National Transportation Safety Board Washington, D.C. 20594 PRSRT STD OFFICIAL BUSINESS Postage & Fees Paid Penalty for Private Use, $300 NTSB Permit No. G-200 Controlled Flight Into Terrain Era Aviation Sikorsky S-76A++, N579EH Gulf of Mexico, About 70 Nautical Miles South-Southeast of Scholes International Airport, Galveston, Texas March 23, 2004 Aircraft Accident Report NTSB/AAR-06/02 PB2006-910402 Notation 7646B National National Transportation Transportation Safety Board Safety Board Washington, D.C. Washington, D.C. Aircraft Accident Report Controlled Flight Into Terrain Era Aviation Sikorsky S-76A++, N579EH Gulf of Mexico, About 70 Nautical Miles South-Southeast of Scholes International Airport, Galveston, Texas March 23, 2004 RAN S P T O L R A T LUR IBUS N P UNUM A E O T I I O T A N N S A D FE R T Y B OA NTSB/AAR-06/02 PB2006-910402 National Transportation Safety Board Notation 7646B 490 L’Enfant Plaza, S.W. Adopted March 7, 2006 Washington, D.C. 20594 National Transportation Safety Board. 2006. Controlled Flight Into Terrain, Era Aviation, Sikorsky S-76A++, N579EH, Gulf of Mexico, About 70 Nautical Miles South-Southeast of Scholes International Airport, Galveston, Texas, March 23, 2004. Aircraft Accident Report NTSB/AAR-06/02. Washington, DC. Abstract: This report explains the accident involving an Era Aviation Sikorsky S-76A++ helicopter, N579EH, which crashed into the Gulf of Mexico about 70 nautical miles south-southeast of Scholes International Airport (GLS), Galveston, Texas. Safety issues discussed in this report focus on terrain awareness and warning systems for helicopters, flight control system training, flight-tracking technology for low-flying aircraft in the Gulf of Mexico, and preflight testing and maintenance checks for cockpit voice recorders. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2006-910402 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. iii Aircraft Accident Report Contents Figures . v Abbreviations . vi Executive Summary . viii 1. Factual Information . 1 1.1 History of Flight . 1 1.2 Injuries to Persons. 4 1.3 Damage to Aircraft . 4 1.4 Other Damage. 4 1.5 Personnel Information. 4 1.5.1 The Captain . 4 1.5.2 The Copilot. 6 1.6 Aircraft Information . 7 1.6.1 Main Rotor and Tail Rotor Systems. 7 1.6.2 Powerplants . 8 1.6.3 Flight Control Systems. 8 1.6.3.1 Cyclic, Collective, and Tail Rotor Pedal Control Systems . 8 1.6.3.2 SPZ-7000 Dual Digital Automatic Flight Control System . 8 1.6.3.2.1 Autopilots . 10 1.6.3.2.2 Flight Directors . 10 1.6.3.2.3 Coupling Function. 11 1.6.3.3 Electronic Flight Information System . 12 1.6.4 Maintenance Records . 13 1.6.5 Previous Flights . 14 1.7 Meteorological Information . 14 1.8 Aids to Navigation . 15 1.9 Communications . 15 1.10 Airport Information. 16 1.11 Flight Recorders . 16 1.11.1 Cockpit Voice Recorder. 16 1.11.2 Flight Data Recorder . 17 1.12 Wreckage and Impact Information . 19 1.12.1 Main Rotor and Tail Rotor Systems. 19 1.12.2 Powerplants . 20 1.12.3 Landing Gear . 20 1.13 Medical and Pathological Information . 21 1.14 Fire . 21 1.15 Survival Aspects . 21 1.16 Tests and Research . 22 1.16.1 Cockpit Voice Recorder Study. 22 1.16.2 Actuator Testing. 22 1.17 Organizational and Management Information . 23 1.17.1 Era Aviation . 23 Contents iv Aircraft Accident Report 1.17.1.1 S-76A Configurations . 23 1.17.1.2 Ground and Flight Training . 24 1.17.1.3 Visual Flight Rules Flight Plans . 25 1.17.1.4 Federal Aviation Administration . 26 1.18 Additional Information . 26 1.18.1 Flight Simulations . 26 1.18.2 Gulf of Mexico Helicopter Operations. 29 1.18.3 Automatic Dependent Surveillance–Broadcast Technology . 31 1.18.4 Controlled Flight Into Terrain. 32 1.18.5 Comparison of SPZ-7000 and SPZ-7600 Dual Digital Automatic Flight Control Systems . 34 1.18.5.1 Federal Aviation Administration SPZ-7000 Evaluation . 37 1.18.6 Previous Flight Recorder Safety Recommendations . 38 1.18.6.1 Safety Recommendation A-02-25 . 38 1.18.6.2 Safety Recommendations A-06-17 and A-06-18. 39 2. Analysis . 40 2.1 General . 40 2.2 Accident Sequence . 41 2.2.1 Accident Summary. 41 2.2.2 Indications of Descent and Proximity to the Water . 42 2.2.3 Human Factors . ..