact." N2620 replied "OK, good deal. Radar contact." During interviews, the accident pilot and copilot stated they understood this to mean that they had been given an IFR clearance to conduct the approach in IMC conditions.
At 2016:32 on the LCH Tower tape N2620 reported "leaving final approach fix and starting our descent to three hundred sixty." They reported to Lake Charles that "...we just broke out here, at 400 feet...we got Cameron in sight. Looks like we got underneath here, we got about...5 miles visibility... ."
The LCH ATC Tower tape transcript shows N2620 transmitted at 2018:31, "Hey Lake Charles uh Sikorsky 2620 we just broke out here at 400 feet and Cameron in sight." At 2019:00, 29 seconds later, LCH ATCT transmitted "Sikorsky 2620 report cancellation this frequency." No reply was received. Statements received from LCH ATCT, and the Principal Operations Inspector, were that N2620 was not issued an IFR clearance.
The CVR transcript shows the same transmission. Thirteen seconds later the CVR records impact sounds. No response by LCH ATCT was recorded on the CVR prior to the sound of impact. (Note: the sequence of transmissions is consistent, but the time channels vary slightly between the CVR and the FAA tower tape.)
The captain, age 47, held an airline transport pilot (ATP) certificate with a rotorcraft helicopter rating, and commercial privileges for airplane single and multiengine land and instrument airplane. He held type ratings in the SK-76, BH-206, and BH-214. He held a flight instructor certificate for helicopters, and single engine airplanes, with instrument instructor privileges in both. His first class medical certificate dated December 1, 1993, reverted to a valid second class certificate, and contained the limitation of "Holder shall wear lenses that correct for distant vision... ."
The captain had accumulated approximately 15,000 hours of total flight time. He was hired by MASCI on May 28, 1985, as a BH-206 captain, and began S-76 copilot training in August 1991. At the time of hire, he had both military and civil experience as a pilot and flight instructor.
He had accumulated a total of 1,036.5 hours in the S-76 at the time of the accident. Of these, 395 were as PIC or Instructor. He had accumulated 3,500 hours in the BH-206 while employed by MASCI, 552 hours after beginning S-76 training. He passed a line evaluation as an S-76 captain in September 1993, initial check airman ground training for the S-76 on June 10, 1994, a proficiency and line check per FAR's 135.293, 297, and 299 on July 17, 1994, and initial FAR Part 135 ground training on August 19, 1994.
He owned his own company specializing in safety and survival equipment, and had purchased and carried in his survival vest his own Helicopter Emergency Egress Device (HEED). The HEED is a pocket size compressed air cylinder designed to provide an emergency source of breathing oxygen in case of underwater immersion.
For the three months prior to the accident, the captain had been the senior S-76 pilot assigned to the Cameron base during his 7 day rotation. As such, he was the aviation point of contact between the Mobil Marine dispatchers and the aviation base at Morgan City. The day prior to the accident, he asked the rig supervisor on the Baltic-1 if he could shut down sometime and provide a brief to the rig hands on helicopter operations, and planned to schedule an opportunity in the future.
During 1992, the captain logged no night or instrument flight time with MASCI. In 1993, he logged 1.5 hours at night, 2.8 hours of actual instruments, and 5 instrument approaches.
On July 11-13, 1994, the captain attended recurrent simulator training which included 1.5 hours of instrument flight, an instrument competency check, and 3 instrument approaches. No discrepancies were noted.
The annual proficiency training received in 1992, 1993, and 1994, at Flight Safety International (FSI) included nine hours of simulated flight time, all in a night environment. The 1994 FSI training report stated "...instrument flying skills and procedural knowledge was good. Crew Resource Management and Decision Making was excellent."
In 1994, the captain flew 11.9 hours at night, 1.5 hours actual instruments, 5.6 hours simulated instruments, and 16 instrument approaches. Of these, in the last 30 days he flew 1.9 hours at night, 1.5 hours actual instruments, and 1.5 hours simulated instruments. In the last 4 days he flew 3 instrument approaches, of which 2 were the Copter VOR/DME 010 to Cameron. During the 24 hours, 30 days, and 90 days preceding the accident, the captain had flown 8, 83, and 244 hours, respectively.
The copilot, age 56, held an airline transport pilot (ATP) certificate with both rotorcraft helicopter and airplane multiengine land ratings. He had type ratings in the BH-206, CE- 500, and IA-JET, also had a certified flight instructor certificate with airplane single engine and multiengine land ratings. His first class medical certificate, issued on December 31, 1993, had reverted to a valid second class certificate, and contained the limitation of "Must wear lenses for distant, possess glasses for near vision."
According to company records, the copilot had 7,973 hours total time, of which 1,646 were in helicopters, and 1,012 were in the S-76. During the 24 hours, 30 days, and 90 days preceding the accident, the copilot had flown 8, 23, and 256 hours, respectively.
The copilot was an employee of Excalibur Support Services, a company which provided contract pilots to MASCI. He began to fly for MASCI and passed both proficiency and line checks as a VFR captain on the BH-206, administered by the chief pilot on April 5 and 6, 1993, and began training as a copilot on the S-76. He passed a proficiency check in the BH-206 on September 16, 1993. He did not fly the line as a BH-206 pilot for MASCI. MASCI initially assigned him to the position of copilot on the S-76.
On February 11, 1994, the copilot passed a line evaluation in the S-76, which was administered by the accident captain acting as check airman.
In 1994, company records showed the copilot had flown 2.4 hours at night, and 15.6 hours in actual or simulated instrument conditions, 2.0 in the last 30 days.
N2620 was owned and operated by Mobil Administrative Services Company, Inc., of Morgan City, Louisiana. It was configured with 12 passenger seats, 2 pilot seats, and was certificated as a Transport Category aircraft. The helicopter was equipped with 2 Allison 250-C30 turboshaft engines, each rated at 650 shaft horsepower. At the time of the accident the total time accumulated on the airframe was 12,121 hours. The left and right engines had accumulated 5,676 and 8,980 hours respectively. The helicopter was maintained under a continuous airworthiness inspection program, and the last inspection occurred on November 7, 1994, the day prior to the accident.
All of the major components of the helicopter were located except for the main rotor blades and tail gear box/rotor head assembly. The wreckage, maintenance records, testing of components, and interviews with the flight crew revealed no evidence of preexisting airframe, system, engine or flight instrument malfunction. At the time of the accident, the helicopter had a current airworthiness certificate, and was operated within weight and balance limitations.
The helicopter was equipped with a Collins ALT-50A Radar Altimeter system, with a 339H-4 Radio Altitude Indicator installed in front of the captain. The indications presented to the pilot are a needle which indicates height above the surface, and a single light which illuminates when the aircraft descends below the decision height selected by the pilot. The copilot was provided with a DH setting and readout, with a DH light on his ADI, which was slaved to the captain's indicator.
According to Collins Publication 523-0766822-002118; ALT-50 Theory, the ALT-50A has four adjustable altitude thresholds which are factory set at 200, 500, 1,000, and 1,500 feet, but may be locally changed. According to Collins, these settings can provide fixed altitude visual or aural warnings to the pilots, if installed. The accident helicopter did not have these fixed altitude settings, nor aural warnings installed.
The captain received an abbreviated weather brief from the Federal Aviation Administration DeRidder Flight Service Station at 1643. The forecast for the time period of this flight was to remain VFR until after 2400. The temperature/dewpoint spreads at Galveston and Beaumont, Texas, and Lake Charles, Louisiana, were all greater than 6 degrees Fahrenheit. Fog was forecast after 2400. Time of sunset was 1710, and the accident occurred during hours of darkness.
The captain stated that the weather at the time of the accident was a 500 foot ceiling with 5 miles visibility. He stated that the weather rapidly deteriorated while they were on the water.
The recorded weather observation taken by the Lake Charles Air Traffic Control Tower, 23 miles north of the accident, at 2055 was:
Ceiling 500 foot broken, 3 miles visibility in fog, with temperature and dewpoint both at 72 degrees.
ERA Helicopters, Inc., was maintaining radio communications and flight following for N2620. When communications were lost, and they confirmed that the helicopter had not arrived at the Cameron Heliport, an ERA rescue helicopter was launched from Lake Charles Airport at 2118. The rescue helicopter crew described the weather at Lake Charles as 500 foot ceilings with 2 mile visibility in fog. As they proceeded toward Cameron, the ceilings lowered, and they were unable to remain in visual conditions at 300 feet. They climbed above the overcast and conducted the same approach as N2620, the COPTER VOR-DME 010. At 2130, after descending to 380 feet above mean sea level they performed a missed approach and returned to Lake Charles. They were unable to descend below the ceiling.
The crew of the first Coast Guard helicopter to conduct a search at 2135 for N2620 reported on-scene visibility of 1/4 mile in fog.
The primary navigation source used by the flightcrew during both the outbound and inbound legs was Long Range Aid to Navigation (LORAN). The crew stated that when it became apparent that low stratus clouds and fog would be present near the shoreline, they requested an IFR clearance and intended to perform the COPTER VOR-DME 010 approach procedure to Cameron.
The COPTER VOR/DME 010 approach was a Special Instrument Approach Procedure approved by the FAA for use by MASCI. The approach utilized the Lake Charles, Louisiana VORTAC for course guidance and is an approach to a point in space. No discrepancies were reported with the Lake Charles VORTAC, either by the local FAA facilities or by aircraft. No pre-accident discrepancies with the navigation systems on N2620 were discovered by the Safety Board, or described by the crew.
The accident occurred approximately two miles offshore, in open water which was approximately 14 feet in depth. The wreckage was located at N29-46.2 W93-16.0, which was 3 miles southeast of Mobil's Cameron base.
The helicopter impacted the water in a level attitude with a slight left roll, and came to rest inverted, with its rotorhead resting on the mud bottom and its underside barely above water. All windows on the left side of the helicopter were missing, and all windows on the right side remained in place. The left horizontal stabilizer separated at the spar root, and was not recovered. The right horizontal stabilizer was intact. All four composite main rotor blades were sheared immediately outboard of the blade mounting cuffs, opposite the direction of rotation, and the rotor head vibration damper (bifilar) exhibited permanent deformation on the damper weight mounting arms. The tail gear box and tail rotor head assembly separated from its mounts and remains missing.
Mud and debris was found throughout both engines, and the airframe. An internal inspection of both engines revealed no mechanical or thermal distress. Packed debris indicated that the helicopter was resting with its rotorhead on the mud bottom. The height of the helicopter is 14 feet. The crew stated that water was washing over the helicopter.
The post accident altimeter settings were found at 30.05 on the captain's altimeter, and 30.12 on the copilot's altimeter. These settings would result in the captain's altimeter indicating 30 feet high, and the copilot's altimeter indicating 100 feet higher than the actual altitude.
Prior to the outbound departure, the helicopter was serviced and fueled with 1,300 pounds (200 gallons) of jet fuel. After wreckage recovery, 88 gallons of jet fuel remained in the fuel tanks. The captain and copilot said there were no problems with the helicopter prior to impact.
The helicopter was not equipped with a flight data recorder (FDR), nor was one required by Federal Aviation Regulations. The helicopter was equipped with a Sundstrand AV-557D Cockpit Voice Recorder. The recording covered the final 30:57 minutes of the accident flight. The voice recording of the accident flight begins with conversation general in nature during the inbound cruise portion of the flight. The CVR was read at the Safety Board's laboratory and a transcript was made of the final 15:00 minutes. The recording contained good quality audio information from 3 recorded channels. One channel provided audio signals from the cockpit area microphone and the other two contained audio signals from the captain's and the copilot's respective audio panels. No warning signals were heard on any of the channels.
No challenge and response checklist procedures were heard on any of the channels. At 2020:34 the captain stated "You got 300 feet on the radar altimeter. There you go. Got the village in sight." At 2020:41 he stated "come on down." At 2020:46 the captain transmitted "Hey Lake Charles uh, Sikorsky 2620, we just broke out here, at Four hundred feet, and uh, we got Cameron in sight. Looks like we got underneath here, we got oh about five miles visibility, ... ." Thirteen seconds later the sound of impact was heard.
The Cockpit Voice Recorder was returned to the Mobil Party Representative on November 29, 1994.
Both pilots voluntarily submitted to toxicology testing, and results were negative for any foreign or impairing substances.
On the accident flight, one passenger was dropped off at the Pride-950 oil rig, the inbound passenger was boarded, and then the 617 pound drilling tool and remaining passenger were transported to the Baltic-1, where they were offloaded.
On the outbound flight from Cameron to the oil rig, the load consisted of two passengers, and a drilling tool which weighed 617 pounds. The length of the tool required it to be carried in the passenger cabin, oriented from back right to forward left across the cabin. Formed aluminum decking from the aft cargo compartment was placed on the passenger seats to protect them. The tool was wrapped in plastic "visqueen" sheets approximately 15 feet by 15 feet, and seatbelts were used to secure the tool. The passengers were seated in the forward right and aft left seats for the outbound trip.
The captain said that prior to boarding the helicopter on the inbound trip, he instructed the Baltic-1 rig workers who were holding some plastic sheets, to take the loose plastic and ropes below the helideck. While the captain was briefing the inbound passenger, the copilot supervised unloading of the tool. Both pilots stated they thought all plastic and loose gear had been removed from the aircraft and helideck.
The following items were found unrestrained in the passenger cabin of the helicopter after recovery: Two 15 x 15 foot sheets of plastic, two aluminum deck plates which measured 3 feet by 4 feet, 11 life jackets, and a variety of small items normally carried in the cabin.
The Baltic-1 drilling rig had recently moved on location, and the passenger was onboard at the time of rig relocation. There was no record found that this passenger had ever flown on a Mobil helicopter before, nor seen the MASCI helicopter safety video.
At the Baltic-1, the captain gave the passenger a safety and egress briefing, and told him he could move from the aft left to the forward right seat, directly behind the captain. The passenger was briefed that his emergency exit was the captain's door. According to the captain, he was not able to open the exit door during his egress from the submerged helicopter. When recovered, the passenger was found floating free in the cabin. His seatbelt was found buckled and intact. The passenger seats were not equipped with shoulder harnesses.
An autopsy of the passenger by the Calcasieu Parish Coroner's Office, Lake Charles, Louisiana, noted a slight bruise above the right eyebrow, which could not be directly attributed to the accident. The passengers' death was attributed to drowning.
Both pilots had successfully completed Shallow Water Egress Training required by MASCI. During this training, the pilot is secured by a safety belt and shoulder harnesses to a seat, which is then inverted underwater. The pilot then is required to unstrap the restraints and swim out of the seat while underwater. Various companies in the Gulf of Mexico voluntarily provide this training for crews. It is not a requirement under the FAR's.
Once both pilots were on top of the helicopter, they became concerned with the helicopter sinking. Since the captain had no flotation vest (he had removed it inside the helicopter), they decided he would try to reach back into the cabin to get a vest, a raft, or the passenger. The captain was able to recover a raft, which they inflated.
During this time, the first Coast Guard helicopter was sighted, and the survivors attempted to signal with the light from the copilot's vest. It overflew their position, and departed. MASCI provides pilots with a survival vest. The copilot had a water activated survivor light on his vest. He did not carry flares in his vest; the captain carried flares in his personal vest, but had been forced to abandon it in order to egress the helicopter.
After inflating the raft, the pilots believed it would puncture if it remained tied to the helicopter, so they cut the raft free. Immediately upon entering the raft, the copilot became violently seasick, and remained so until they reached shore. The captain described him as "incapacitated, sick to the point of dehydration, and I was concerned that if we did not reach shore, he would expire." He also stated he was concerned for himself due to the large amount of seawater which he had ingested.
The pilots stated that they knew that the breeze was slightly toward shore, so they removed their shirts, buttoned them together, and fashioned a sail which they used to reach the shoreline approximately one hour later. They then walked to the ERA helicopter facility about 1 mile up the beach road. ERA reported the pilots arrived at their facility at 2317. Both pilots were transported to the Lake Charles hospital, treated, and released the following day.
The captain stated that the only reason he survived was that he carried his own HEED bottle. The HEED is designed to provide approximately four minutes of breathing oxygen, which varies with temperature and workload.
Search and Rescue
MASCI, ERA, and the Air Traffic Controller were aware that the helicopter was missing within 10 minutes of the accident, when it did not arrive at the destination, and radio communications could not be reestablished. MASCI policy is to maintain flight following at all times, and pilots from companies throughout the Gulf of Mexico routinely use other companies for this when their own personnel are unavailable.
Search efforts were initiated at 2035 by MASCI and ERA. Coast Guard Group Galveston, Texas was notified at 2109 by MASCI, and an HH-65A helicopter was diverted from another search at 2111. At 2135, the first Coast Guard HH-65A was on-scene and commenced searching. At approximately 2145 they flew directly over the wreckage with the two survivors still on board, but did not locate them.
The partially submerged and overturned wreckage was located at 0510 on November 9, 1995, by the third Coast Guard helicopter sortie using an infrared sensor. The body of the deceased passenger was found inside the cabin of the overturned helicopter at 0920, during salvage efforts.
Tests and Research
1. Forward Looking Infared Radar (FLIR)
The U.S. Coast Guard initiated a search upon notification that N2620 was overdue. The initial Search Rescue Unit (SRU) assigned was an Aerospatiale HH-65A "Dolphin" helicopter. This helicopter was diverted from another search, and was not equipped with Forward Looking Infrared Radar (FLIR) sensors.
The first helicopter began searching at 2111. The third helicopter sortie departed CGAS Houston at 0352, after delaying its launch while awaiting delivery of a hand held FLIR from the Coast Guard's Marine Safety Office in New Orleans.
This helicopter located the partially submerged wreckage at 0510 by means of the FLIR, 18 minutes after arriving on scene and beginning to search. The search continued throughout the night for the missing passenger, who was eventually located inside the submerged cabin.
2. Emergency Locator Transmitter (ELT)
No signal was received from the helicopters' Emergency Locator Transmitter (ELT). Neither pilot, nor the raft, had an emergency radio or an Emergency Locator Transmitter (ELT). The helicopter's ELT did not operate. It was mounted in the chin bubble, found full of water, and inoperable after recovery of the helicopter.
3. Night Vision Goggles (NVG's)
The captain of the accident helicopter, who was an Army National Guard pilot qualified on NVG's, stated that he saw the Coast Guard helicopter approaching from a distance, and since it did not have an external spotlight illuminated, he assumed that the crew "must have been searching on goggles." He had sufficient time to get out the copilot's survival light and wave it as the HH-65A approached. He stated that "I knew that if they were on goggles, I would have 'blasted them out of the sky' with our light."
The HH-65A overflew the survivors "so close that I could have read the numbers if it had been light, and they would have split me in half if they'd had a bandsaw." The HH-65A flew past the survivors, made several turns along the approach radial, and then departed. Both survivors were confident that if the Coast Guard helicopter pilots had been provided with NVG's, that they would have been located immediately.
Coast Guard Report Number CG-D-09-93, Evaluation of Night Vision Goggles (NVG) for Maritime Search and Rescue, resulted from a series of target acquisition tests performed by the U. S. Coast Guard, and provided the following factual information: The probability of detection (POD) for a person in the water equipped with a red safety light is 97% when the helicopter flies within 0.1 miles, and decreases to 67% at a range of 0.5 miles. The POD for a person in the water with a "firefly" ("firefly" was the make and model used in the tests) strobe light is 94% at 0.1 miles and decreases to 67% at 1.5 miles. This same report concludes, "Given the relatively poor search condition that prevailed on the night these data were collected, it is reasonable to expect that much larger helicopter/strobe sweep widths would be achieved in clear weather."
4. Avionics and Flight Instruments
Detailed inspection, disassembly, and testing were performed on the avionics, flight instruments, and aircraft wiring. No discrepancies were noted.