NTSB: Duke Life Flight pilot shut down
wrong engine before fatal crash
A Duke Life Flight medical helicopter crashed in Perquimans County in
northeast North Carolina on Sept. 8, 2017, killing four people.
RALEIGH, N.C. — The pilot of a Duke Life Flight medical helicopter that
crashed in northeast North Carolina more than three years ago, killing all four
people aboard, likely got confused by an array of emergency indicators about a
problem with one of his two engines and mistakenly shut down the other one,
according to federal investigators.
The helicopter, which was based at Johnston Regional Airport in Smithfield,
was en route to Duke University Hospital in Durham from Sentara Albemarle
Medical Center in Elizabeth City on Sept. 8, 2017, when it crashed in a grassy
field outside the town of Belvidere, south of the Perquimans-Gates county line,
officials said.
Pilot Jeff Burke, flight nurses Kris Harrison and Crystal Sollinger and
patient Mary Bartlett were killed.
In their final report on the crash, National Transportation Safety Board
investigators said damaged roller bearings in the No. 2 engine likely caused the
engine to seize up during flight.
Because investigators couldn't recover any recorded data from the flight –
the battery on a recorder installed on the aircraft may have died, according to
the report – they said they couldn't know exactly which indicators went off and
in what sequence. But they said Burke likely misread his instruments and
believed he was losing power from the No. 1 engine, prompting him to shut it
down.
"A failure of the rear bearing in the No. 2 engine ... created multiple and
likely unexpected and confusing cockpit indications, resulting in the pilot's
improper diagnosis and subsequent erroneous shutdown of the No. 1 engine," the
report states.
The damaged No. 2 engine then likely lost all power, according to the
report, and the wreckage "indicated that the helicopter was in a near-vertical
descent
before impacting the ground."
NTSB investigators couldn't determine the reason why the No. 2 engine
failed because of a combination of damage from its continued operation and from
the crash, as well as a subsequent fire.
Witnesses told investigators that they saw a trail of dark smoke coming
from the helicopter before the crash, but the NTSB couldn't determine if the No.
2 engine was on fire during flight.
Investigators also noted that metallic contaminants were found in oil from
the No. 2 engine during routine tests in the months before the crash, indicating
a potential bearing failure. But the amount of contamination never rose to the
level specified by the engine manufacturer to warrant action.
"The oil test evaluation procedures did not include steps to monitor trends
of contaminant concentration levels over time. If the engine manufacturer’s
procedures had included appropriate trend monitoring criteria, the impending
bearing failure in the No. 2 engine might have been detected and mitigated," the
report states.
The helicopter had its last scheduled maintenance a week before the crash.
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