ASN Wikibase Occurrence # 21516
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| Date: | Sunday 29 June 2008 |
| Time: | 15:47 |
| Type: |  Bell 407 |
| Owner/operator: | Classic Helicopter Lifeguard |
| Registration: | N407MJ |
| MSN: | 53079 |
| Year of manufacture: | 1996 |
| Fatalities: | Fatalities: 4 / Occupants: 4 |
| Other fatalities: | 3 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | 0,5 mi from Flagstaff Medical Centre, Flagstaff, AZ -
 United States of America
|
| Phase: | Approach |
| Nature: | Ambulance |
| Departure airport: | Tusayan, AZ |
| Flagstaff, AZ (3AZ0) | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
On June 29, 2008, at 1547 mountain standard time, a Bell 407 emergency medical service (EMS) helicopter, N407GA, and a Bell 407 EMS helicopter, N407MJ, collided in mid air while approaching the Flagstaff Medical Center (FMC) helipad (3AZ0), Flagstaff, Arizona. Both helicopters were destroyed. N407GA's commercial pilot, flight nurse, and patient sustained fatal injuries; and N407MJ's commercial pilot, flight paramedic, flight nurse, and patient sustained fatal injuries.
Both Emergency Medical Services (EMS) helicopters were on approach to the Flagstaff Medical Center (FMC) helipad to drop off patients. During the flights, the N407MJ pilot had established two-way communications with his communications center and provided position reports, and the N407GA pilot had established two-way communications with FMC's communications center (which was his company's communication center and which also monitored and advised all traffic at the helipad) and provided position reports. The FMC communications center transportation coordinator advised the N407GA pilot that N407MJ would also be dropping off a patient at FMC. The coordinator also advised N407MJ's communication center that N407GA would be landing at FMC, but the N407MJ's communication center did not inform the N407MJ pilot nor was it required to do so.
Established arrival and departure procedures for the FMC helipad required pilots to contact the FMC communications center at the earliest opportunity or at a minimum of 5 miles from the helipad. According to the FMC communications center's staff, N407MJ's pilot did not make the required contact with the communications center at any time during the flight.
About 3 minutes before the collision, N407GA dropped off a medical crewmember at the local airport (about 5 miles south of the medical center) to reduce the weight on the aircraft and to improve aircraft performance during landing at the medical center. According to witness information, flight-track data, and a hospital surveillance video, N407GA approached the helipad from the south, flying past or slightly inside the southeast tip of the noise abatement area on a direct line toward a final approach position just east of the helipad. However, according to helipad arrival guidelines and company procedures, N407GA should have approached the helipad from farther to the east. (After the on-scene accident site investigation, the Air Methods regional chief pilot, accompanied by NTSB investigators, flew the accident route in another Air Methods Bell 407 using GPS data retrieved from N407GA. According to the regional chief pilot, the “trained route” was much farther to the east and not in a direct line to the hospital.) N407MJ approached the helipad from the northeast, and it is likely that the pilot would have been visually scanning the typical flight paths, as described in the noise abatement and helipad arrival guidelines, that other aircraft approaching the medical center would have used. Thus, if N407GA had approached from a more typical direction, the pilot of N407MJ may have been more likely to see and avoid it.
At the time of the collision, both pilots were at a point in the approach where their visual attention typically would have been more focused on the helipad in preparation for landing, rather than on scanning the surrounding area for other traffic. The helicopters collided approximately 1/4 mile east of the helipad. There were no communications from either helicopter just prior to or after the collision.
Neither helicopter was equipped with a traffic collision avoidance system, nor was such a system required. Had such a system been on board, it likely would have alerted the pilots to the traffic conflict so they could take evasive action before collision. No radar or air traffic control services were available for the helipad operations to ensure separation. However, if N407MJ's pilot had contacted the FMC communications center, as required, the FMC transportation coordinator likely would have told him directly that another aircraft was expected at the helipad. If the pilot had known to expect another aircraft in the area, he would have been more likely to look for the other aircraft.
Nevertheless, the pilots were responsible for maintaining vigilance and to see and avoid other aircraft at all times. Under 14 Code of Federal Regulations Sections 91.111 and 91.113, all pilots are responsible for keeping a safe distance from other aircraft and for maintaining vigilance so as to see and avoid other aircraft. Advisor
Probable Cause: Both helicopter pilots’ failure to see and avoid the other helicopter on approach to the helipad. Contributing to the accident were the failure of N407GA’s pilot to follow flight arrival route guidelines, and the failure of N407MJ’s pilot to follow communications guidelines requiring him to report his position within a minimum of 5 miles from the helipad.
Sources:
NTSB
Location
Images:
(c) NTSB
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 29-Jun-2008 22:39 | JINX | Added |
| 30-Jun-2008 10:07 | harro | Updated |
| 30-Jun-2008 23:39 | harro | Updated |
| 01-Jul-2008 15:07 | JINX | Updated |
| 17-Jul-2008 10:24 | Fusko | Updated |
| 15-Jan-2009 11:04 | harro | Updated |
| 30-Jun-2009 12:15 | harro | Updated |
| 01-Mar-2013 10:35 | TB | Updated [Time, Location, Source, Narrative] |
| 21-Dec-2016 19:14 | ASN Update Bot | Updated [Time, Damage, Category, Investigating agency] |
| 21-Dec-2016 19:16 | ASN Update Bot | Updated [Time, Damage, Category, Investigating agency] |
| 21-Dec-2016 19:20 | ASN Update Bot | Updated [Time, Damage, Category, Investigating agency] |
| 03-Dec-2017 11:19 | ASN Update Bot | Updated [Operator, Total fatalities, Total occupants, Other fatalities, Departure airport, Destination airport, Source, Narrative] |
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