NTSB cites pilot errors in fatal helicopter crash

Nearly a year and a half after the Dec. 14, 2006, helicopter crash outside Dagsboro that killed developer/philanthropist Joshua Freeman and his pilot, Alisa Danielle Howell, investigators at the National Transportation Safety Board (NTSB) have released a report identifying the probable cause of the accident.

The report cites numerous problems with Howell’s flights that day, including the decision to fly at night, with poor visibility in the area due to fog, from a location that she was not familiar with, in a helicopter that was only equipped for flight by visual flight rules. Howell herself was not certified to fly by instrument only, nor was the helicopter equipped for such flight.

Citing both physical evidence from the crash scene and eyewitness statements regarding the helicopter’s movements prior to the crash, investigators in this week’s report noted that there were no apparent mechanical problems leading to the crash and that Howell had apparently decided to take off despite visibility issues that had forced her to land in a farm field instead of her original destination — the Bear Trap Dunes golf course, where she had been scheduled to pick up Freeman and take him back to his suburban Washington, D.C., home.

“A witness watched as the helicopter climbed vertically to a height just above the trees to its left and the utility lines to its front, and hovered for a few seconds. While hovering, the landing light of the helicopter cycled on and off two times,” the report reads, in part. “The helicopter then pitched nose down and accelerated forward. Instead of climbing, the helicopter accelerated forward in a shallow descent until it impacted the ground.

“The witness described that the conditions of darkness and fog prevented him from making his way to the accident scene without the aid of a light,” the report noted. Visibility in the immediate area was reported at less than an eighth-mile at the time of the crash, though areas of clear sky were reported throughout the night.

The report does not directly speculate why or how the helicopter slammed into the ground instead of climbing, but a note at the end of the lengthy report does list one potential cause, quoting the FAA Airplane Flying Handbook about some hazards associated with flying in airplanes under VFR when visual references, such as the ground or horizon, are obscured:

“The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation.”

The report further notes that, according to the FAA Instrument Flying Handbook (FAA-H-8083-15), a rapid acceleration “...stimulates the otolith organs in the same way as tilting the head backwards. This action creates the somatogravic illusion of being in a nose-up attitude, especially in situations without good visual references. The disoriented pilot may push the aircraft into a nose-low or dive attitude.”

The NTSB found that similar disorientation was a factor in the Atlantic Ocean crash of the small private plane flown by John F. Kennedy Jr. in 1999 that killed Kennedy, his wife and sister-in-law. Spatial disorientation, the dark of night and a haze were cited as elements leading to that crash.

Weather a concern from the start

The report from the NTSB noted numerous problems with Howell’s flight on Dec. 14, 2006, starting as she worked at the Georgetown airport, where she refueled the craft after having delivered Freeman from his home to Bear Trap earlier that day.

“Another pilot saw and spoke with the accident pilot while at the airport in Georgetown,” the report notes. “The pilot observed the accident pilot as she used the weather computer in the pilot lounge to obtain weather information. He then discussed some of this information with the accident pilot including the weather radar, surface observations, and forecasts, as well as general weather patterns in the area. He described that the accident pilot was ‘nervous’ about the weather, and that she expressed this concern to him. The accident pilot checked the weather several times before she departed Georgetown.”

After departing from Georgetown, headed back to Bear Trap, Howell encountered heavy fog. She turned away from Bear Trap, eventually landing the helicopter in the farm field near Dagsboro.

The report records that “An AIRMET (AIRman’s METeorological information) for instrument metrological conditions encompassing the route of flight between the departure point and the eastern shore of Northern Virginia was issued at 1545. It warned of ceilings below 1,000 feet, and visibilities less than 3 statute miles due to mist and fog, with the conditions continuing beyond 2200.”

Howell had filed a flight plan under visual flight rules for the final leg of her return flight to Manassas, Va., at 3:48 p.m., some three minutes after the metrological warning was given, but at that time she only filed the flight plan and did not request any additional information, meteorological or otherwise.

A witness who saw the helicopter approach the farm noted the adverse weather conditions at the time, about 5:15 p.m.

“One witness observed the helicopter disappear into fog, and then reappear traveling in the opposite direction. When asked to describe the lighting and the weather in the area at the time, the other witness stated that it was dusk, and that fog was beginning to form. She added that by the time it was dark, around 1730, the fog had worsened and ‘you couldn’t see.’”

After the helicopter had landed, the farm owner called the Delaware State Police, concerned about the unexpected visitor. The trooper who responded to the call spoke with Howell, ascertained her reasons for landing there and went on his way while she waited for Freeman to be driven to her new location.

“When he was asked about the light and weather conditions at the time that he talked to the pilot, the trooper noted that it was ‘dark and foggy,’” the report says.

‘A piece of cake’

The NTSB notes that the person who drove Freeman to the farm field had been concerned about the weather conditions as it neared 6 p.m. and even asked Howell directly about them.

“The driver stopped his vehicle in front of the helicopter, and greeted the pilot. He then asked the pilot if she felt comfortable with the conditions. He specifically pointed out the power lines, irrigation equipment, and the tree line adjacent to the helicopter.

“The pilot replied that it was a ‘piece of cake,’ and pointed to the sky above. The driver recalled that at that time, the stars could clearly be seen. The pilot stated that her only worry was getting across the Chesapeake Bay and to Dulles on time. The driver then asked the pilot if she needed or wanted to use the headlights of his vehicle in any way, to which the pilot responded that it was not necessary.

“The driver then pulled the vehicle away, and briefly stopped to watch the helicopter take off. Due to the dark lighting conditions and the foggy weather, the driver was unable to see the helicopter or its lights. He drove away shortly thereafter,” the report says.

At 6:01 p.m., weather conditions reported at Sussex County Airport in Georgetown, about 11 nautical miles northwest of the accident site, included winds from 100 degrees at 3 knots, 3 statute miles visibility in mist and clear skies. (After the crash, at 6:40 p.m., the visibility at Sussex County Airport was reported as 1.25 statute miles in mist.)

A man working near the Dagsboro-area farm witnessed the crash itself, around 6:15 p.m.

“The witness expected to see the helicopter climb, as he had seen other helicopters do in the past; however, the accident helicopter just accelerated forward in a shallow descent until it impacted the ground. When asked about the sound of the helicopter or its engine during the takeoff, he stated that the sound was smooth and continuous, and that nothing sounded abnormal,” the report notes.

Examination of the engine from the craft indicated no pre-impact problems, NTSB investigators said in their report.

“The engine was removed and shipped to the manufacturer for further examination. On February 6, 2007, the engine was mounted in a test stand and run. The engine developed takeoff power and no abnormalities were noted. Examination and download of the engine’s Full Authority Digital Engine Control revealed no evidence of any pre-impact mechanical malfunction or failure,” the report reads.

The shifting weather in the area is again implicated in the report, according to the man who had been working nearby and witnessed the crash.

“The witness additionally described that at the time of the accident it was dark, the fog was dense, and that it thickened throughout the evening. The witness attempted to respond to the accident site, but could not find his way in the darkness and thick fog, and subsequently returned to where he was working to retrieve a video camera with a light attached.”

In their additional notes on the report, NTSB investigators also included cautions about flying at night.

“According to the FAA Airplane Flying Handbook (FAA-H-8083-3), ‘Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references.

“‘Therefore, flight instruments should be used to a greater degree.… Generally, at night it is difficult to see clouds and restrictions to visibility, particularly on dark nights or under overcast. The pilot flying under VFR must exercise caution to avoid flying into clouds or a layer of fog.”

While Howell had more than 3,300 hours of flight at the time of the crash, including many operating the model of helicopter she flew that night, she had only 600 hours of experience flying at night, investigators noted.

Pilot out of contact with base, ground control

The NTSB report further indicates deviations from rules regarding communications from the aircraft to ground-based flight controllers and the chief pilot of the craft’s operator, HeloAir.

Howell is reported to have made more than 43 calls from her personal mobile phone in the space of about 90 minutes, between approximately 4:30 and 6:05 p.m. Two of those calls were apparently to flight control in Leesburg, Va., but no recorded conversation exists.

Some 19 of the 43 calls were to various automated weather stations throughout the region.

But at no point in that time did Howell contact the HeloAir’s chief pilot or file an updated flight plan with flight controllers — something with which the NTSB found fault, citing Section 2.30 of the Operations Manual, Flight Following/Locating.

“It was the [pilot-in-charge]’s responsibility to ensure that they could remain in radio contact with the principal operations base, maintain positive flight following, file a VFR flight plan, or to leave all flight plan information with the principal operations base. Any deviations or alterations to the route of flight, itinerary, or number of passengers would need to be updated with the chief pilot or flight service as soon as possible.

“In the event that the pilot operated to or from an area or facility where no communications were available, or where communication difficulties could arise, they would establish predetermined reporting times and/or procedures with the principal operations base.”

The NTSB said HeloAir had reported that their last contact with Howell occurred shortly after she had arrived at Georgetown Airport. “The operator further stated that they expected the pilot to report in if she encountered any problems, or needed to change her itinerary.”

NTSB officials said the company’s pilots were expected to maintain contact with the operations base via radio or mobile telephone. When this was not possible, in accordance with the company operations specifications, pilots could file a flight plan, obtain flight following services, or leave flight plan information on file with the operations base.

When flights were conducted after normal business hours, pilots were expected to check in with the president of the company, the chief pilot or the director of dispatch.

Howell did not check in after leaving Georgetown. HeloAir’s chief pilot called ground controllers about the overdue flight after 8 p.m., nearly two hours after the crash.

Landing at farm deviated from rules

The NTSB also found fault with Howell’s handling of the decision to land in the farm field, noting deviations from Section 2.27, Flight Destination Minimum Requirements, of the Operations Manual.

Several guidelines for the PIC were listed including:

(1) If the destination is not an approved FAA landing area that the permission of the land owner has been received. (Howell did not obtain permission prior to landing in the field.)

(2) If the landing is to occur at night that the proper ground lighting or reflective material is in place for the landing. (There was little, if any, lighting in the area of the farm field.)

(3) Familiarize [yourself] with the terrain and obstruction hazard. (Farm equipment, a roadway and overhead utility lines were in the vicinity of the landing/takeoff site.)

(4) If the destination is unfamiliar, that an appropriate landing area check has been completed prior to the initiation of the flight.

(5) Prior coordination to ensure public safety at the landing site.

(6) Prior to landing the, PIC will determine wind direction from an illuminated wind direction indicator, local ground communications, or the PIC’s personal observation. (There was no illuminated wind direction indicator in the area of the landing site, and Howell did not contact local ground communications.)

Decision to fly violated company’s rules

In summarizing the findings about the accident, the NTSB investigators noted:

“The ceiling and visibility conditions were significantly worse than the minimum values required by the company’s operations specifications.”

They also again noted failings in communications that could potentially have halted the ill-fated flight:

“Further review of the operations specifications revealed that the pilot was required to report any changes in her itinerary to the operator. No evidence was found to indicate that the pilot had notified the operator of her initial deviation and subsequent landing in the field, or of her intent to depart from that field after sunset.”

And, investigators said, HeloAir’s procedures for determining whether the flight was overdue may have been an additional problem.

“During post-accident interviews the operator could not clearly articulate its actual method for determining whether an aircraft was overdue, since no one individual was charged with that specific duty for operations after normal business hours.”

Howell, 30, lived in Virginia and had been flying with HeloAir for four years prior to the crash. She was licensed to teach helicopter flying, as well as to fly charter flights.

Freeman, 42, was a husband and father of three. He was head of the Freeman Companies development group and the Carl M. Freeman Foundation, a charitable organization named after his father. After his death, the Joshua M. Freeman Foundation was begun, with a similar legacy of philanthropy to communities in the areas that the Freeman Companies have operated.

Among other awards and accolades, Freeman was awarded with the 2004 Marriott International Inc. Arts and Humanities Corporate Patron Award for Excellence and the 2005 Bethany-Fenwick Area Chamber of Commerce Lighthouse Award for lifetime achievement. The Joshua M. Freeman Valor Awards are now held by the Chamber every year in his honor, to denote the contributions of local public safety workers.