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ASN Wikibase Occurrence # 34466
Last updated: 29 November 2019
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Date:15-OCT-2008
Time:23:58
Type:Silhouette image of generic B222 model; specific model in this crash may look slightly different
Bell 222
Owner/operator:Air Angels Inc
Registration: N992AA
C/n / msn: 47062
Fatalities:Fatalities: 4 / Occupants: 4
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:Aurora, IL -   United States of America
Phase: En route
Nature:Ambulance
Departure airport:Sandwich, IL (0LL7)
Destination airport:Chicago, IL (40IS)
Investigating agency: NTSB
Narrative:
The emergency medical services (EMS) helicopter was on a night cross-country flight in visual meteorological conditions and was transporting an infant patient from one hospital to another when the accident occurred. During the flight, the pilot contacted DuPage Airport’s (DPA) air traffic control (ATC) facility, reported the helicopter's position and altitude of 1,400 feet above mean sea level (about 700 feet above ground level in Aurora, Illinois) to the air traffic controller, and asked permission to pass through the airspace surrounding the airport. The controller acknowledged the transmission and cleared the helicopter through DPA’s airspace but did not give the pilot specific instructions regarding his flight route because the pilot was flying under visual flight rules and had chosen his specific route of flight on a direct course from the departure point to the destination. (During preflight planning, the pilot should have identified the obstacles along the route of flight, including the radio station tower.) Subsequently, the helicopter struck a radio station tower while flying at the same altitude that had been reported to ATC. Video and still image evidence obtained during the investigation indicated that the strobe lights attached to the radio station tower were operational at the time of the accident.

The accident helicopter was not equipped with a terrain awareness and warning system (TAWS). TAWS detects terrain or other obstructions along the flightpath and provides pilots with an alert to take corrective action. On February 7, 2006, the National Transportation Safety Board (NTSB) issued Safety Recommendation A-06-15, which asked the Federal Aviation Administration (FAA) to require EMS operators to install terrain awareness and warning systems on their aircraft and to provide adequate training to ensure that flight crews are capable of using the systems to safely conduct EMS operations. The FAA responded that, while it would work with industry to address issues related to the installation of TAWS on EMS aircraft, it would address the issue of controlled flight into terrain by emphasizing effective preflight planning. The FAA further stated that the Radio Technical Commission for Aeronautics established a committee tasked with developing helicopter TAWS (H-TAWS) standards and that, in March 2008, the commission completed the development of minimum operational performance standards for H-TAWS. On December 17, 2008, the FAA published Technical Standard Order C194, “Helicopter Terrain Awareness and Warning System,” based on the commission standards. On January 23, 2009, the NTSB indicated that the continuing delays in development of a final rule to require H-TAWS were not acceptable. Pending issuance of a final rule to mandate the installation and use of TAWS on all EMS flights, Safety Recommendation A-06-15 was classified “Open—Unacceptable Response.” On November 4, 2009, the FAA responded by indicating that it was developing a notice of proposed rulemaking (NPRM) to address this recommendation and that it planned to complete work on the NPRM in January 2010; the NPRM had not been issued as of March 2010. On November 13, 2009, the NTSB reiterated Safety Recommendation A-06-15 in its report regarding the September 27, 2008, accident involving an Aerospatiale SA365N1, N92MD, operated by the Maryland State Police, which crashed during approach to landing near District Heights, Maryland. Safety Recommendation A-06-15 is on the NTSB’s Most Wanted List of Transportation Safety Improvements.

The radio station tower was depicted on the Chicago Aeronautical Sectional Chart, the Chicago Visual Flight Rules Terminal Area Chart, the Chicago Helicopter Route Chart, and as an obstruction on the air traffic controller’s radar display. Radar data obtained during the investigation showed the helicopter at a constant altitude and on a straight course to the point of impact with the tower.

The radar information was available to the air traffic controller. Additionally, the position and height of the tower were included
Probable Cause: The pilot's failure to maintain clearance from the 734-foot-tall lighted tower during the visual night flight due to inadequate preflight planning, insufficient altitude, and a flight route too low to clear the tower. Contributing to the accident was the air traffic controller's failure to issue a safety alert as required by Federal Aviation Administration Order 7110.65, “Air Traffic Control.”


Vice Chairman Hart did not approve this probable cause and filed a dissenting statement. The statement can be found in the public docket for this accident.

Sources:

NTSB: https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20081016X94016&key=1


Revision history:

Date/timeContributorUpdates
16-Oct-2008 10:00 harro Updated
23-Jul-2012 22:20 Anon. Updated [Destination airport, Source, Narrative]
30-Nov-2012 03:55 TB Updated [Time, Phase, Destination airport, Source, Narrative]
03-Dec-2017 12:09 ASN Update Bot Updated [Time, Other fatalities, Departure airport, Destination airport, Source, Narrative]

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