DFW05MA230
DFW05MA230

HISTORY OF FLIGHT

On September 6, 2005, about 1605 central daylight time (all times referenced in this report are central daylight time), the flight crew of a Sikorsky S-76A helicopter, N90421, registered to and operated by Houston Helicopters, Inc. (HHI), executed a forced landing into the open waters of the Gulf of Mexico about 24 miles southeast of Sabine Pass, Texas, after a loss of power to both engines. Both pilots and all 10 passengers were able to evacuate the helicopter before it submerged. All occupants wore personal flotation devices (PFD) to keep them afloat during the 7.5 hours that passed before they were rescued. (HHI's Operation Specifications [OpsSpec] require that crewmembers and passengers wear PFDs during flight.) Seven of the passengers sustained minor injuries, and three of the passengers and the captain and first officer sustained serious injuries. The on-demand air taxi flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 135. Visual meteorological conditions prevailed at the time of the accident.

The captain and first officer arrived at HHI's hangar in Pearland, Texas, about 0600 to begin duty. The pilots' first flight of the day departed about 0645. The accident flight was the 14th in a series of flights between various offshore oil rigs to provide scheduled crew changes for the Rowan Drilling Company. (At the time of the accident, the captain and first officer had been on duty for more than 10 hours and had completed 13 landings.)

According to the accident pilots, the flight to the Bob Keller oil rig (the departure point for the accident flight) was uneventful. After landing, the first officer exited the helicopter to help deplane the passengers and then board the passengers for the accident flight to Sabine Pass, which was about 100 miles north of the oil rig. The accident flight departed about 1545. The first officer was the flying pilot, and the captain was performing the duties of the pilot monitoring.

About 1603, as the helicopter was in cruise level flight, about 1,500 feet above the water, the pilots noticed that the Smoke Detector Baggage Warning light had illuminated. Subsequently, the No. 1 Engine Fire Warning light illuminated and tone alerted, and the captain took over control of the helicopter. Immediately thereafter, the No. 1 Engine Low Fuel Pressure and the No. 1 Engine Chip Detector Caution lights illuminated. The pilots stated that, at this time, they noted visible grayish-black smoke within the cockpit and passenger compartment areas.

The captain stated that, as he turned the helicopter about 20 to 25 degrees to the north toward a nearby oil rig platform, the No. 1 engine lost all power. According to the cockpit voice recorder (CVR) transcript, at 1604:01, the captain instructed the first officer to lower the landing gear; the first officer complied with the captain's instruction. (The CVR was recovered from the helicopter before the wreckage was lost because of a hurricane.) Three seconds later, the first officer stated, "the floats are armed." Within 8 seconds, the No. 2 Engine Out Warning alerted. The captain stated that he entered the helicopter in an emergency autorotation to the surface of the water and then instructed the first officer to "get a mayday out." At 1604:29, the first officer transmitted the following on emergency frequency 121.5: "mayday, mayday, mayday, anyone on this frequency? This is Houston four two one." The CVR transcript indicated that, when asked to go ahead by the pilot of "aircraft 542" (a military aircraft flying near the helicopter at the time of the transmission), the first officer stated, "roger we're going in." The pilot of aircraft 542 asked the location of the helicopter twice, but each time, the first officer replied, "standby." The CVR recording ends 31 seconds after the mayday call.

The captain stated that, when the helicopter was about 25 feet above the water, the main rotor blades stopped turning, and the helicopter descended vertically. Subsequently, the right side of the helicopter impacted the water in a nose-low attitude. Both pilots and the 10 passengers evacuated the helicopter before it completely submerged. The helicopter sank before the two emergency liferafts, which were stored under the first row of passenger outboard seats, could be removed by the crew and passengers.

PERSONNEL INFORMATION

Captain
The captain, age 59, held an airline transport pilot (ATP) certificate with airplane single- and multiengine land ratings and commercial privileges for rotorcraft-helicopter. The captain held a first-class Federal Aviation Administration (FAA) airman medical certificate, dated December 9, 2004, with the limitation that he "must wear corrective lenses."

The captain was hired by HHI in 1991 as a contract pilot to fly Bell 206 and S-76A helicopters. HHI records indicated that he qualified as a captain for the S-76A on May 15, 1992. HHI did not maintain a record of the dates or hours that the captain flew for the company. Pay stubs and expense report records revealed that the captain flew for HHI in November 2001, January and February 2002, June 2004, and August 2005. His most recent training record was dated 2001.

A review of the captain's logbooks from January 1 to September 2, 2005, revealed that, during this period, he logged 263.5 total flight hours, 19.1 hours of which were in helicopters (all helicopter flights logged were local flights from/to the Pearland Heliport facility in the Gulf of Mexico) and 15.3 hours of which were in the S-76A (5.6 hours on July 19; 1.0 hour on July 29; and 8.7 hours on September 2, 2005). A search of the FAA's Enforcement Information System (EIS) revealed no records pertaining to the captain. A review of the captain's medical records did not reveal any noteworthy issues.

The captain reported that he did not work in the 3 days before the day of the accident. He stated that he received at least 12, 12, and 10 hours of sleep on the fourth, third, and second nights, respectively, before the accident and about 7 hours of sleep the night before the accident.

First Officer
The first officer, age 51, was hired by HHI as a full-time employee on June 15, 2005. He held an ATP certificate with a helicopter-rotorcraft and instrument helicopter rating. The first officer held a second-class FAA airman medical certificate, dated November 1, 2004, with the limitation that he "must possess corrective lenses that correct for near and intermediate vision."

According to HHI records, the first officer received flight training in the U.S. Army from 1983 to 1998. From 1998 to August 2004, he worked for DynCorp as a helicopter mechanic and an aviation instructor, and, from September 2004 to May 2005, he worked as a helicopter pilot for another Gulf of Mexico operator. He qualified as a second-in-command on the S-76A on July 14, 2005.

According to HHI flight and duty time records from June 15 to August 23, 2005 (flight and duty time records were not provided for the remainder of August or September), the first officer received Part 135 training from June 15 to 17, 2005, and started completing flights on June 20. HHI records indicated that he accumulated about 29.1 total flight hours, 2.9 hours of which were in the accident helicopter. (He logged 4.4 hours of flight time in June, 19.7 hours in July, and 5.0 hours in August 2005). A search of the EIS revealed no records for the first officer. A search of the first officer's medical records revealed no noteworthy issues.

The first officer reported that he did not work the second and third days before the accident. He stated that he worked as the radio dispatcher for HHI on the day before the accident from 0600 to 1700. He reported that, on the night before the accident, he attended an evening class at a local college and then went to bed no later than 2330. On the morning of the accident, he woke up about 0445.

HELICOPTER INFORMATION

The accident helicopter was a Sikorsky Aircraft twin-engine, four-bladed, single-rotor helicopter. The helicopter was equipped with two Rolls Royce Allison gas turbine 250-C30S engines. The helicopter was certified to carry up to 13 passengers and 1 pilot under visual flight rules (VFR) and 12 passengers and two pilots under instrument flight rules (IFR) and had a maximum takeoff gross weight of 10,500 pounds. At the time of the accident, the estimated gross weight of the helicopter was 10,039 pounds.

The helicopter was equipped with a caution advisory panel, which was mounted in the center of the flight instrument panel between the pilots, and two master caution warning panels, one of which was mounted in front of each pilot on the front instrument panel. When smoke in the baggage compartment is detected, the Smoke Det(ection) Baggage Warning light on the caution advisory panel illuminates, and the Master Caution Warning light on the two master warning panels also illuminates. When an engine fire is detected, the Engine Fire Warning lights illuminate; the light for the affected engine (which is on the T-handle located on the engine throttle quadrant above and in front of the pilots) illuminates and a continuous 250-Hertz aural tone alerts in both pilot headsets. According to the Sikorsky S-76A Flight Manual, the emergency procedures for responding to an engine compartment fire include pressing the Engine Fire Warning light (to reset the fire warning tone), establishing safe single-engine flight (76 knots), fully retarding the illuminated T-handle, and, if necessary, selecting and activating the fire extinguishing system. The pilots completed the first step of this procedure.

The helicopter was equipped with a crew-activated flotation system designed to keep the helicopter upright and afloat for sufficient time to permit occupants to evacuate. When the helicopter impacted the water, the floats on the right side of the helicopter burst.

METEROLOGICAL INFORMATION

The closest official weather observation station was located at the Scholes International Airport, Galveston, Texas, located about 60 miles southwest of the accident site. On September 6, 2005, about 1652, an automated weather observation system reported, in part, the following: Wind, 080 degrees at 15 knots; visibility, 10 miles; ceiling and clouds, clear; temperature, 88 degrees Fahrenheit; dew point, 68 degrees Fahrenheit; altimeter, 30.05 inches of mercury.

FLIGHT RECORDERS

The helicopter was equipped with a CVR. The helicopter was not equipped, and was not required to be equipped, with a flight data recorder.

WRECKAGE AND IMPACT INFORMATION

According to the accident pilots, the helicopter impacted the water about 24 miles southeast of Sabine Pass. The helicopter wreckage subsequently sank in the Gulf of Mexico, in 40- to 50-feet deep water, with strong underwater current activity. An extensive underwater search effort was initiated, and the helicopter wreckage was subsequently located, and the CVR was recovered. However, an approaching hurricane in the area prevented the recovery of the helicopter wreckage. After the hurricane had passed, recovery crews returned to the last known site, but they were unable to locate the wreckage.

SURVIVAL ASPECTS

Safety Briefing
The HHI Standard Operating Procedures Manual, dated 2005, states that all passengers must be briefed before flight on company aircraft. The manual also states that printed cards supplementing the briefing and applicable to the aircraft must be available to the passengers during flight. The briefing should be in accordance with 14 CFR 135.117, "Briefing of passengers before flight" [a] [6], which requires that, before each takeoff, the pilot ensure that all passengers have been orally briefed on ditching procedures and the location of required flotation equipment and that the oral briefing be supplemented with a printed card located in a convenient location for passenger use and contain instructions necessary for the use of emergency equipment on board the aircraft. The regulation also addresses, in part, seat belts, entry and emergency exits, and fire extinguishers and survival equipment. Although the first officer stated in postaccident interviews that he had asked the passengers if they had received a safety briefing and that they had replied, "yes," passengers stated in postaccident interviews that they did not receive a safety briefing before the accident flight.

Occupant Evacuation
During the impact with the water, the floats on the right side of the helicopter ruptured, and the helicopter rolled to the right and partially submerged. Both pilots and the 10 passengers evacuated the helicopter before it completely submerged. The last passenger to evacuate the cabin was almost entirely under water when he pulled himself through the left cabin doorway, which was facing skyward. Both pilots reported that the helicopter sank before they were able to remove the two emergency liferafts. Passengers reported that they did not know where the liferafts were located.

Before each flight, HHI provided each pilot and passenger with a PFD, each of which is equipped with a rescue light. Eight of the passengers and the two pilots reported that their PFDs inflated when they pulled the inflation chord and that five of the PFD rescue lights illuminated and five of them did not illuminate. (Investigators were unable to contact two of the passengers despite numerous attempts to do so.) The occupants were in the water for 7.5 hours before they were rescued, and several of the passengers sustained hypothermia.

Communications Regarding the Overdue Helicopter
The pilots did not file a flight plan with the FAA, and no air traffic control (ATC) facilities in the accident area had any specific information about the helicopter or its operations in the Gulf of Mexico. However, a review of ATC communications from air traffic facilities in the area and situation reports and event logs from the U.S. Coast Guard (USCG) and the U.S. Air Force revealed that, from 1605 to 1620, numerous commercial and military flight crews reported that they heard a "mayday" transmission on emergency frequency 121.5. The flight crews reported that they did not have any information about the flight, including its tail number or location, because the information was not provided in the "mayday" transmission. Further, none of the reporting pilots were able to make contact with the flight. The only pertinent information about the distressed helicopter was provided by the pilot of Omaha 44, located 125 nautical miles northeast of Corpus Christi, Texas, who reported that he heard, "421. . .going in."

About 1606, the Conroe Automated Flight Service Station (AFSS) in-flight controller relayed the information from the commercial flight transmissions to the San Angelo AFSS, Houston Air Route Traffic Control Center (ARTCC), and law enforcement agencies throughout southeastern Texas. About 1613, the Houston ARTCC provided this information to the Air Force Rescue Coordination Center (AFRCC), and the FAA Southwest Regional Operations Center (SW ROC). Further, the Polk County Sheriff Office was dispatched to the location of a possible incident about 30 miles south of Lufkin.

About 1621, another flight crew advised the Houston ARTCC that they had heard "Houston 421" on the emergency frequency stating that he was "going in." Ten minutes later, the Houston ARTCC notified the SW ROC about a possible aircraft going down near Lufkin. About 1658, the Houston ARTCC was contacted by Navy Corpus Christi Base Operations on behalf of the flight crew of Omaha 44 to ask whether there was any closure on the "mayday" call. Houston ARTCC replied that there was still no confirmed position but that second-hand information indicated that the aircraft in distress might have been operating about 30 miles south of Lufkin.

About 1749, the AFRCC contacted the Houston ARTCC to ensure that it was continuing to solicit information regarding the location of the distressed aircraft. About 1834, the owner of HHI called the Conroe AFSS to ask whether the radio communications air-to-ground (RCAG) outlets in the Gulf of Mexico were operational (The FAA maintained a network of five very-high frequency [VHF] RCAG sites with collocated remote communications outlets [RCO] on offshore platforms) and to report that he was having trouble locating one of his aircraft. (At the time of the accident, HHI manuals did not contain a formal procedure for reporting an overdue aircraft. However, one pilot stated that the informal procedure was for the radio dispatcher to notify the chief pilot, who would inform the director of operations, who would inform the owner of HHI.) The Conroe AFSS confirmed that the two RCAGs were out of service, and the owner reported that his company radio was also out of service.

About 1919, an HHI operations employee called the USCG in Galveston, Texas, to report the overdue helicopter and to provide information about the helicopter, including information about its emergency equipment and its departure and expected arrival times and locations. About 1925, the HHI operations employee contacted the Conroe AFSS to report that HHI's helicopter, N90421, was overdue and not in communication with the company and that he had contacted the USCG. The Conroe AFSS subsequently notified Houston ARTCC, USCG, AFRCC, and the FAA SW ROC of the overdue aircraft.

Search-And-Rescue Operations
Shortly after 1920, the USCG Galveston requested permission from the USCG regional headquarters in St. Louis, Missouri, to ready USCG search-and-rescue personnel, aircraft, and marine vessels to respond to the suspected location of an overdue helicopter. About 1940, the USCG Galveston also requested that a Falcon 20 jet stand by at the Coast Guard Air Station (CGAS) in Corpus Christi, Texas, and that a USCG HH-65 (Dauphin) helicopter stand by at Sabine Pass. The USCG Galveston subsequently issued an Urgent Marine Information Broadcast (a general call to all surface and air operators) in the Gulf of Mexico regarding the overdue helicopter and contacted the FAA for additional information.

About 1950, the USCG Galveston contacted the Conroe AFSS and was told that six commercial pilots had reported hearing a "mayday." Subsequently, the USCG Galveston received a call from an Allied Drilling (Allied Drilling was the company responsible for transporting Rowan employees from the Bob Keller platform) technician who stated that the helicopter had departed the oil rig at 1545 with 2 pilots and 10 passengers on board. In response to the information provided by the FAA and the Allied Drilling technician, the USCG Galveston ordered two USCG cutters to search the waters and a Falcon 20 airplane and two HH65 Dauphin helicopters to begin planning the search-and-rescue operations for N90421. About 2023, USCG Galveston called CGAS Corpus Christi to launch a search-and-rescue flight. About 2053, the Falcon 20 was en route to the suspected location of the downed helicopter. (During postaccident interviews, the USCG stated that it took about 30 minutes to plan and gear up for a search-and-rescue launch and that the timing for the accident launch was typical.)

According to the Falcon 20 pilot, the airplane was cruising at 1,500 feet above ground level (agl), doing a grid pattern, and searching the Gulf of Mexico with no visibility (no moon light). He stated that the right seat observer was wearing night vision goggles and that they were using an infrared camera to pick up the body heat of the survivors in the water. He stated that the right seat observer spotted a "dim light" in the water and that they then descended to 500 feet agl and made several passes before they located the survivors in the water about 2124.

About 2125, the USCG diverted HH 6535, which was en route to a staging area in the Gulf of Mexico, to the coordinates where the survivors were found. About 2149, HH 6535 dropped a rescue diver in the water to help the survivors and picked up and flew five of them to Sabine Pass. The first group of survivors reached Sabine Pass about 2212 and were then transported to local hospitals. About 2240, HH 6535 rescued three more survivors, and, about 2325, HH 6587 transported the remaining four survivors to Sabine Pass.

According to USCG Galveston, about 2140, an off shore supply vessel (OSV) in the vicinity of the survivors called the USCG and offered its assistance and later acted as a lee (blocking the waves for the survivors) during the rescue. Also, two other OSVs and a ram charger vessel offered assistance to the USCG but were turned away when HH 6587 arrived to rescue the remaining survivors.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

According to the Air Operator Data Sheet, dated September 7, 2005, HHI was certified on September 24, 1990, as an on-demand air carrier. A review of the company's Operations Manual revealed that the director of operations had the ultimate responsibility for operational control over company aircraft and/or flight crews, including control and authority of the initiation, conducting and termination of Part 135 flights, and flight locating. The director of operations could delegate this authority to the chief pilot.

HHI Flight-Following Procedures At the Time of the Accident
The pilots did not file a flight plan with the FAA nor communicate directly with FAA air traffic controllers or with the HHI radio dispatcher as required by company guidelines. HHI's OpsSpec referred to the Operations Manual, dated March 15, 2004, revision 2, for details about flight plan and flight-locating procedures. The Operations Manual stated that no flights could be conducted unless the operation was covered by an activated flight plan or the company flight locating system. (If filing with HHI dispatch was not possible, the crew was to file a flight plan with an FAA AFSS.) The plans were to include no less than the aircraft identification, point and time of departure, destination, estimated time of arrival, and total number of persons and fuel on board. For flights to remote areas, the pilot was to file and leave the itinerary with the home base and make every effort to contact them with any deviations. HHI's OpsSpec required pilots to contact the radio dispatcher, who was responsible for overseeing flight plans and tracking flight progress according to these plans, before loading, in 15-minute intervals while en route with time and distance to destination, and upon arrival. When shut down at any location, pilots were to check in with HHI dispatch by telephone or radio every hour.
If the home base had not received activation from the pilot within 15 minutes after the estimated departure time, the home base was to initiate overdue flight procedures. As noted, at the time of the accident, the Operations Manual did not contain specific procedures on reporting overdue flights. Since the accident, HHI's guidance has been amended to include specific overdue aircraft notification procedures and the timing for their implementation.

The pilots at HHI shared the duty of radio dispatcher on a rotational schedule. When in close range of the home base, HHI pilots would announce their departure or arrival to the radio dispatcher directly. Outside this range, pilots would communicate with the radio dispatcher by using the remote site closest to them. If outside the range of any remote site, pilots would attempt to communicate with the home base through another en route HHI pilot. If necessary, they also had the option to contact pilots of other operators on their discrete frequencies.

The HHI Training Manual, approved on October 24, 2005, outlined the flight-following and locating procedures to be covered in both initial and recurrent training for airmen. This included flight-locating system and procedures; organizations, duties, and responsibilities; weather and notice to airmen information; company communications; types of flight plans; flight plan posting and closing; and overdue aircraft. Further, The HHI Training Program Manual, dated April 8, 2003, required S-76 pilots to review FAA operating procedure guidelines and information from the HHI Operations Manual, including flight-locating and -following procedures.

HHI Postaccident Flight-Following Procedures
On September 12, 2005, HHI's OpsSpec was amended to reflect new flight-following and -locating procedures. The OpsSpec stated that the certificate holder shall use only the following flight-locating procedures for all flights: (a) before takeoff, the pilot-in-command (PIC) must first file and activate a VFR flight plan with an FAA AFSS for each separate flight leg; (b) the PIC is prohibited from operating on an air carrier flight without an activated flight plan until their actual arrival at the destination airport or other landing location; (c) the PIC shall not take off on an air carrier flight if they cannot comply with these procedures; and (d) it is recommended that the PIC should make a position report at least every 15 minutes and no later than 60 minutes to an FAA AFSS. The HHI Operations Manual was also amended after the accident to include specific guidance regarding the use of proposed flight plans and company radio operator/dispatcher duties and responsibilities.

HHI Communications Network
Before Hurricane Katrina occurred on August 19, 2005, HHI's communication system consisted of a base radio with a limited VHF range and a minimum altitude range of about 800 to 1,000 feet. HHI contracted with a vendor to install and maintain nine transceivers throughout the Gulf of Mexico. At the time of the accident, only four transceivers had been installed and verified, and the range was limited and significant gaps in coverage existed. Most HHI pilots interviewed reported that they thought that the communications system before Hurricane Katrina was acceptable, albeit frustrating. Some felt that, together with the poor radio equipment, the system was unacceptable.

Because of extensive damage caused by Hurricane Katrina, at the time of the accident, neither HHI's transceivers and cellular towers nor the AFSS RCO sites in the area were functioning. The communication lost was not unique to HHI. Other Gulf offshore helicopter operators secured alternate means for their pilots to communicate with their base operations. Houston Flight Standards District Office (FSDO) staff surveyed a subset of Gulf of Mexico operators for compliance with flight-following procedures. The survey revealed that some operators were using "repeater" aircraft, which are aircraft that fly over the area and relay calls from the helicopter to base, or issuing satellite telephones. HHI was not one of the operators surveyed. The FAA assumed that, because other operators had developed alternate methods of communication to comply with flight-following requirements, HHI had done the same. The principal operations inspector (POI) did not follow up specifically with HHI to inquire about its methods of conducting flight following. According to the chief pilot and director of operations at HHI, although the other operators offered to include HHI on this joint effort, HHI declined on account of the expense. Further, at the time of the accident, HHI pilots had not been issued cellular or satellite telephones for company use.

During postaccident interviews, HHI pilots stated that, because the management did not offer any solutions, the pilots spoke amongst themselves to determine their options for communicating with base operations. They reported that they had no other option but to attempt to communicate with the company at the start and completion of flights only and that they could do so using personal cell phones or by asking oil rig/platform personnel or other airborne pilots to contact the company on their behalf. One pilot stated that he was told by management to use his cell phone despite the fact that many of the cell towers were not in service. HHI pilots reported that they believed that declining to follow through with the flights was not an option despite the lack of a reliable communication method.

Maintenance Information
The maintenance records for the accident helicopter were reviewed for any maintenance writeups or work conducted on the engines. The most recent writeup was dated September 1, 2005, and indicated that a quart of oil had to be added to each engine. A note stated that, after 1.5 flight hours, an additional quart of oil had to be added to the No. 1 engine. As a result, the No. 1 engine's starter/generator was replaced because of a bad seal and o ring.

Because the pilots and passengers reported that only about half of the PFDs' lights worked, Safety Board staff reviewed the maintenance records and manuals for the PFDs. HHI's inspected their PFDs quarterly and documention of the inspection was stored in the canvas cover pocket of each PFD. The HHI repairman who inspected and repaired the PFDs followed the inspection and repair instructions in the life preserver component maintenance manual (CMM), dated May 1985. The CMM stated that it was acceptable to repair broken wires, but, if a battery was swollen or damaged, the battery assembly should be replaced. The current CMM, dated June 2005, stated that all damaged battery assemblies must be replaced, and the manufacturer of the PFDs stated that a damaged battery with loose or disconnected wires must be discarded and replaced with new rescue light and battery assemblies.Examinations of the 11 recovered PFDs revealed that the rescue light batteries in five of the PFDs were missing the top of the battery and had been altered with shrink-wrap that secured the electrical wires to the battery. One of the five altered batteries was found with the wires disconnected from the battery. None of the rescue lights illuminated during postaccident salt-water immersion tests; however, when the PFD with the disconnected battery was reconnected and immersed in salt water, its rescue light illuminated.

Federal Aviation Administration Oversight
According to the FAA Operations Work Program for HHI, developed in 2004, there were 4 required surveillance items and 43 planned surveillance items to be carried out by the POI in fiscal year 2005. The required surveillance items included a review of manual procedures, training program, and dispatch records, and to conduct a ramp check. At the time of the accident, all of the required fiscal year 2005 surveillance items for HHI were completed.

In February 2005, the POI, who accepted responsibility for HHI in January 2005, recorded HHI's lack of adherence to flight-locating procedures. In July 2005, the POI, principal maintenance inspector (PMI), and FSDO management identified, in part, the following issues that needed to be addressed at HHI for fiscal year 2006: emergency drills training (passenger briefing cards and inadequate rotors turning briefings) and flight-locating and -following procedures for dispatchers. (These issues were first identified in 2003 as a result of the February 16, 2003, accident involving an HHI Bell 407. See National Transportation Safety Board accident brief No. FTW03FA097 and the section titled, "Previous Accidents," in this brief report for more information.) In August 2005, the POI tried to suspend operations at HHI until several issues related to the company's training program and manuals were addressed. However, HHI received an extension from the Houston FSDO manager, and the company received another extension on the morning of the accident.

On March 10, 2006, the PMI responsible for inspecting HHI's repair station visited the HHI repair station at the Safety Board's request and found eight PFDs with unapproved electrical repairs identical to the altered accident PFD batteries. The PMI stated that the Airworthiness Inspector's Handbook, FAA Order 8300.10, recommended that he focus on verifying inspection dates and the documentation of repairs. The PMI did not think that he was required to observe repairs, and, therefore, he did not visually inspect HHI's stock of PFDs before the accident. However, Order 8300.10, Chapter 2, "Conduct Spot Inspection of Operator's Aircraft" states, "emphasis should be placed on ‘observing' maintenance tasks, and persons performing inspections outside the authorization or limitations and items not being properly identified or accomplished." Further, Chapter 131, Part E, "Inspect the Operator's Technical Library," recommends that PMIs ensure that all required technical data are available and current.

ADDITIONAL INFORMATION

Previous Accidents
Information regarding HHI's history of incidents, accidents, and violation enforcements from 1979 to the date of the accident was obtained from the Houston FSDO. Including the current accident, 21 accidents (including 5 fatal accidents) and 13 incidents involving aircraft operated by HHI occurred during this period. (Also during this period, 44 FAA violation enforcements were recorded, and 8 additional violations have been recorded from the accident date to December 7, 2006, including four maintenance violations, two records and reports violations, one drug testing violation, and one flight operations violation.)

One of the accidents occurred on February 16, 2003, and involved an HHI Bell 407, operating as a Part 135 on-demand air taxi flight, which experienced a catastrophic engine failure 5 minutes from its intended destination. About 1225, the pilot transmitted a "mayday" call, citing an engine failure and his intention to land the helicopter on the water. The pilot autorotated and ditched the single-engine turbine helicopter into the Gulf of Mexico. The pilot and four passengers survived the initial ditching and safely evacuated the helicopter; however, before the occupants were rescued 2 hours later, the pilot and one passenger drowned. The remaining three passengers sustained serious injuries.

According to the surviving passengers, the pilots did not brief the passengers about the location of the liferaft, and the liferaft was not deployed during the evacuation from the submerged helicopter.

Safety Recommendations Issued as a Result of this Accident
In response to this accident and 62 other helicopter accidents and incidents in the Gulf of Mexico since 2000, the Safety Board issued Safety Recommendations A-07-87 and -88 on October 19, 2007. Safety Recommendation A-07-87 asked the FAA to require that all existing and new turbine-powered rotorcraft operating in the Gulf of Mexico and certificated for five or more passenger seats be equipped with externally mounted liferafts large enough to accommodate all occupants on board the rotorcraft. Safety Recommendation A-07-88 asked the FAA to require that all flight crewmembers operating rotorcraft in the Gulf of Mexico provide their flight crews with PFDs equipped with a waterproof global-positioning-system-equipped 406-megahertz personal locator beacon, as well as one other signaling device, such as a signaling mirror or strobe light.

Further, on February 3, 2009, the Safety Board issued Safety Recommendation A-09-001, which asked the FAA to ensure that all offshore helicopter operators in the Gulf of Mexico comply with a communication contingency plan that supports continued adherence to required flight-following procedures in the event of a catastrophic incident that interferes with standard operations.

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