Flight Was Conducting Deer Survey For CA Fish And Game
The NTSB has released a factual report in a helicopter accident
which fatally injured four people last January. The initial
investigation found that the pilot may have been paying too much
attention to the deer, and missed seeing the powerlines which
brought the aircraft down. He also had a history of DUI
convictions, and had been issued a 2nd class medical only after
agreeing to abstain from alcohol or "mood altering chemicals."
On January 5, 2010, at 1209 Pacific standard time, a Bell
206B, N5016U, collided with power lines near Auberry, California.
The helicopter was registered to Palm Springs Aviation, Inc.,
d.b.a. Landells Aviation, and operated by the California Department
of Fish and Game (CDFG) as a public-use deer surveying flight. The
certificated commercial pilot and three passengers were killed. The
helicopter was substantially damaged by post crash fire. The local
flight departed Trimmer Heliport, Trimmer, California, at 1007.
Visual meteorological conditions prevailed at the accident site,
and a company flight plan had been filed.
The mechanic assigned to the helicopter drove up from Landells
Aviation the afternoon prior to the accident. He stated that the
pilot departed Landells in the helicopter about 1300, and arrived
at Trimmer at 1545. The mechanic then drove with the pilot for an
hour to their hotel. They then had dinner and the pilot retired to
his room about 2000. The mechanic reported that the following
morning they met in the hotel lobby at 0700; the pilot appeared
well rested, in a good mood, and his "normal self." They then drove
to Trimmer, arriving at 0900, and were greeted by the three CDFG
passengers. The mechanic then serviced the helicopter with the
addition of 38 gallons of fuel, for a total of 75 gallons. He then
checked the helicopter fluids, and removed the aft doors. The
mechanic stated that he observed the pilot then perform a preflight
inspection, followed by a briefing with the three passengers.
At the time of the accident, two witnesses, who were law
enforcement officers for the United States Forest Service (USFS),
were located on a north facing ridge at the confluence of Willow
Creek and the San Joaquin River. Both officers observed the
helicopter emerge from a valley to the north, and fly southbound
along Willow Creek and directly towards them. A set of power
transmission lines spanned the valley from the east to west. The
officers reported that the helicopter continued through the valley,
on a trajectory towards the power lines. As the helicopter came
within the immediate vicinity of the lines it reared back, and then
began an immediate descent, colliding with the ground. The officers
noted that prior to the accident, the helicopter was flying
straight and level, with the engine sounding, "normal and
A review of FAA airman records revealed that the
70-year-old pilot held a commercial pilot certificate with ratings
for airplane single-engine land, land, rotorcraft-helicopter,
instrument airplane, and helicopter. He additionally held a flight
instructor rating for airplane single and multi engine, and
instrument airplane. The pilot held a second-class medical
certificate issued on May 12, 2009, with limitations that he have
glasses available for near vision.
According to records provided by the Landells Aviation, as of
December 2009, the pilot had accumulated a total flight time in all
aircraft of 16,864 hours, of which 13,560 was in helicopters, with
3,369 in the Bell 206 series. The records also indicated that the
pilot had 47 years of flying experience, which included helicopter
emergency medical services (HEMS), search and rescue, aerial
survey, photography, mapping, and animal capture.
The pilot's total flight time for 2009 was 95.4 hours, and was
comprised of HEMS, fire suppression, sling, and survey missions,
all of which were flown in either the Bell 206 or Bell 222U. His
most recent flight prior to the accident was a deer survey mission,
which took place on December 23, 2009.
Two CFDG employees, who had last flown with the accident pilot
on deer surveying missions about 1 month prior to the accident both
reported that the pilot did not perform his usual pre-flight
briefing, but rather an abbreviated briefing followed by a reminder
to watch for obstructions in-flight. Additionally, during one
mission they noted that the pilot appeared to be, "trying too hard"
to observe deer. They became alarmed, and admonished the pilot
during the flight.
The helicopter, serial number 2634, was manufactured in
1979 and equipped with a Rolls-Royce/Allison 250-C20J gas turbine
A review of the helicopter's maintenance logbooks revealed that
the last inspection was for a 100-hour engine and airframe exam
dated October 30, 2009, at a total airframe time of 15,339.6 flight
hours. At that time, the engine was replaced. According to the
maintenance records, the replacement engine had a total time since
new of 6,675 hours. The last maintenance entry was for battery
service, and occurred the day before the accident at a total
airframe time of 15,376.4 hours. Later that day, the helicopter
flew for approximately 2.5 hours to Trimmer.
The helicopter was equipped with a wire strike protection
system. FAA records indicated that the system was manufactured by
Bristol Aerospace Limited, under supplemental type certificate
number SH4083SW. The wire strike protection kit was comprised of an
upper and lower fuselage deflector/cutter, and a serrated
windshield center post deflector channel.
The helicopter's equipment list referenced the installation of a
Trimble TNL 1000 Global Positioning System (GPS) receiver. The GPS
unit was destroyed by post-accident fire.
The helicopter was equipped with dual pedal controls, and single
right seat pilot controls for the cyclic and collective.
The closest aviation weather observation station was
Fresno Yosemite International Airport, Fresno, California, located
27 miles southwest of the accident site, at an elevation of 336
feet mean sea level (msl). An aviation routine weather report was
recorded at 1153, and stated: winds calm; visibility 2 miles with
mist; skies 600 feet overcast; temperature 6 degrees C; dew point 4
degrees C; altimeter 30.22 inches of mercury.
The USFS officers reported the weather conditions at the
accident site to be clear skies with a few high scattered clouds,
and light winds out of the north. They stated that the accident
site elevation was above the lower cloud layer in Fresno.
According to the United States Naval Observatory Astronomical
Applications Department, the altitude and azimuth of the sun in
Fresno at 1210 were 30.7 degrees and 181.4 degrees,
The helicopter was equipped with an Automated Flight
Following (AFF) system. According to Landells, the system was not
required per the CDFG contract, and was not being used at the time
of the accident.
An impact damaged Garmin III global positioning systems receiver
(GPS) was recovered from the accident site. The unit was sent to
the National Transportation Safety Board Office of Research and
Engineering for data extraction. Due to the damage sustained during
the accident sequence, flight track data could not be
Wreckage And Impact Information
The main wreckage came to rest in the Sierra National
Forest, within a heavily-wooded valley floor, 50 feet east of
Willow Creek at an approximate elevation of 1,200 feet msl. The
elevation of the valley peaks directly to the east and west of the
creek were about 2,500 feet.
The valley was spanned by two separate sets of intersecting
electrical power transmission lines, crossing diagonally over
Willow Creek adjacent to the main wreckage.
The first set of lines were on a southwest-northeast
orientation, and strung between two metal towers separated by a
span of about 2,900 feet. The tower to the east was 81-feet-tall,
with the tower to the west 95 feet. The base of the east tower was
located at an elevation of about 1,570 feet, with the west tower at
1,680 feet. The cables strung between the towers consisted of two
parallel steel 'skylines' at the top, and three 220,000 volt power
conductor lines mounted about 20 feet below. The power lines and
skylines exhibited differing degrees of droop such that their
vertical separation was about 70 feet at the midspan point. The
skyline to the south had severed approximately midspan,
subsequently becoming entangled in the remaining lower conductor
The second set of lines consisted of a group of 5 cables spanned
by two, 40-foot-tall wooden towers. The lines followed a
southeast-northwest orientation about 200 feet below the first set
of power transmission lines.
Neither of the sets of power lines were equipped with spherical
visibility markers, or similar identification devices.
The upper power lines were owned by Southern California Edison
(SCE). Examination of the severed skyline at the accident site
revealed it to be about 0.5 inches thick. According to a SCE
representative, the skylines were comprised of 7 strands of
high-strength steel wire. The conductor lines were 0.994 inches
thick, and comprised of 30 strands of aluminum, wrapped around 19
strands of steel.
The main wreckage, which consisted of the cabin, tailboom, and
tail rotor, came to rest inverted, 100 feet south of the upper
power transmission lines' midspan point. The entire cabin area had
been consumed by fire.
The debris field continued to the north and consisted of the
forward cowling, air filter assembly, pilot door, and segments of
The main transmission gearbox and mast were located about 300
feet north of the main wreckage. The main rotor assembly,
consisting of the 'red' blade, hub assembly, and inboard section of
the 'white' blade, came to rest on the adjacent banks of Willow
Creek, about 90 feet northwest of the main wreckage. A 4-foot-long
outboard section of the white main rotor blade was located 1,100
feet south of the main wreckage on a rocky outcropping beyond the
banks of the San Joaquin River.
The sun's position was reviewed 2 days following the accident
from a south-facing vantage point within the valley. The vantage
point closely matched the helicopter elevation noted by the
witnesses. At the accident time of day, the skyline appeared
partially obscured by the sun.
All major sections of the helicopter were accounted for at the
Medical And Pathological Information
An autopsy of the pilot was conducted by Pathology
Associates of Clovis, for the Madera County Sheriff's Department.
The cause of death was reported as right hemothorax, and
lacerations of heart, aorta, and pulmonary artery.
Toxicological tests on specimens from the pilot were performed
by the FAA Civil Aeromedical Institute. Analysis revealed no
findings for carbon monoxide, cyanide or ethanol. The results
contained the findings for doxylamine detected in the blood and
liver, and hydrocodone detected in liver. Refer to the toxicology
report included in the public docket for specific test parameters
The pilot had not reported the use of doxylamine or hydrocodone
on his most recent application for an airman medical certificate.
He did report the use of Celebrex, Prevacid, and Simvastatin.
FAA medical records revealed a prior conviction for driving
under the influence of alcohol (DUI) in 1982, which the pilot did
not report on his medical certificate application until 1992, when
he was subsequently convicted for a second DUI offense. In August
1992, he was issued a second-class medical certificate contingent
upon total abstinence from alcohol or mood altering chemicals.
In July 2001, the pilot's medical certificate application was
denied based on his intermittent use of Luvox to control Obsessive
Compulsive Disorder (OCD). The pilot was subsequently
psychiatrically evaluated, and it was determined that he did not
have OCD, but rather manifested a, "life-long pattern of compulsive
traits and perfectionist tendencies." The pilot then discontinued
the use of Luvox, and was issued a second-class medical certificate
in September 2001.
Tests And Research
The engine and airframe were recovered from the accident
site to a remote storage facility for further examination.
The engine sustained thermal damage during the post
accident fire, and as such, most ancillary components were
consumed. Fire damage prevented examination of all fuel lines, the
fuel controller, fuel pump, bleed valve, and power turbine
The accessory gearbox had become fire consumed, with only white
ash case remnants remaining. The associated gears remained in the
general vicinity of the gearbox. The gears exhibited thermal
distortion; the teeth for all observed gears remained intact.
Both exhaust outlets and the combustor case exhibited malleable
crush damage, and were free of internal dents. The compressor case
exhibited crush damage, and appeared bent about 10 degrees from the
centerline. The case appeared to impinge on the first and second
stage axial compressor wheels, the blades of which were noted bent
opposite the direction of travel. Six blades from the first stage
wheel had become liberated at the root.
Circumferential rub marks were noted to the seal of the sixth
stage compressor wheel, consistent with component rotation during
Examination of the turbine section revealed the fourth stage
wheel to be soot-covered and intact. The first stage wheel was
examined utilizing a borescope; the blades appeared intact and no
damage was noted. The fuel nozzle orifices appeared clear, and
displayed light sooting.
The entire cabin area including the flight controls and
cockpit instruments sustained heavy crush damage and subsequent
thermal exposure. The flight control servos, and their associated
control rods, had become fire consumed.
The main transmission gearbox remained attached to its mounts,
which had become separated from the fuselage assembly. The main
rotor mast remained attached to the gearbox, and had separated at
the hub. The fracture surface was on a 45-degree plane around the
mast circumference, and displayed granular features. Rotation of
the mast by hand resulted in rotation of the gearbox input
Both main rotor blade roots remained attached at the hub, with
the blades separated into five sections. The pitch link tubes
remained attached at the blade horns, but had become twisted and
separated about midspan. Examination of the blades revealed
serrated leading edge gouges, with upper and lower skin striations
consistent in appearance with the severed skyline.
The tail had become separated into two sections consisting of
tail rotor and gearbox assembly, and the center tailboom. The
remaining sections of the tail through to the fuselage had been
consumed by fire. The tail rotor assembly remained intact and
attached to the gearbox; rotation of the tail rotor by hand
resulted in rotation of the gearbox input shaft.
The air filter assembly appeared clear and free of
Examination of the airframe and engine did not reveal any
evidence of pre-accident failure or malfunction.
Wire Strike Protection System
The upper and lower wire cutter assemblies had sustained
varying degrees of thermal damage. Examination of the blade and
cutting surfaces revealed them to be free of scratches, nicks,
abrasions or any indication of cable contact.
Deer Survey Flight Procedures
A CDFG employee explained the general procedures for
conducting deer survey flights. He stated that the mission profile
is defined prior to the flight by a specialist who creates a route
based on the area of study. The area is bisected by a set of
parallel 'transect lines', which are then followed by the
A helicopter survey mission typically includes two 'spotters' in
the rear of the helicopter, with the pilot and a navigator in the
front seats. The pilot's responsibility is to fly the helicopter,
and see and avoid obstructions. The navigator's duties include
assisting the pilot with following the correct transect lines, as
well as spotting obstructions. When deer are observed, the spotters
call the position relative to the helicopter; the pilot then turns
the helicopter towards the deer while they are counted. Typically a
200-meter-wide 'window' is defined along the transect line for deer
observation. The helicopter will divert from the transect to
observe deer within this window. Once the deer are documented, the
helicopter returns to the original diversion point.
The CDFG employee reported that typically the pilot gives a
preflight briefing prior to the flights. The briefing includes
helicopter safety, and procedures for spotting and reporting aerial
A CDFG employee who had flown on previous deer surveying
missions revealed that she did not receive any formal safety or
operational training with regards to surveying missions, and that
she learned through, "on the job training." Another employee
reported that he was not aware of any formal surveying guidelines
explaining the duties of each person on board the helicopter, and
that no formal training regarding surveying flights was provided by
The CDFG contract with Landells Aviation makes reference to the
type of flying maneuvers required. In particular, the
specifications for helicopter services states, "Pilots and their
helicopters must routinely perform extremely low level and
intricate flying maneuvers. The work includes, but is not limited
to…flying close to the ground at variable speeds in
mountainous terrain…negotiating abrupt sharp turns in
response to animal movements…" With respect to survey and
census services, the contract further states, "Oftentimes, this
requires approaching the animal to within several feet and becomes
even more difficult when the animal is attempting to flee in an
erratic manner in mostly steep, mountainous terrain…Surveys
require the pilot to navigate the helicopter to a precise set of
coordinates, fly in a prescribed direction or pattern (transect) to
a predetermined location or distance while maintaining an altitude
generally 20 to 200 feet above the surface in through variable