Aircraft Accident/Incident Report

Doyle, California 96109
Saturday, November 14, 2009 2:01 PST

NTSB Narrative Summary Released at Completion of Accident

Ten minutes after dropping off a patient at the local hospital and while returning to home base in dark night conditions, the flight crew made a routine position report. About 8 minutes later, the flight crew transmitted that the helicopter was going down. Radar data indicated that after departure from the hospital, the helicopter initiated a climb from about 4,500 feet mean sea level (msl) and established a northwesterly course. In the vicinity of the accident site, the target indicated a climbing turn to the northeast followed by a turn to the southwest, and then a climbing turn back to the northeast. The last two targets indicated a turn to the right. The last recorded altitude was at 10,200 feet msl. On-site documentation of the wreckage suggested that the helicopter was in a nose-low attitude and about a 90-degree bank angle when it contacted the ground. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. A study of the weather conditions in the vicinity of the accident site indicated clouds were present with tops reaching about 13,000 feet msl. Light clear icing was present with the potential for moderate clear icing in or near clouds. Visibility was at or greater than 10 statute miles. Given the helicopter’s flight path shortly before the accident, it is likely that the pilot was maneuvering to avoid clouds and became disorientated in the dark night conditions, which resulted in a loss of helicopter control.

NTSB Probable Cause Narrative

The pilot became spatially disoriented while maneuvering on a dark night, which resulted in a loss of helicopter control.

Event Information

Type of Event Accident
Event Date 11/14/2009
Event Day of the Week Saturday
Time of Event 201
Event Time Zone Pacific Standard Time
Event City Doyle
Event State CALIFORNIA
Event Country --
Zipcode of the event site 96109
Event Date Year 2009
Event Date Month 11
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 395105N
Event Location Longitude 1202100W
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 --
Investigator's weather source Weather Observation Facility
Time of the weather observation 155 Pacific Standard Time
Direction of event from weather observation facility (degrees) 150
Weather Observation Facility ID KRNO
Elevation of weather observation facility 4415
Distance of event from weather observation facility (units?) 25
Time Zone of the weather observation PST
Lighting Conditions Night/Dark
Lowest Ceiling Height 5500
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 4
Dew Point at event time (in degress fahrenheit) -4
Wind Direction (degrees magnetic) 320
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 5
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.95
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 3
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 31518
NTSB Notification Source FAA NW Regional Operations Cen
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Jun 19 2013 1:13PM
User who most recently changed record coos
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N5793P
NTSB Number WPR10FA055
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed Company VFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name AEROSPATIALE
Aircraft Model AS350BA
Aircraft Series Identifier --
Aircraft Serial Number 1476
Certified Max Gross Weight 4630
Aircraft Category Helicopter
Aircraft Registration Class --
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 Continuous Airworthiness
Date of Last Inspection Nov 13 2009 12:00AM
Airframe hours since last inspection 18
Airframe Hours 5895
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type Unknown
Aircraft Owner Name Mountain Lifeflight
Aircraft Owner Street Address 471-920 Johnstonville Rd
Aircraft Owner City Susanville
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 96130
Operator is an individual? No
Operator Name Mountain Lifeflight
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address 471-920 Johnstonville Rd
Operator City Susanville
Operator State CA
Operator Country USA
Operator Zip code 96130
Operator Code --
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
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 No
Departure Point Same as Event No
Departure Airport Code --
Departure City Reno
Departure State NV
Departure Country USA
Departure Time 144
Departure Time Zone PDT
Destination Same as Local Flt --
Destination Airport Code SVE
Destination City Susanville
Destination State CA
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jun 19 2013 1:13PM
User who most recently changed record coos
Since inspection or accident Last Inspection
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight Yes
Medical Flight --