Bell 407 Safety Record

The pilot’s improper landing flare while making a power off practice autorotative landing. Contributing was the decreased visual cues provided by the recently paved runway during the night landing conducted with the aid of night vision goggles.

A total loss of engine power due to the failure of the engine’s Nos. 3 and 4 bearings and the power turbine pinion gear, and subsequent loss of main rotor rpm, which resulted in a loss of control and impact with the water.

The pilot's loss of control during cruise flight as a result of spatial disorientation while operating the helicopter in close proximity to terrain in marginal meteorological conditions.

The ambulance driver’s failure to see the helicopter’s rotating main rotor blades in dark night conditions, which resulted in the ambulance’s inadvertent collision with the helicopter. Contributing to the accident was the ambulance driver's failure to follow procedures when approaching the helicopter.

The NTSB determines that the probable cause of this accident was Survival Flight's inadequate management of safety, which normalized pilots' and operations control specialists' noncompliance with risk analysis procedures and resulted in the initiation of the flight without a comprehensive preflight weather evaluation, leading to the pilot's inadvertent encounter with instrument meteorological conditions, failure to maintain altitude, and subsequent collision with terrain. Contributing to the accident was the Federal Aviation Administration's inadequate oversight of the operator's risk management program and failure to require Title 14 Code of Federal Regulations Part 135 operators to establish safety management system programs.

The pilot's loss of helicopter control after entry into vortex ring state, leading to a high rate of descent to the ground with a right spin. Contributing to the accident was the pilot's lack of recent and recurrent training in vortex ring state recognition and recovery.

An in-flight separation of the tip block from the tail rotor blade due to an inadequate blade repair, which resulted in a rotor imbalance sufficient to crack the gearbox attachment studs and gearbox support assembly, and inadequate postrepair test procedures, which failed to detect the inadequate adhesive bonding.

The pilot's failure to maintain proper altitude resulting in a collision with water for reasons that could not be determined based on the available information.

The flight instructor's failure to prevent the engine/rotor overspeed condition during the demonstration maneuver and the excessive descent rate during the emergency landing, which resulted in a hard landing. Contributing to the engine/rotor overspeed condition was the flight instructor's failure to comply with the demonstration procedure.

An incorrect and unapproved repair of the engine compressor diffuser performed by a machinist at a repair facility, which resulted in failure of the compressor diffuser aft plate and a partial loss of engine power.

The pilot's loss of control and collision with terrain while attempting a course reversal after inadvertently entering an area of reduced visibility weather conditions. Contributing to the accident was the pilot's lack of recent experience with night time operations.