Eurocopter Deutschland GMBH MBB-BK 117 C-2 accident near Danville, Pennsylvania, February 14, 2013

The NTSB's narrative final · quoted from the NTSB record

The pilot reported that, as the helicopter approached mountainous terrain near the hospital during a helicopter emergency medical services (HEMS) flight, he turned the helicopter slightly right to pass through a gap in the ridgeline and then continued to fly directly to the heliport. The pilot then radioed that he was "3 minutes out." About this time, the medical crew intubated the patient, and the communications center advised the pilot that two people were on the roof to assist him. He then observed two individuals on the rooftop helipad, which, "while not abnormal," was "not routine." He was "a bit concerned" because he wanted to make sure the personnel were clear of the helipad before landing. The pilot recalled that he was somewhat more attuned to the patient's condition because the medical crew was working hard to keep the patient alive and was moving around the cabin unrestrained. He continued descending the helicopter on a straight-in approach and began the final approach to the rooftop helipad. About 100 yards from touchdown, he noticed something "orange" out of the left window. At almost the same time, the flight paramedic mentioned that he also "saw something orange." The pilot then felt a "slight low frequency vibration," which was also noticed by the flight nurse. About 6 seconds later, he landed the helicopter on the helipad, executed an emergency shutdown, and then cleared the crew to exit. A contractor who was operating a construction crane near the heliport reported that he was lowering a piece of equipment onto the roof of a building when he observed a helicopter approaching. Another contractor then observed one of the helicopter's blades contact the flag marker, which was mounted on the top of the construction crane boom, and "pieces of wood and flag…flying all over the place." Examination of the helicopter confirmed that the main rotor had contacted the flag marker and that one of its blades was substantially damaged. According to the pilot, neither he, the flight nurse, nor the flight paramedic had seen the construction crane before the helicopter contacted it while approaching the helipad. Review of photographs taken after the accident revealed that the pilot's straight-in approach to the rooftop helipad passed over the location of the construction crane, which was positioned next to a nearby building. Flight crews had been notified of the construction crane's position 2 days before the accident, and the pilot believed that he had briefed the crew about the presence of the construction crane at the medical center. According to the notification, the crane was to be in position between about 0700 to 1000 local time and was going to have a beacon on top because of the proximity of the helipad. However, no beacon was installed, and the crane was still in use and in position 2 hours 21 minutes after the notification advised that the work was supposed to be completed. No evidence was found indicating that the continued operation of the construction crane nor its presence was transmitted to the flight crewmembers when the flight was approaching the hospital. The investigation revealed that the communications technician was on the rooftop helipad at the time of the accident, not at her duty station manning the radio. The investigation also revealed that another helipad, which was located at ground level and was not near the construction crane, was available at the time of the accident and could have been used for the landing. If the pilot had been provided with correct information about the construction crane's operation time and its presence or if he had used the available ground-level helipad, he would have been more likely to have avoided the crane. However, if the pilot had followed the guidance in the company's general operations manual, which required that a high-orbiting reconnaissance be completed before beginning the approach and that all published helicopter procedures for the heliport and helipad be observed (which in the case of the rooftop helipad designated a left traffic pattern), the accident could have been prevented. Instead, the pilot flew a straight-in approach, which placed the helicopter's flightpath near the construction crane, restricted his ability to see due to sun glare, and placed the helicopter in a position that obstructed his view of the construction crane, which would have been behind the instrument panel as the helicopter approached the rooftop helipad. The National Transportation Safety Board has previously cited time pressure as a risk factor in HEMS flights. Due to the patient's critical condition, the pilot likely felt a sense of urgency to land, which influenced his decision to fly a straight-in approach to the rooftop helipad rather than to conduct a high-orbiting reconnaissance before initiating the approach. Although attempts are generally made to isolate HEMS pilots from the patient's condition while making go/no-go decisions, once onboard, it is difficult for pilots to be unaware of serious medical conditions that may be time critical, which leads to self-induced time pressures.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

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