Aircraft Accident/Incident Report

Susanville, California 96130
Thursday, March 21, 2002 13:35 PST

NTSB Narrative Summary Released at Completion of Accident

The helicopter collided with the surface of a glassy smooth lake while in cruise flight at low altitude. The purpose of the flight was to reposition the helicopter to the operator's base, after a patient delivery to a regional medical center. The approximate 10-miles in diameter lake is a shallow non-perennial body of water located about 11 miles east of the operators base. The wreckage was located about 2.5 miles from the east shore line and about 3.5 miles from the west shore. The lake is on a normal routing from the hospital to the operator's base. The flight nurse said he was sitting directly behind the pilot in a forward facing seat. He said that usually they crossed the lake about 500 feet above the surface, but this time they were much lower. He estimated that they had descended to within 20 to 50 feet of the lake surface, and, as they flew further out over the water they seemed to get lower and lower. He looked over the pilot's shoulder, and to the right, and noted how glassy smooth the water was. He stated that it was like a mirror and reflected the clouds and the sky perfectly, and was "kind of mesmerizing and disorienting" to see clouds both above and below with no distinct horizon. Just before they hit the water the pilot said on the intercom, "Boy, it's disorienting when the lake is this smooth." The nurse looked out the right side window at the distant shoreline and thought to himself that the flight seemed very, very low. The helicopter then hit the water. The flight nurse and paramedic medical crew members stated that there were no apparent mechanical malfunctions or failures with the helicopter prior to the collision with the lake surface. Examination of the extensively fragmented helicopter disclosed that all control system torque and push/pull tubes, and their associated rod end fittings, were accounted for. Scoring and other rotational evidence was noted on all drive system components.

NTSB Probable Cause Narrative

Failure of the pilot to maintain sufficient altitude/clearance above the water while performing a low altitude flight. Factors relating to the accident were the glassy water condition, and a lack of visual cues concerning perception of altitude.

Event Information

Type of Event Accident
Event Date 3/21/2002
Event Day of the Week Thursday
Time of Event 1335
Event Time Zone Pacific Standard Time
Event City Susanville
Event State CALIFORNIA
Event Country --
Zipcode of the event site 96130
Event Date Year 2002
Event Date Month 3
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 402237N
Event Location Longitude 1203423W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Full
Investigator's weather source Weather Observation Facility
Time of the weather observation 1356 Pacific Standard Time
Direction of event from weather observation facility (degrees) 127
Weather Observation Facility ID RNO
Elevation of weather observation facility 4412
Distance of event from weather observation facility (units?) 64
Time Zone of the weather observation PST
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height 15000
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) --
Air Temperature at event time (in degrees celsius) 20
Dew Point at event time (in degress fahrenheit) 6
Wind Direction (degrees magnetic) 110
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 8
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.02
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 1
Injury Total Minor --
Injury Total None --
Injury Total Serious 2
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 15303
NTSB Notification Source FAA
NTSB Notification Date Mar 21 2002 12:00AM
NTSB Notification Time 1610
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Apr 28 2004 3:34PM
User who most recently changed record NTSB\MONR
Basic weather conditions Visual Meteorological Cond
FAA District Office Reno, NV FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N1184H
NTSB Number LAX02FA114
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed Company VFR
Flight plan Was Activated? No
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Eurocopter
Aircraft Model AS-350B
Aircraft Series Identifier --
Aircraft Serial Number 1124
Certified Max Gross Weight 4520
Aircraft Category Helicopter
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 5
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Mar 5 2002 12:00AM
Airframe hours since last inspection 17
Airframe Hours 8139
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Pitt Helicopter, Inc.
Aircraft Owner Street Address 6100 Neil Rd. Ste 500
Aircraft Owner City Reno
Aircraft Owner State NV
Aircraft Owner Country USA
Aircraft Owner Zipcode 89511
Operator is an individual? No
Operator Name Dave Reger
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 700 Ash Street
Operator City Susanville
Operator State CA
Operator Country USA
Operator Zip code 96130
Operator Code ML6A
Owner has at least one certificate --
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Positioning
Second Pilot on Board --
Departure Point Same as Event No
Departure Airport Code NONE
Departure City Reno
Departure State NV
Departure Country USA
Departure Time 1300
Departure Time Zone PST
Destination Same as Local Flt --
Destination Airport Code SVE
Destination City Susanville
Destination State CA
Destination Country USA
Specific Phase of Flight Cruise
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Mar 4 2004 6:32PM
User who most recently changed record COOS
Since inspection or accident --
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight Yes
Medical Flight Discretionary