FORM APPROVED FOR USE THROUGH 09/30/2011 BY OMB NO. 3147-0001 NATIONAL TRANSPORTATION SAFETY BOARD NTSB Form 6120.1 PILOT/OPERATOR AIRCRAFT ACCIDENT/INCIDENT REPORT The pilot/operator aircraft accident/incident report may be filed by mailing in this form, per instructions on the last page. Copies of this form B. DEFINITIONS 1. "Aircraft Accident" means an occurrence associated with the operation of an aircraft that takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suffers death, or serious injury, or in wh"1ch the aircraft receives substantial damage. For purposes of this form, the definition of "aircraft accident" includes "unmanned aircraft accident," as defined at 49 C.F.R. 830.2. may be obtained from the NTSB Web site , the National Transportation Safety Board Regional Offices, and the Federal Aviation Administration Flight Standards District Offices. Rules pertaining to aircraft accidentsfmcidents, overdue aircraft, and safety issues are contained in Part 830 of the National Transportation Safety Board's Regulations, 49CFR. These rules state the authority of the Board, define accidents, incidents, injuries, and other terms, and provide procedures for initial and immediate notification by aircraft pilots/operators. 2. "Substantial Damage" means damage or failure which adversely affects the structural strength, performance or flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected component. NOTE: Engine failure or damage limited to an engine if only one engine fails or is damaged, bent fairing or cowling, dented skin, small puncture holes in the skin or fabric, ground damage to rotor or propeller blades, and damage to landing gear, wheels, tires, flaps, engine accessories, brakes, or wing tips are not considered "substantial damage" for purposes of this report. A. APPLICABILITY The pilot/operator of an aircraft shall file a report with the Regional Office of the National Transportation Safety Board nearest the accident or incident for which immediate notification is required by section 830.5(a). The report shall be filed within ten (10) days after an accident for which notification is required by Section 830.5 or when, after seven (7) days, an overdue aircraft is still missing. An aircraft accident, as defined in 49CFR 830.2, is determined as an occurrence that involves a fatality, serious injury, or substantial damage. For occurrences that do not involve a fatality, the determination that the occurrence is an accident can be appealed by writing to the Director, Office of Aviation Safety, National Transportation Safety Board, 490 L'Enfant Plaza, S.W., Washington, D.C. 20594. 3. "Operator" means any person who causes or authorizes the operation of an aircraft, such as the owner, lessee, or bailee of an aircraft. 4. "Fatal Injury" means any injury that results in death within thirty (30) days of the accident. 5. "Serious Injury" means any injury that (1) requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fracture of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves injury to any internal organ; or (5) involves second- or third-degree burns, or any burns affecting more than 5 percent of the body surface. The Pilot!Operator Aircraft Accidentllncident Report Form is used in determining the facts, conditions, and circumstances for aircraft accident prevention activities and for statistical purposes. It is necessary that ALL questions be answered completely and accurately to serve the above purposes. INSTRUCTIONS TO PILOTS/OPERATORS FOR COMPLETING THIS FORM It is necessary that ALL questions on this report be answered completely and accurately. If more space is needed, continue on a blank sheet. cargo/baggage compartment emergency ground equipment. Date & Time: Indicate the date and local time of the event. Be sure to indicate the time zone. Engine: Enter engine make and model information as indicated on the engine data plate. Phase of Operation: Indicate the phase of operation during which the accident/incident occurred. Owner/Operator Information: Enter the owner information as shown on the registration certificate. Commercial operators, enter the operator information, inducflng "Doing Business as" when applicable, as shown on the operator certificate. Aircraft Information: Enter aircraft make and model information as indicated on the aircraft registration certificate, including series. If the involved aircraft is certified as "amateur-built," include the name of manufacturer of the kit or plans when appropriate. fire suppression system, or airport Nearest City/Place: Use the name of the nearest community that has a Post Office in the state where the accident/incident occurred. Revenue Sightseeing Flight: Indicate whether the accident aircraft was conducting revenue sightseeing operations under FAR Part 91 at the time of the accident. Max Gross Weight: Enter the certificated max gross weight for the aircraft involved in the occurrence. This should be the same as the maximum gross weight indicated on the aircraft weight and balance documents. Public Use: Federal, state or local government flight operations such as official travel, law-enforcement, low-level observation, aerial application, firefighting, search and rescue, biological or geological resource management, or aeronautical research. Military operations should not be included under public use. If public use, also indicate whether the flight was conducted by Federal, State, or Local government. Airworthiness Certificate: For light sport aircraft, if aircraft certificated as "Light Sport - Experimental", check both the "Light Sport" and "Experimental" check boxes. Type of Fire Extinguishing System: If a fire extinguishing system was used to fight an aircraft fire, specify the type(s) of extinguishing system(s) used. Examples include handheld extinguisher, engine fire bottle, Air Medical Flight: Indicate whether accident flight was being conducted for the purpose of carrying medical personnel, patient(s), or organs. NTSB Form 6120.1 (rev. 2/2011). This form replaces 6120.1/2. 1 Purpose of Flight (FAR 91, 103, 133, 137): Indicate the type of operation that was being conducted at the time of the occurrence using the following definitions: Condition of Runway/Landing Surface: Indicate the condition of the intended runway/landing surface. If multiple conditions existed at the time of the accident, check all that apply. PERSONAL-Flying for personal reasons (excludes business transportation) including pleasure or personal transportation. This also includes practice or proficiency flights performed under flight instructor supervision and not part of an approved flight training program. Weather Information at the Accident/Incident Site: Indicate the weather conditions reported at the accident/incident site at the time of occurrence. If no weather reporting was available for the accident/incident site, indicate the reported conditions at the nearest reporting site. Specify the weather reporting site identifier, the observation time, and distance from the accident/incident site. BUSINESS-Includes all personal flying without a paid, professional crew for reasons associated with furthering a business, including transportation to and from business meetings or work. This does not include corporate/executive operations, air taxi, or commuter operations. Sky/Lowest Cloud Condition: Indicate the height above ground level of the lowest cloud condition present at the time of the accident and whether coverage was reported as few, scattered, broken or overcast. Also indicate the height above ground level and coverage of the lowest cloud ceiling present at the time of the accident (reported as broken or overcast). EXECUTIVE/CORPORATE-Company flying with a paid, professional crew. OTHER WORK USE-Miscellaneous flight operations conducted for compensation or hire such as construction work (not FAR Part 135 operation), parachuting, aerial advertising, towing gliders, etc. NOTAMs ((D), (L) and FOG), AIRMETs, SIGMETs, PIREPs: Describe all NOTAMs, AIRMETs, SIGMETs, PIREPs in effect near the accident/incident. For NOTAMs, state if they were distant (D), local (L), or Flight Data Center (FDC), if known. INSTRUCTIONAL-Flying while under the supervision of a flight instructor or receiving air carrier training. Personal proficiency flight operations and personal flight reviews, as required by federal air regulations, are excluded. Pilot Information: Indicate the category that best describes the capacity served by this flight crewmember at the time of the accident. The designators "Pilot A" and "Pilot 8" do not refer to a specific pilot position or responsibility. If more than one pilot is aboard, they may be entered in any order and their capacity entered as appropriate. FERRY-Non-revenue flight under a special flight or "ferry" permit. Refer to 14 CFR 21.197 for details of special flight permit issuance. POSITIONING-Non-revenue flight conducted for the primary purpose of moving the aircraft to a maintenance facility or to load passengers or cargo, etc. Degree of Injury: See Definitions on the top half of Page 1 of the Instructions. Minor injury is not defined. If an injury does not meet the criteria for another injury category, select Minor. AERIAL APPLICATION-Operations using an aircraft to perform aerial application or dispersion of any substance. Examples include agricultural, health, forestry, cloud seeding, firefighting, insect control, etc. Date of Last Flight Review or Equivalent: Enter the date of the most recent flight review, or equivalent, completed by this pilot. Refer to 14 CFR 61.56 for accepted equivalents. AERIAL OBSERVATION-Aerial mapping/photography, patrol, search and rescue, hunting, highway traffic advisory, ranching, surveillance, oil and mineral exploration, criminal pursuit, fish spotting, etc. AIR DROP-Aerial operations, other than aerial application, that are intended to release items in flight. Type Ratings: List all type ratings on the pilot certificate. If the pilot holds no type ratings indicate "none". If the pilot holds a pilot certificate other than student, and was flying an aircraft requiring an endorsement enter the type and date of any logbook endorsement(s) for that aircraft. See 14 CFR 61 for examples of required endorsements. AIR RACE/SHOW-Includes any flight operations conducted as part of an organized air race or public demonstration. Student Endorsements: If the pilot holds a student pilot certificate, enter all solo endorsements and dates on the student pilot certificate. FLIGHT TEST-Flight for the purpose of investigating the flight characteristics of an aircraft/aircraft component, or evaluating an applicant for a pilot certificate or rating. Flight Time: Complete the flight time matrix. Solo flight time should be included as "Pilot-in-Command (PIC)" and all dual flight instruction given should be included as "Time as Instructor''. PUBLIC USE-See definition above. Additional Flight Crew Members: Complete this section if there were more than two required flight crew members on the aircraft. This also includes a check airman performing official duties, but does not include cabin crew. State the capacity served by each included crewmember at the time of the accident. UNKNOWN-Use only if the primary purpose of flight is not known. Other Aircraft - Coflision: For all accidents involving a collision with another aircraft, including parked aircraft, check "Collision with other aircraft" under Basic Information and complete this section indicating details about the OTHER aircraft involved in the collision. Passenger(s)!Other Personnel: Please enter identification and injury severity information for all passengers and other personnel involved in the accident. See page 1 of the instructions for the official definition of injury levels. Occupants are considered "Revenue" passengers if they were being carried for compensation or hire. The option "FAA" refers to any FAA personnel performing a flight related function, including flight check, airman practical test, etc. Airport Information: Complete this section if the accident/incident occurred on approach, takeoff, or within 3 miles of an airport. Please refer to the FAA Airport/Facility Directory or other official source for airport information. Airport Identification: Provide the official3 or 4 character airport identifier. Runway: Indicate the number of the runway used, including L, R, or C if applicable. Several questions throughout the form allow for multiple responses; when appropriate choose all responses that apply. Runway/Landing Surface: Indicate the type of intended runway/landing surface (do not indicate surface conditions). If the surface type was mixed, check all that apply. These instructions only pertain to major issue areas covered by the NTSB Form 6120.1 Pilot/Operator Aircraft Accident/Incident Report. For additional definitions of questions and responses, please refer to _ 2 NATIONAL TRANSPORTATION SAFETY BOARD PILOT/OPERATOR AIRCRAFT ACCIDENT/INCIDENT REPORT This form to be used for reporting civil and public use aircraft accidents and incidents ~IOfll ~ Accident/Incident Location ~ '·'' State: Nearest City/Place: ZIP: mmldd/yyyy (dd:mm:ss N/S) Longitude: Standing DTaxi 0 Collision with Other Aircraft D D Cruise Takeoff(incL initial climb) D Climb D Descent Time Zone: (ddd:mm:ss EIW) Phase of Operation D Local Time: Date: Country: Latitude: ~ Dateffime ~ Maneuvering D Approach Landing D Hover 0 Other D 0Unknovm 0None •i:;,;'::f::/ Y'i2J.> : .:,.:·:: . <:: .·. r.· .•F:T Altitude ofln-Flight Occurrence Midair DOn-ground Manufacturer: Bell Textron ::c :;'1'!1::~~:: ftMSL ,.,:;: ~i'!i'.cii~ 5,250 lbs Max Gross Weight: Model: 407 Weight at Time of Accident/Incident: Serial Number: 53006 Location of Center of Gravity at Time of Accident/Incident: . Registration Number: N191SF Amateur-built: DYes !i1No -or- Category of Aircraft D Airplane D Balloon D Blimp/Dirigible 0Glider D Gyrocraft Ill Helicopter 0 Powered lift D Ultralight 0Unknown Type of Airworthiness Certificate (Check all that apply) Number of Seats: Standard Special If Large Aircraft, how many seats for: ~Normal D Restricted 0 0 Utility Acrobatic Transport D lOOHour ELT Installed li1 Yes 0No ELT Activated Ill! Yes 0No 0Amphibian Continuous Airworthiness D Conditional Inspection 0Unknown 0Annual 1;21 No Eng. 1 Engine Roll• Royce Airframe Total Time: ills hours measured at (check one) D Last Inspection D Time of AccidentJincident Type of Fire Extinguishing System Ill None D Specify 0Unknovm Model/Series: ME406HM Serial Number: unknown Sysi:m Type D D Carburetor Fuel Injected .. Battery Exp. Date: Propeller D Fixed Pitch 0 Controllable Pitch Manufacturer: ModeL Date Engine mm!ddlyyyy Battery Type: D Turbo Jet D TurboFan 0Unknown 0Ski D Ski/Wheel Date Last Inspection: 0 GliAAIP OHighSkid ill Skid ELT Manufacturer: ARTEX bZI No Engine Type D Reciprocating Ill Tucbo Shaft D Turbo Prop 0Tailwheel D Emergency Float D Float Stall \Yarning System Installed ELT Aided in Locating Accident/Incident DYes D Tricycle 0Hull 0Unknovm Last Inspection Type DYes Check any additional landing gear configuration that applies: Cabin Crew: 0Annual 0 Conditional (Amateur-built only) 0 Manufacturer's Inspection Program GlJ Other Approved Inspection Program (AAIP) 0 Continuous Airworthiness D Othec, speoizyi . 0Unknovm D Retractable Landing Gear 5 Passengers: Type of Maintenance Program IFR Equipped DYes Gl!No inches from D nose or D datum Percent Mean Aerodynamic Cord (% MAC) Flight Crew: 0Limited D Provisional D Experimental D Special Flight D Light Sport 4 300 lbs . ~:_gln.•,. Manufacturer's Serial I\'umber of~~~· Engine Rated Power Measured as (check one) ~ Total Time ibs o(Thrust m lthours) 650 250 C478 Eng.2 Eng. 3 Eng.4 3 1,180 ~::::: 1lboursl Time Since Overhaul (hours) I OWNER/OPERATOR :niiFORIIIIA.TION, \ii:,;c\; 'if,,,,, ;;, i '''", >: ,,,,, :r:, Owner Address Name: N191SF LLC City: Mesa State: AZ Country: USA Fractional Ownership Aircraft: Operator of Aircraft DYes GZJ No D Same As Registered Owner ii', i'1ifci Registered Aircraft Owner 'L''' ;',,, /': >';!,!, <,:''i'VX' ZIP: 85206 0 Operator Address Same As Registered Owner Name:Viking Aviation LLC Doing Business As: Survival Flight Air Carrier/Operator Designator (4 Character Code): City: Batesville State: AR Country: USA Regulation Flight Conducted Under Revenue Sightseeing Flight DYes 0FAR91 FAR 103 FAR 121 FAR 125 D D D D FAR 129 0FAR133 0FAR135 D FAR 137 0 FAR 91 Special Flight D Non-US, Commercial D Non-US, Non-commercial D Armed Forces D Public Use (select type) 0 Federal 0 State D Local 0Unknown Revenue Operation D Personal D Scheduled or Commuter (Check all that apply) 0None D Flag Carrier Operating Certificate (121) 0 Supplemental 0 Air Cargo D Foreign Air Carriers (129) D Commuter Air Carrier (135) 121 On-Demand Air Taxi (135) or Air Taxi D International 0 Large Helicopter (127) Cargo Operation !ill Passenger/Cargo D Passenger D Cargo 0Mai1 OTHER AIRCRAFT- COLLISION Aircraft Registration Number (Select one) Domestic or International ~Domestic 0No Type of Commercial Operating Certificate Held for FAR 121, 125,129,135 ~Non-Scheduled !;ZI No Air Medical Flight I;ZI y" Purpose of Flight for FAR 91, 103, 133, 137 (Select one) ~Business Executive/Corporate D Other Work Use D Instructional D Ferry D Positioning D Aerial Application D Aerial Observation OAirDrop D Air Race I Show D Flight Test D Public Use Ounlmown ZIP: 72501 0 Rotorcraft External Load (133) -or- 4 How many? lbs 0 Agricultural Aircraft (137) D Other Operator of Large Aircraft (If air or ground collision occurred, complete this section for other aircraft) Damage to Other Aircraft D Destroyed D Minor D Substantial 0None Manufacturer: Model: Registered Owner of Other Aircraft First Name: Middle Initial: Last Name: City: State: Country: ZIP: City: State: Country: ZIP: Pilot of Other Aircraft First Name: Middle Initial: Last Name: MECHANICAL MALFUNCTION/FAILURE 'Vas there .LVIechanical Malfunction/Failure? (If more space is needed, continue on separate sheet) DYes 0No GZI Unknown Total Time/Cycles On Part (Ifyes, list the name of the part, manufacturer, part no., serial no., and describe the failure.) Hours Cycles Time Since This Part Insp ected/Ove rha u led Hours DAMAGE TO AIRCRAFT AND OTHER PROPERTY Aircraft Damage 0None D Substantial 0 Minor (;li Destroyed Aircraft Fire bZl None 0 In-Flight 0 On-Ground D Both Grm.md and In-Flight D Unlmown Origin 4 Aircraft Explosion None DIn-Flight DOn-Ground Ji1 D Both Ground and In-Flight D Unknown Origin Description of Damage to Aircraft and Other Property (use additional sheet if necessary) aircraft destroyed on impact, long debris field AiRPORT INFO.RMATION. {lt1h~/-8d{id9.htn'ncident octUtred pil ·-app·roach,"titke_off ;ci~;v.;i~hi'ri 3illu~s ·df an alrp·ort;·-:c~·m·plete·th!s ~e~tiO~> ,. Airport Identifier: Airport Name: Proximity to Airport SM Distance From Airport Center: degrees MAG Direction From Airport: DOff AirportJAirstrip DOn Airport D On Airstrip ft.MSL Airport Elevation: Approach Segment (Select one) D Landing D On Instrument Approach 0 Crosswind IFR Approach (Check all that apply) 0None 0PAR D Sidestep OADFINDB OILS OSDF D Localizer Only OVOR!IVOR OVOR/DME D LOC-back course 0TACAN 0RNAV 0 0MLS OLDA 0ASR D Visual D Contact D Circling Practice 0GPS 0 Loran 0Unknown Runway Information RunwayiD: (L/R/C) Length: ft Width: Runway/Landing Surface (Check all that apply) D Asphalt D Grass/Turf 0Macadam D Concrete D Gravel D Metal/Wood Dice 0Dirt 0Snow Time of Departure Airport ID: Condition of Runway/Landing Surface (Check all that apply) 0Dry 0 Snow-Compacted D Water-Calm 0Holes D Snow-Crusted D Water-Choppy D Ice Covered D Snow-Dry D Water-Glassy 0Snow-Wet D Rough 0Wet D Rubber Deposits D Soft 0Unknown D Slush Covered D Vegetation ····"''~ Destination ·:,y.:, . .,,,.• 0None 0VFR Activated? Country: USA Type of ATC Clearance/Service (Check all that apply) D Special VFR lZJ None 0IFR 0VFR D Special IFR D VFR Flight Following D Traffic Advisory DVFROnTop Airspace where the accident/incident occurred (Check all that apply) D Prohibited Area OClassA 0 ClassE D ClassB eJ Class G D Restricted Area ODemoArea 0 Military Operations Area (MOA) D ClassC D Warning Area D Airport Advisory Area OClassD Aircraft Load Description (Check all that apply) D Towing Glider 0None D Towing Banner Ill Passengers D Cargo D Other External D Parachutists DWater D Chemical/Fertilizer/Seeds il.UEL.i& S.ERVICES'II\.II:,ORMATION :; :;:;;--f};' .. i ·~·,.,.-· Fuel on Board at Last Takeoff (convert from pounds, as necessary) 110 Gallons .. ·:?-:!.·.:>:\':'-'; ,·;),>'<":-'";''' Fuel Type D so/&7 D 100 Low Lead D 100/130 ·-.:d(\i:::: I ••' ··:.?5··· lZJ Company VFR D Military VFR State: OH Country: USA ,,,·~·>. Type Flight Plan Filed City: Pomeroy Time Zone: EST State: Ohio OGoAround VFR Approach (Check all that apply) D Stop and Go 0None D Touch and Go D Traffic Pattern D Simulated Forced Landing D Straight-In D Valleyfferrain Following D Forced Landing D Precautionary Landing OGoAround D Full Stop 0Unknown Airport ID: N/A Time: 0640 City: Grove City ft DWater 0Unknown ,:-;-;-:::,, i:ti} ·.••.. "l'iUGHi ITINERARY.IriiFORMATION ·:';-3,':; Last Departure Point 0 Final D Aborted Landing (after touchdown) 0 Base leg D Low Approach 0Downwind D Jet Training Area 0TRSA 0FAR93 0VFRJIFR 0IFR 0Unknown l;l] Yes ONo D Cruise D Unknown INA D Special D Air Traffic Control Area D Unknown D Livestock 0Unknown 'i::<}'!~;;,i•;,::•(•::·•.>C;;" ·'·.· )'·. . D 1151145 li'J Jet A D Automotive Other Services, if Any, Prior to Departure 5 0JP3 0JP4 0JP5 D Other, specifY ···· . .•..•.•,_., >;_Y:i; EVACUATION .OF AIRCRAFT •. Was an emergency evacuation of the aircraft performed? . ... Ill No DYes Method of Exit- Describe how the occupants exited and how many occupants evacuated each location . WEATHER INFORMATION AT THE ACCIDENT/INCIDENT SITE Source of\Veather Information Weather Observation Facility Method of Briefing (Check all that apply) Facility ID: (Check all that apply) IJ1 Company I!ZJ National Weather Service Observation Time: D Flight Service Station OTV!Radio Time Zone: 0 Automated Report D Commercial Weather Service (DUATS) Distance from Accident Site: 7 NM Direction from Accident Site: degrees :MAG Briefing Type/Completeness D Abbreviated !;ZI Unknown 0 Lowest Cloud Condition Height OTV!Radio ~Unknown 0Dawn 0Dusk 0Day IZJ Night D Dark Night D Bright Night Ceiling None (clear) D Broken Restriction to Visibility (Check all that apply) D 0 Obscured D Indefinite 0 Unknown ~Overcast Ceiling Height Wind Direction 'Wind Speed D Velocity: -or- 10 miles 0 Not Reported 0None D Blowing Dust D Blowing Sand D Blowing Snow D Blowing Spray 0Dust 0Fog D Ground Fog 0Haze DIce Fog D Smoke 0Unknown ftAGL 2,800 ftAGL \Vind Gusts KTS 0Calm 0 Light and Variable D Variable 0Unknown Visibility Not Pertinent Sky/Lowest Cloud Condition D Clear D Thin Broken 0 Thin Overcast 0Few D Partial Obscuration D Unknown D Scattered degrees rv1AG D Internet Light Condition 0Full D Partial I Limited By Pilot D Partial I Limited By Briefer Indicated: DIn Person D Teletype D Telephone/Computer D Aircraft Radio OMilitary Velocity: Type of Turbulence (Check all that apply) KTS 0None D Clear Air DIn Clouds Vicinity of Thunderstorm D Severity of Turbulence 0 Gusting D Not Gusting D Extreme 0 Severe D D Moderate Moderate Chop 0Light NOTAMs (D, Land FDC), AIRMETs, SIGMETs, PIREPs in effect at the time of the accident/incident Temperature: (F) 0< Altimeter Setting: or ~~~ ~~~ Density Altitude: Dew Point: or Icing Forecast Amount Ill None D Moderate D Trace 0 Severe 0Light (C) in.HG MB ft Icing Actual Amount (C) ~None (F) D Trace 0Light Type ofPrecipitation (Check all that apply) Type DRime 0 Clear D Mixed Type ORime D Clear D Mixed D Moderate D Severe 6 0None DRain 0Snow 0Hail D Rain Showers 0 Freezing Rain 0 Snow Shower 0 Drizzle DIce Pellets D Snow Pellets D Snow Grains D Ice Crystals D Ice Pellets Shower 0 Freezing Drizzle Intensity of Precipitation D Light D Moderate 0Heavy Pilot "A" Responsibilities at the Time of Accident/Incident ~Pilot D Co-Pilot D Student Pilot D Flight Instructor D Check Pilot D Flight Engineer D Other Flight Crew Pilot "A" Identification FITstNrume:cJ~eTn~n~if~e~r_____________________________________ Middle Initial: ;;;;;;:;;--Last Name: _:Tc:o:.<:p:.<:p.::e:_r- - - - - - - - - - - - - - - - - - - - - - - City: Sunbury State: OH Country""-:7 u;;;s"'A-- Age at time of Accident/Incident: _ __ Certificate Number:------------------------------- Degree of lnj ury 0 None JiZl Fatal D Minor 0 Date of Birth: Seat Occupied 0 Unknown D Serious Right D Center Shoulder Harness Seat Belt D Front 0 Rear D Left ZIP: 43704 0Unknown Used Available D Single rill Yes DNo 0No ~Yes ~!:]Yes Used Available ~ Yes 0No 0No Pilot Certificate(s) {Check all that apply) DNone D Private 0 Student !ill Flight Instructor Principal Occupation !i1 Pilot 0 Other 0Unknown D Recreational 0 Ill Commercial D Airline Transport Sport Medical Certificate D None 0 Class 1 [t1 Class 2 D Flight Engineer U.S. Military Medical Certificate Validity 0 Class 3 D Driver's License (Sport Pilot only) D Unknown D Foreign 0 Date of Last Medical ~ Without limitations/waivers D With limitations/waivers 0Unknown 10/19/018 mmlddlyyyy Certificate Limitations Medical Certificate \Vaivers None Date of Last Flight Review or Equivalent, Including FAR 1211135 Checks: Flight Review Aircraft Make: BHT Model: 206L-3 04/27.018 mmlddlyyyy Airplane Rating(s) Other Aircraft Rating(s) Instrument Rating(s) Instructor Rating(s) (Check all that apply) (Check all that apply) (Check all that apply) (Check all that apply) DNone ~Single-Engine Land D Single-Engine Sea D Multiengine Land D Multiengine Sea 0None D Airship D Free Balloon 0Glider D Gyroplane ~ Helicopter D Powered Lift DNone D Airplane e1 Helicopter D Powered Lift Type Ratings 0None D Airplane Single-Engine D Airplane Multi-Engine D Gyroplane D Powered Lift D Instrwnent Airplane 0 Instrwnent Helicopter Ill Helicopter 0Glider 0 Sport Student Endorsements (Include dates) All This Make Airplane Single Airplane Glider 7 Lighter Than Air ·.~~~·~·~·i.:.•/Xi::.···•···:x:.•r.:t:i•:•·<>·····················~.·'0::,;;::;c•,•:rJ.·.•· PIL.:Ot~'Bn Pilot "B" Responsibilities at the Time of Accident/Incident OPilot D Co-Pilot D Student Pilot D Flight Instructor D Check Pilot D Flight Engineer D .Other Flight Crew Pilot "B" Identification City: State: Country: First Name: Middle Initial: Last Name: Degree oflnjury 0None 0Minor D Serious Seat Occupied 0Left D Front D Right DRear OFatal 0 Unknown 0 Certificate Number: Date of Birth: Age at time of Accident'Incident: Seat Belt 0Unknown Used Available D Single Center ZIP: DYes DYes 0No 0No Shoulder Harness DYes DYes Used Available 0No 0No Pilot Certificate(s) {Check all that apply) D Recreational D Student D Flight Instructor 0None D Private D Sport Principal Occupation Medical Certificate 0Pilot Other 0Unknown 0None D Class I D Class 2 D D 0 0 Flight Engineer D U.S. Military Commercial Airline Transport Medical Certificate Validity D Class 3 D Driver's License (Sport Ptlot only) D Without limitations/waivers D With limitations/waivers 0Unknown 0Unknown 0 Foreign Date of Last Medical mm/ddlyyyy Medical Certificate Limitations Medical Certificate "\Vaivers Date of Last Flight Review or Equivalent, Including FAR 1211135 Checks: Flight Review Aircraft Mal{e: Model: mmlddlyyyy Airplane Rating(s) Other Aircraft Rating(s) Instrument Rating(s) Instructor Rating(s) (Check all that apply) {Check all that apply) {Check all that apply) {Check all that apply) 0None 0 Single-Engine Land D Single-Engine Sea D Multiengine Land 0 Multiengine Sea None Airship Free Balloon Glider Gyroplane Helicopter Powered Lift 0None D Airplane D Helicopter D Powered Lift I Student Type Ratings Fiigh~ !;~:r~e~t:~zJI;;;;' number ~in ~ !Pilotin I Time 0None D Airplane Single-Engine D Airplane Multi-Engine D Gyroplane D Powered Lift D D D D Instrument Airplane Instrument Helicopter Helicopter Glider D Sport (Include dates) Arrplon< All Aircraft This Make & Model •;;;·~-, Arrplon< Niebt ;n;;;:;\ f1.bi;' !Last 90 Davs 11.;;30Davs r:::l24 Ho;;; 8 Actu•l Simulott"'i~'~'"'''f''"~ti'"'''!i'"'>; RASSENGER(S) IOT!iER PERSONNEl/ (i rldude trig'ti(atten-dal1bi(tO.nfi riUEi _o·~:·S~Pifr~tE{~h-~et :tf_ ilt!t~SS~i'Y) -,~1{ '"'"L: to • • •• • • 5t-st-·= • • ~e < ·- = c = ,_, !l• ~ §t ~ Name and Address eli ~ ~0 ;:: 0: ~]':E§ ~ • u "" • • .. . ~ First Name: Rachel Middle Initial: L Last Name: Cunmngnam City; Galloway State: OH Country; USA ZIP: ZJ3119 First Name: Bradley Middle Initi'j!j J Last Name: aynes City; London State: OH Country: OSA ZIP: 43140 First Name: Middle Initial: Last Name: City: State: Country: ZIP: First Name: Middle Initial: Last Name: City; State: Country: ZIP: First Name: Middle Initial: Last Name: City: State: Country: ZIP: First Name: Middle Initial: Last Name: City: State: Country: ZIP: First Name: Middle Initial: Last Name: City: State: Country: ZIP: First Name: Middle Initial: Last Name: City; State: Country: ZIP: 9 --- -- -- --- -- -- . "' ~D D D D ~ D D D D Iii D D D D li!D D D D D D D D DD D D D D D D D D DD D D D D D D D D DD D D D D D D D D DD D D D D D D D D DD D D D D D D D D DD D D D D . NARRATIVE HISTORY OF FLIGHT (Pieas~e or print in Ink) . . Describe what occurred in chronological order, including circumstances leading to and nature of accident/incident. Describe terrain and include wreckage distribution sketch if pertinent. Attach extra sheets if needed. State time and point of departure, intended destination, and services obtained. HAA flight from Mt Carmel Hospital in Grover City Ohio. Destination was hospital in Pomeroy, Oh RECOMMENDATION (How could this accident/incident have been prevented?) Operator/Owner Safety Reconnnendation After in airframe data Is analyzed 10 ADDITIONAL INFORMATION (Please type or print in ink) Use this space if additional space is needed for any answers. I HEREBY(:;E~TIFYTHJ\,tTijE AB()VE !NFORM)\,TiON .IS C.OMPLETE 1\f'IDAc§ur#'rE TO Date of this Report Signature and Name ofPilot/Operator 02/05/018 mmlddlyyyy Signature and Name Signature: TH~.BESTOF MY.KNOWL~DGE ··.··•· £ Signature: Type or Print Name: of~n Filing Report if Other than Pilot/Operator --··· Type or Print Narrr€(Gary E Mercer Title: Director of O~erations . . ·• < ······· •·· .... · NTSB Accident/Incident No. CEN19FA072 . <. ICentral - Denver, CO . f'ORNTSB USE ONLY •.. •• ·.·. / ··.·•·· Name of Investigator Reviewed by NTSB Regional Office Shaun Williams 11 .. ... · · ···. .. ··. ·.. . ·.·......•... ~··· Date Report Received 2/14/2019