The founder and president of a charter operation succumbed to self-induced pressure to complete the flight of a Mayo Clinic doctor to procure a heart for transplant when he flew his Bell 206B into instrument meteorological conditions (IMC) and crashed, the U.S. National Transportation Safety Board (NTSB) says.
The pilot, the doctor and a medical technician were killed when the helicopter struck the ground near Green Cove Springs, Florida, at 0554 local time on Dec. 26, 2011.
In its final report on the accident, the NTSB attributed the crash to “the pilot’s improper decision to continue visual flight into night [IMC], which resulted in controlled flight into terrain.”
The report cited as a contributing factor the pilot’s self-induced pressure, which stemmed largely from millions of dollars in financial losses related to the downturn in the national economy and the knowledge that the Mayo Clinic — his largest customer — had been “identifying other aviation companies that might better fulfill its needs.”
Therefore, the report added, “the pilot would have been highly motivated to complete trips as requested so that he could demonstrate the reliability of his service. … The pilot likely wanted to make the most of every revenue-generating opportunity.”
The pilot received a call from a company scheduler about 0335 informing him of the clinic’s request for a flight from the Mayo Clinic Heliport in Jacksonville to Shands Cair Heliport in Gainesville, about 60 nm (111 km) southwest. A few minutes later, he reviewed weather reports for airports along the flight route, and at 0423, he arrived at Northeast Florida Regional Airport (SGJ) in St. Augustine.
He left SGJ about 0517 for Jacksonville and arrived about 0530 after an uneventful repositioning flight. He picked up his two passengers and departed, contacting air traffic control at 0549. Over the next few minutes, the helicopter’s altitude varied from 450 to 950 ft above ground level, with calibrated airspeed between 100 and 110 kt.
The last three radar returns indicated that the helicopter had turned right about 45 degrees and descended about 300 ft, nearly on a direct course to Shands Cair. The accident site was about 0.5 nm (0.9 km) south of the last radar return.
When the helicopter failed to arrive at Shands Hospital, it was reported overdue, and search and rescue operations began. The wreckage was found about 1000 in a remote wooded area.
Founder, President and Pilot
The 68-year-old pilot — also the founder, president, owner and director of operations of SK Jets — had learned to fly when he was 16 and held an airline transport pilot certificate with ratings for single- and multi-engine airplanes, and a commercial pilot certificate and flight instructor certificate with ratings for rotorcraft and instrument helicopter. He had 11,343 flight hours, including 3,646 hours in helicopters and 1,648 hours in Bell 206s. His total time included 3,288 hours of night experience and 3,259 hours of instrument experience. He had flown 10.7 hours, including 3.1 hours at night, in the 90 days before the accident and 2.5 hours, including one hour at night, in the 30 days before the accident; none of that flying involved instrument time. He did not fly during the seven days before the accident.
He had been the pilot of an earlier accident flight involving an Agusta A109 that departed from St. Augustine on Dec. 22, 2007, and was cut short because of a 400-ft ceiling and 2.5-mi (4.0-km) visibility. The helicopter was substantially damaged when its tail rotor struck trees during the return to the fuel pump area. The accident was not reported to the NTSB until Jan. 15, 2008, and the agency noted conflicting reports on whether it occurred during the helicopter’s approach to the departure airport or while taxiing.
“According to current and former employees at SK Jets, a different helicopter pilot had turned down the flight due to the poor weather,” the report added. “Following that accident, the [accident] pilot successfully completed an FAA reexamination.”
The accident helicopter was manufactured in 1979 and had accumulated 11,173 total hours. The helicopter was maintained in accordance with an FAA-approved manufacturer’s maintenance program, and its last inspection before the accident was completed Dec. 1. It was flown 3.5 hours after that inspection before the accident.
The Rolls-Royce (Allison) 250-C20B turbine engine had accumulated 11,054 hours total time and 167 hours since an overhaul in 2005, when it was installed.
The helicopter was not certified for instrument flight rules flight and not equipped with a radio altimeter or autopilot. It had a global positioning system (GPS) receiver and a VHF omnidirectional range unit that provided localizer and glideslope indications, but the GPS had not been upgraded to provide terrain/obstacle warnings.
There was no indication that the pilot had contacted a U.S. Federal Aviation Administration (FAA) Flight Service Station for weather information before the flight, but his laptop computer had been opened to an aviation weather website, indicating that he had viewed aviation routine weather reports and terminal area forecasts (TAFs) for the airports along his planned flight route. The service he used was not among those approved in SK Jets operations specifications.
Closer to his departure time, he called the Gainesville automated surface observing system, which was reporting 7 mi (11 km) visibility and a broken ceiling of 1,400 ft.
Information current at the time of his search of weather data reported visibility of 10 miles at SGJ; at Craig Municipal Airport, about 7 nm (13 km) northwest of the Mayo Clinic Heliport; and at Gainesville Regional Airport, 5 nm (9 km) northeast of the destination heliport. Ceilings were reported at 7,000 ft at SGJ and Craig and 1,600 ft at Gainesville.
By the time the helicopter departed from SGJ, there was a broken ceiling at 900 ft. At 0553, the ceiling at Craig had dropped to 700 ft. The TAF at Gainesville for the flight’s estimated time of arrival at Shands Cair called for visibility of more than 6 mi (10 km) and an overcast ceiling of 800 ft, with a “temporary condition” around the arrival time of IMC, with 4 mi (6 km) visibility, mist and an overcast ceiling of 400 ft.
Airmen’s meteorological information in effect at the time of the accident warned of IMC with mist and fog. Satellite images at 0602 — the time closest to the accident — showed low clouds and stratus over the site.
The report said that a former SK Jets helicopter pilot told accident investigators that the area near the accident site was swampy and “susceptible to fog.
“He added that once fog developed, the area was a ‘black hole’ at altitudes of 200 to 400 ft agl [above ground level], and a flight in these circumstances was effectively in IMC.”
The SK Jets general operations manual specified visual flight rules night weather minimums of a 1,000 ft ceiling and 3 mi (5 km) visibility, “unless otherwise approved by the director of operations or chief pilot.” There was no restriction preventing the accident pilot — also the director of operations — from approving his own deviation from the policy.
The report noted that U.S. Federal Aviation Regulations Part 91 prohibits helicopter flight in Class G uncontrolled airspace at or below 1,200 ft at night unless visibility is at least 1.0 mi (1.6 km).
Other company pilots said that, although they would have accepted the flight, based on the weather reports, they also would have had a back-up plan, such as using ground transportation, in case the flight could not be completed.
There was no record that the accident pilot had made such arrangements, the report said, noting that helicopters were the preferred method of transportation because “shorter transportation times increased the odds of a successful operation.”
SK Jets had a flight risk analysis tool (FRAT) that called on pilots to complete preflight forms designed to determine whether a flight should be canceled because of risks, but one pilot told investigators that he did not use the forms “because the grading criteria typically yielded such low risk scores that they would never result in a flight being canceled,” the report said. A FRAT form was not found for the accident flight.
SK Jets was founded by the accident pilot in 1997 and, at the time of the accident, had four airplanes and three helicopters, including an A109 that had been down for maintenance for four months. The accident helicopter had been leased to the company several days before the accident.
The company ended flight operations and filed for bankruptcy protection in February 2012.
A former director of safety, director of maintenance, chief pilot and others told NTSB investigators that they had no particular safety concerns and believed that the company had a positive safety culture. Former company pilots said that they were “not worried about repercussions for making safety-oriented decisions,” the report said, and the most recent FAA principal operations inspector (POI) said SK Jets seemed to be a “normal” operator.
However, two former company pilots who had witnessed the 2007 accident said they had concerns about the company’s safety culture.
“They cited management efforts to cover up the  accident and threats of retribution that they experienced for reporting the accident to the FAA,” the report said, noting that both pilots — one of whom flew airplanes and the other, helicopters — had left the company about three years before the 2011 crash.
“The former company fixed-wing pilot said that, when company managers discovered that he had reported the accident to the FAA, they assigned him more difficult work schedules and pressured him to fly in situations that made him feel unsafe. He further stated that if pilots refused such flights, the company would fire them and make them repay their training expenses. He added that the chief pilot and general manager tried to intimidate younger pilots by threatening to provide negative reports to future employers.”
The former helicopter pilot said that company pilots were “always on call, and managers urged them to falsify duty time records to indicate that they had received rest periods when they were not flying.” The former airplane pilot added that pilots were “retroactively considered to be in a rest period when not called for a flight” while on call.
A former FAA POI said that he had received pilot complaints about scheduling and had told managers that they “could not continuously keep pilots on duty,” the report said. The company subsequently instituted a rotating duty schedule, and he heard no further complaints about the issue. He added, however, that pilots who left the company had numerous complaints about how it was operated; when he asked managers to make changes, they complied.
The former airplane pilot also told investigators that pilots had been told not to use aircraft logbooks to note maintenance issues. “They had been advised to instead write up issues on adhesive notes and leave them inside the logbooks so that the company could decide when and if it would address the maintenance issues,” the report said.
Pilots and managers who worked at SK Jets at the time of the accident blamed the economic recession, which began in 2008, for a decline in business. During the bankruptcy filing that followed the accident, the company indicated that it had lost several million dollars in the three years before the crash, and that it had $1.3 million in assets and $9 million in debt.
Mayo Clinic representatives had noticed the delays in aircraft maintenance, including the A109 that had been down for maintenance since August 2011, and an official said that he was “concerned about the company’s finances because of its apparent inability to service aircraft in a timely manner.” As a result, he had identified other companies that “could better fulfill the Mayo Clinic’s air transportation needs”; the accident pilot was aware of his concerns and had scheduled a meeting with him in January 2012 to discuss Mayo’s requirements, the report said.
This article is based on NTSB accident report ERA12MA122 and supporting docket information.