Holy COW! The chain of pilot errors in this NTSB report

Jaybird180

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Jaybird180
In addition to all this, some low-life scumbag pillaged the wreckage site for helicopter parts prior to recovery efforts. UNBELIEVABLE!!!

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Helo Pilot In 2010 Fatal Accident In Georgia Tested Positive For Medications
NTSB Factual Report Shows Two Substances FAA Says Are 'Not Appropriate' For Use While Flying
The NTSB has released a factual report in a 2010 accident in Georgia in which the pilot of a Robinson R44 (N34JS) and his passenger were fatally injured. On August 2 1900 EDT, the helicopter collided with mountainous terrain while maneuvering near Blood Mountain, Blairsville, Georgia. Instrument meteorological conditions (IMC) prevailed around the accident site, and no flight plan was filed for the flight which departed Madison Municipal Airport (52A), Madison, Georgia, about 1830, and was destined for the Brasstown Valley Resort, Young Harris, Georgia. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91.
R44 File Photo

The flight originated from West Palm Beach, Florida, early on the morning of the accident date. According to fuel receipts, fuel was purchased for the accident helicopter at 1809, at 52A. In a telephone interview, the airport manager said that the pilot purchased fuel, advised the resort by telephone of his pending arrival, boarded the helicopter and departed. When the helicopter did not arrive as expected, a search was initiated, and an Alert Notice (ALNOT) was issued on August 4, 2010. The wreckage was located from the air by the Civil Air Patrol on August 6, 2010.
In a telephone interview, a friend of the pilot stated that the purpose of the flight was to attend a motorcycle racing event in Georgia. The friend owned the Robinson Helicopter sales and service center where the pilot/owner of the accident helicopter purchased and maintained his helicopter. He said the pilot had asked him to go along on the trip, but he couldn't due to a prior commitment. According to the friend, "He asked me to go and I told him, 'You really need mountain experience before you go.' I gave him a few pointers, but there was no talking him out of it. He called me Monday morning (August 2, 2010) or Sunday and asked me a few more questions about flying through the mountains. He didn't give me the route of flight. I just knew he was going to the motocross nationals."
In a telephone interview, a witness who lived about 8 miles south of the accident site stated that she heard a small helicopter approach her house and went outside to watch, as she "loved" airplanes and helicopters. She said she was unable to see the helicopter as it passed, because her view was blocked by trees. She said the helicopter passed by between 1800 and 1900, and that the sound of the helicopter was smooth and continuous.
PERSONNEL INFORMATION
The pilot was issued a private pilot certificate with a rating for rotorcraft-helicopter on September 28, 2009. The pilot's logbook was not recovered and his total flight experience could not be determined. His most recent FAA second class medical certificate was issued in May 2009. He reported 11 hours of flight experience on that date.
AIRCRAFT INFORMATION
According to FAA records, the helicopter was manufactured in 2006. A review of the helicopter's maintenance logbooks revealed its most recent annual inspection was completed February 26, 2010, at 299.4 total aircraft hours.
METEOROLOGICAL INFORMATION
At 1853, the weather conditions reported at Lee Gilmer Memorial Airport (GVL), 31 miles south of the accident site, at 1,276 feet elevation, included scattered clouds at 1,600 feet and an overcast ceiling at 2,500 feet. The visibility was 5 miles in haze, the temperature was 26 degrees C, the dew point 23 degrees C, and the altimeter setting was 30.10 inches of mercury. The winds were from 120 degrees at 3 knots.
According to a Safety Board senior meteorologist, AIRMET Sierra update number 4 was current over the area that encompassed the route of flight and the crash site for mountain obscuration conditions. GOES-13 visible satellite images from over the accident site around the time of the accident depicted an area of low stratiform clouds that extended over the area, and supported the AIRMET for mountain obscuration.
According to the Lockheed Martin Office of Quality Assurance, the pilot did not request a weather briefing nor file a flight plan prior to the accident flight.

WRECKAGE INFORMATION
The helicopter was examined at the site on August 7, 2010, and all major components were accounted for at the scene. The accident site was located on steep, mountainous, heavily wooded terrain, about 3,100 feet elevation, below the peak of Blood Mountain, which rose to 4,436 feet elevation. The initial impact points were in trees that stood about 6 feet apart, and were perpendicular to the direction of flight. The scars on the trees were consistent with a 200-degree direction of flight, approximately parallel with the ridge.
The downhill tree displayed a large, almost rectangular scar, about 18 inches tall and 12 inches wide. The uphill tree was scarred at the same elevation, with a deep, horizontal slash about the same dimension as the leading edge of a main rotor blade.
The main rotor hub and blade assembly, with the swashplate and support assembly attached, was located at the base of the first trees struck. One rotor blade was intact but impact damaged. The other blade was fractured and separated about 5 feet outboard of the hub. The rotor blade fragments, including the tip with tip weight attached, were accounted for farther down the wreckage path.
The initial ground scar was about 30 feet beyond the first tree strikes on a rock slope of about 60 degrees. The fall line was oriented about 090 degrees. The remainder of the helicopter was scattered down slope over a distance of about 170 feet. The tail section, with the vertical fin, tail rotor gear box, tail rotor assembly, and tail rotor driveshaft were about 100 feet below the initial ground scar. These components were impact and fire damaged. One tail rotor blade appeared severely fire-damaged. The skin was intact, but split along the trailing edge, and the core of the blade appeared consumed by fire.
The main fuselage, with the engine, transmission, and tail boom attached, came to rest against a tree about 40 feet below the tail section. The components were heavily damaged by impact and post crash fire. Control continuity could not be established, but all breaks were consistent with overload or fire damage. All of the flight instruments located were either completely destroyed, or provided no useful information.
A detailed examination of the wreckage could not be conducted at the site due to terrain, and was scheduled for a later date.
The wreckage was recovered from the site by helicopter on November 12, 2010. The complete tailrotor, tailrotor gearbox, and the empennage were stolen from the site prior to recovery. The tail rotor driveshaft was cut with a saw, forward of the gearbox, to affect the theft. A detailed examination of the remaining wreckage was conducted in Griffin, Georgia on November 18, 2010.
The examination revealed that all airframe and component damage was due to impact and fire. The engine could not be rotated due to impact, fire, and corrosion damage. Several holes were drilled in the crankcase halves, and the powertrain and valve train were examined by borescope. The borescope examination revealed no evidence of abnormal wear or pre-impact mechanical anomaly. The engine cooling fan scroll inlet lip displayed rotational scoring.
The main transmission displayed impact and fire damage, and continuity was established through the input drive to the main mast. Flight control continuity could not be established due to impact, fire, and missing components.
MEDICAL AND PATHOLOGICAL INFORMATION
The Division of Forensic Sciences, Georgia Bureau of Investigation, for the State of Georgia, performed the autopsy on the pilot in Decatur, Georgia. The autopsy report indicated that the pilot died as a result of “traumatic injuries…due to helicopter crash.”
The autopsy noted that the pilot had greater than or equal to 60% occlusion of unnamed cardiac vessels. It could not be determined if the pilot would have had any symptoms from his coronary artery disease and thus it cannot be determined if the condition posed a significant hazard to flight safety.
The FAA’s Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of the pilot. Tissue specimens from the pilot tested positive for bupropion, diphenydramine, and phentermine.
Bupropion is an antidepressant medication used to treat major depressive disorder and seasonal affective disorder. At least one brand of bupropion (Zyban) is used to help people stop smoking by reducing cravings and other withdrawal effects.
Diphenhydramine is an antihistamine that blocks the effects of the naturally occurring chemical histamine in the body. Diphenhydramine is used to treat sneezing; runny nose; itching, watery eyes; hives; rashes; itching; and other symptoms of allergies and the common cold.
Phentermine is a stimulant that is similar to an amphetamine. Phentermine is an appetite suppressant that affects the central nervous system. According to the FAA, Bupropion and Phentermine were not appropriate for use while flying. It could not be determined whether the pilot's use of medications posed a significant hazard to flight safety.
The pilot's medical and pharmacology histories could not be established. Numerous records requests were made to the pilot's psychiatrist, with no response. A subpoena was then issued July 15, 2011, received, and signed for on July 19, 2011, with no response. When a follow-up telephone call was made, it was learned that the psychiatrist's practice was closed, and the telephone had been disconnected. Efforts to locate the psychiatrist were unsuccessful.
According to the pilot's May 11, 2009, Application for Airman Medical Certificate, FAA Form 8500-8, Item 17, "Do You Currently Use Any Medication (Prescription or Nonprescription)?" the pilot responded that he did not. Further, Item 18, "Have you ever in your life been diagnosed with, had, or do you presently have any of the following? (m) "Mental disorders of any sort, depression, anxiety, etc." the pilot again responded that he did not.
A review of pharmaceutical records revealed that the pilot had filled prescriptions from his psychiatrist for a wide range of anti-depressant, anti-anxiety, sleep, and stimulant medications, as well as heart medication, for years prior to his application for an FAA medical certificate.
 
Sadly, people will decide that this means small aircraft are unsafe.

Sadder still is that he took someone else with him. :(
 
Reading ntsb reports are a good way to reinforce preflight and decision making. Its usually a series of events that cause the pilot error crashes.
 
Half the time I read them I'm thinking, "Thank God I'm not that dumb". This is one of that half. This wasn't just a series of miscalculations, it sounds more like the pilot was a tragedy looking for a place to happen.
 
yeah it sounds like that was quite a drug cocktail as well. A stimulant, anti-depressant and an antihistamine that makes you drowsy.

That's kinda like taking anti-diarrhea medicine and a laxative at the same time. No one in their right mind would do this but you can imagine the fight they'd be having in there :p
 
This one reads more like a continuous lifestyle than a series of definable events.

It scares me more that we all share the roads with many many more just like him in our cars than it bothers me that he ran his helicopter toy into cumulo-granite.

Prescription drug abuse, signs of manic depressive behavior for years. Etc.

A good story embedded in there kinda... At least his enabler told him the helicopter he sold him would kill him if he didn't have the proper training.
 
This one reads more like a continuous lifestyle than a series of definable events.

+1

It scares me more that we all share the roads with many many more just like him in our cars than it bothers me that he ran his helicopter toy into cumulo-granite.

No kidding. Last week I flew the Aztec up to another airport where I had to fly an airplane simply because there ahd been some bad weather the night before, and the road I have to drive to get to this other airport is a rather unsafe road (in my opinion) when everything is perfect. I will take flying over driving any day, especially in bad weather.

A good story embedded in there kinda... At least his enabler told him the helicopter he sold him would kill him if he didn't have the proper training.

There was a Lancair a few years ago that had a stall-spin into OSH. The Lancair-approved instructor (it was from their official training group, HPAT I think it is) told the pilot "Please don't fly your plane to OSH. You're not ready, you will kill yourself."

Much the same - no talking him out of it. He found out that the instructor was, in fact, correct. :(
 
ran his helicopter toy into cumulo-granite.

+111

Thankyouthankyou. Cumulogranite just gave me a nice hearty belly-laugh.

Agree with the rest of the comment, too. Antideps can definitely mess up your ability to function in an emergency, because they take the edge off your strongest reactions. I know, I was on them for about 3 months a few years back when my world felt like it was collapsing around me.

Interestingly, when I put that fact on my medical request, the medical examiner was convinced it would disqualify me, especially coming on top of my insulin-dependent diabetes. But the FAA asked for clarification, I provided that it was a set of rather disheartening circumstances that led to a short spell on those meds, and they said "fine". Sure, a process, but I'm glad they asked because it forced me to think about it before i even sat in the left seat for my first lesson.
 
What dangers are there of flying a heli in the Georgia mountains? Doesn't seem like it would be much of an issue to me? Why was the friend so excited over it? Doesn't seem to me that an R44 would have much of an issue getting over any of humps in Georgia? Wouldn't you just... Go over them?
 
Yes reading accident reports is great safety training. When I took flying 20 years ago, before the internet, I subscribed to several publications that were nothing more than accident investigations.

With the internet now, they're available for free and I try to read them from time to time. Like an earlier poster said, about half of them involve things that are so dumb that I wouldn't even do them.

Thanks for posting this.
Doc
 
What dangers are there of flying a heli in the Georgia mountains? Doesn't seem like it would be much of an issue to me? Why was the friend so excited over it? Doesn't seem to me that an R44 would have much of an issue getting over any of humps in Georgia? Wouldn't you just... Go over them?

It would seem to me the danger is running into them. In this case, that seemed to be an accurate danger.
 
It would seem to me the danger is running into them. In this case, that seemed to be an accurate danger.

I mean I understand if you're in an under powered plane, flying in the rockies there are some considerations but a R44 on a XC mission in the Georgia Mountains? I'm assuming the weather had something to do with it but I'm wondering what precautions need to be taken when mtn flying an R44 in Georgia over say just flying over a corn field in Iowa? Looks to me like you stick the ole altimeter on 5,500+ and don't worry about it?
 
Considering the source I'm sure it's all a conspiracy and forgery.
 
The bit about the tail rotor being stolen - that makes me want to play devils advocate and wonder if there was perhaps some kind of non-compliant work done on the tail at some point, and someone "in the know" was trying to dispose of incriminating evidence.

I'm familiar with at least one other accident where this was determined to be the cause of missing parts from the scene.
 
Understanding the way the world works, I'd say the surviving family is going to sue the heck out of Robinson for this one.
 
I mean I understand if you're in an under powered plane, flying in the rockies there are some considerations but a R44 on a XC mission in the Georgia Mountains? I'm assuming the weather had something to do with it but I'm wondering what precautions need to be taken when mtn flying an R44 in Georgia over say just flying over a corn field in Iowa? Looks to me like you stick the ole altimeter on 5,500+ and don't worry about it?

The flight at 5,500+ is pretty unusual for helicopter pilots. Perhaps the training would have involved just that - going up to altitude. Coming from Florida, he may never have gone more than 500' off the ground.
 
That's nothing compared to the self-medicating doctor in (you guessed it) a bonanza who crashed in the northeast a while back.

When I read about folks who knowingly mix drugs or alcohol and flying I just hope they don't take other people with them, and I hate that they destroy airplanes. But as far as killing themselves... I tend towards the "Go, Lemmings, GO!" philosophy.
 
one that happened just north of here a few years back.

The aircraft took off in dark night smoky conditions during early morning hours. The purpose of the flight is unknown and the flights destination is unknown. Prior to daylight, the aircraft collided with transmission lines about 40 feet above ground level. Three lines run between towers and the aircraft severed one line, while the remaining two lines showed signs of impact damage. The aircraft came to rest inverted below the lines. Toxicological analysis was positive for high levels of ethanol in blood (0.190%), urine (0.472%), and vitreous (0.239%). Tetrahydrocannabinol (the primary active substance in marihuana) was detected in blood. Oxazepam, a prescription tranquilizer, was detected in blood and urine.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

The pilot's failure to maintain clearance from an object while maneuvering and alcohol impairment. Transmission wires, dark night conditions, and drug impairment were factors.
 
Read up on MIA02FA106, especially the "Additional Information" at the end of the narrative.

http://dms.ntsb.gov/aviation/AccidentReports/b3s5snzivv4qwz45zygtcz551/V12152011120000.pdf

Wow, never read one like that before.

National Transportation Safety Board personnel did not have an opportunity to discuss the circumstances of the accident with the pilot due to the fact that he was fatally injured in an airplane accident the following morning at approximately 0822 hours, which was approximately 10 hours 52 minutes after the helicopter accident or 5 hours 47 minutes after being released from the hospital.

:rolleyes2:
 
Wow, never read one like that before.

National Transportation Safety Board personnel did not have an opportunity to discuss the circumstances of the accident with the pilot due to the fact that he was fatally injured in an airplane accident the following morning at approximately 0822 hours, which was approximately 10 hours 52 minutes after the helicopter accident or 5 hours 47 minutes after being released from the hospital.

:rolleyes2:

And the probable cause from that second crash: "The suicidal act by the pilot resulting in the in-flight collision with trees then the ground. A contributing factor in the accident was the pilot's depression. Findings in the investigation were the pilot's overdose of zolpidem and citalopram before the accident flight departed, and his intentional operation of the airplane while impaired by alcohol."

Man.
 
I mean I understand if you're in an under powered plane, flying in the rockies there are some considerations but a R44 on a XC mission in the Georgia Mountains? I'm assuming the weather had something to do with it but I'm wondering what precautions need to be taken when mtn flying an R44 in Georgia over say just flying over a corn field in Iowa? Looks to me like you stick the ole altimeter on 5,500+ and don't worry about it?

How's he going to get the altimeter to 5,500 when the weather was "scattered clouds at 1,600 feet and an overcast ceiling at 2,500 feet"??
 
How's he going to get the altimeter to 5,500 when the weather was "scattered clouds at 1,600 feet and an overcast ceiling at 2,500 feet"??

I figured in this incident, weather was a factor, but from reading it, it sounded like the guy who didn't go got all excited about him flying in the mountains. I wouldn't think there is much in Georgia an R44 couldn't just... Go over? For an XC mission. Maybe the guy was excited about the weather but it didn't read that way to me.
 
I figured in this incident, weather was a factor, but from reading it, it sounded like the guy who didn't go got all excited about him flying in the mountains. I wouldn't think there is much in Georgia an R44 couldn't just... Go over? For an XC mission. Maybe the guy was excited about the weather but it didn't read that way to me.


Going over means he would have had to punch through the 2500' overcast deck. Obviously this means IFR and the R44 isn't certified for that. The 44 can get up past 9000AGL so clearing the ridges wouldnt have been a problem. Getting through the deck would have been.
 
Going over means he would have had to punch through the 2500' overcast deck. Obviously this means IFR and the R44 isn't certified for that. The 44 can get up past 9000AGL so clearing the ridges wouldnt have been a problem. Getting through the deck would have been.

I understand that and that pertains to this particular instance. I was asking a more general question because the guy that didn't go seemed to imply there were precautions to take when flying in the Georgia mountains and it did't come across to me like he was talking about weather. Perhaps my question wasn't very clear. Aside from crappy weather, which kills VFR pilots in Iowa too. What is there to get excited about when flying an R44 with a service ceiling of 14,000' in a state who's tallest rock is < 5,000'. I'm well aware of the dangers of flying a 150 HP Cherokee in the Montana and Idaho backcountry, none of which would seem to apply to flying a cross country flight in Georgia, other than say engine out procedures in mountainous terrain.
 
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I really think this not so much of a list of errors as is it simply VFR into IMC. Coming from a arrogant pilot which most Vfr's into IMC are.
 
I understand that and that pertains to this particular instance. I was asking a more general question because the guy that didn't go seemed to imply there were precautions to take when flying in the Georgia mountains and it did't come across to me like he was talking about weather. Perhaps my question wasn't very clear. Aside from crappy weather, which kills VFR pilots in Iowa too. What is there to get excited about when flying an R44 with a service ceiling of 14,000' in a state who's tallest rock is < 5,000'. I'm well aware of the dangers of flying a 150 HP Cherokee in the Montana and Idaho backcountry, none of which would seem to apply to flying a cross country flight in Georgia, other than say engine out procedures in mountainous terrain.

His friend cautioned him against flying due to lack of experience with mountain flying. I presume he had none but his logbook could not be recovered to determine that.
 
His friend cautioned him against flying due to lack of experience with mountain flying. I presume he had none but his logbook could not be recovered to determine that.

I know, that's what I'm asking... WHY? What is there to be cautious about in the Georgia mountains in a vehicle that can not only hover but fly 10,000' higher than the highest point in the state? What should he have known but didn't. I go over 9,000'+ peaks all the time in my Cherokee and I wouldn't call that mountain flying.
 
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