Accident Agusta A119 Koala N403CF, Thursday 30 June 2005
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Date:Thursday 30 June 2005
Type:Silhouette image of generic A119 model; specific model in this crash may look slightly different    
Agusta A119 Koala
Owner/operator:Tri-State Care Flight LLC
Registration: N403CF
MSN: 14009
Year of manufacture:2000
Total airframe hrs:753 hours
Engine model:Pratt & Whitney Canada PT6B-37A
Fatalities:Fatalities: 3 / Occupants: 3
Other fatalities:0
Aircraft damage: Substantial
Location:Mancos, CO -   United States of America
Phase: Approach
Departure airport:Animas Airpark, CO (5CO0)
Destination airport:Mancos, CO
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
On June 30, 2005, at 1357 mountain daylight time, an Agusta A119 helicopter, N403CF, operated by Tri-State Care Flight, LLC, of Bullhead City, Arizona, as "Care Flight 4" and piloted by a commercial pilot, was substantially damaged when it impacted terrain while approaching to land at a landing zone (LZ), 7.5 miles northeast of Mancos, Colorado. The pilot, flight nurse, and paramedic were fatally injured. Visual meteorological conditions prevailed, and a company visual flight rules (VFR) flight plan had been filed and activated for the emergency medical service (EMS) flight being conducted under Title 14 Code of Federal Regulations (CFR) Part 91. The flight originated at Animas Airpark (5CO0), Durango, Colorado, at 1242.

The EMS helicopter had been dispatched to medivac a logger who had been injured in a trucking accident. The pilot made a low pass, then circled around to make his landing approach. A volunteer fireman, who was standing at the landing zone (LZ) and directing the helicopter, said the temperature was "about 80 degrees [F.]," and he advised the pilot that the winds were calm. The fireman said the helicopter was about 220 feet above tree level when "it dropped straight down." He heard no unusual engine sounds and did not see the impact. The on-scene examination revealed all four main rotor blades remained attached to the rotor hub and were drooped over the wreckage. Examination of the fuel control unit (FCU) revealed a 1/16-inch gap at the mating flange between the flow (fuel bypass passage, Po) and drive (air pressure passages, Px & Py) bodies. One of four retention-bolts was backed out and the packing was partially extruded. The bolt was too short, another bolt was too long, and the other two bolts were insufficiently torqued. Additionally, the flow and drive bodies were not perfectly flat. Further examination of the FCU revealed no functional anomalies.

Probable Cause: a loss of engine power for undetermined reasons and the pilot's inability to get into autorotation prior to impacting the ground. A factor contributing to the accident was the helicopter's low altitude when power was lost.

Accident investigation:
Investigating agency: NTSB
Report number: DEN05FA103
Status: Investigation completed
Duration: 1 year and 7 months
Download report: Final report





Photo: NTSB

Revision history:

28-Oct-2008 00:45 ASN archive Added
07-Feb-2009 10:15 harro Updated
29-Jan-2013 12:54 TB Updated [Aircraft type, Source, Damage]
21-Dec-2016 19:24 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
06-Dec-2017 10:10 ASN Update Bot Updated [Operator, Nature, Source, Narrative]
10-Jun-2024 23:22 Captain Adam Updated [Nature, Departure airport, Source, Narrative, Photo]

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