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CEN10LA078 · Bell Helicopter Textron Canada 407

25 Dec 2009 · Decatur, TX, United States

Air Evac EMS Bell Helicopter Textron Canada 407 · Accident: loss of engine power (total) during takeoff

From Wise Regional Health System Heliport (XA57) to Wichita Falls, TX

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Event

NTSB case
CEN10LA078
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
0 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
General aviation
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

Bell Helicopter Textron Canada 407

Aircraft type
Bell 407
Category
Helicopter
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N600CE
Operator
Air Evac EMS
Onboard fatalities
Unknown
Route
From Wise Regional Health System Heliport (XA57), Decatur, TXTo Wichita Falls, TX
Aircraft age
Not recorded
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 91: General Aviation
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Takeoff
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Loss of engine power (total)
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Substantial

Cause areas

  • Aircraft › Aircraft power plant
  • Environmental issues › Conditions/weather/phenomena

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

The pilot, flight medic, and flight nurse were departing from a hospital helipad for the purpose of a cross-country positioning flight. As the helicopter ascended about 50 to 60 feet above ground level (agl), the pilot heard two warning horns sound, followed by the helicopter yawing 90 degrees to the left. The pilot lowered the collective in an effort to preserve rotor rpm and maneuvered the helicopter back over the helipad. Around 5 to 8 feet agl the pilot increased collective pitch, but the helicopter continued a quick descent until it experienced a hard landing back on the helipad.

A review of hospital video surveillance footage for the 24 hours prior to the accident revealed that the helicopter remained parked outside for approximately 5 hours in blowing snow conditions; during this time, it was not equipped with plugs or covers over the engine inlets or the exhaust. The plugs and covers were installed later and the helicopter remained outside in temperatures ranging from 16 degrees Fahrenheit (F) to 34 degrees F for the next 19 hours. The video also revealed that at no time did anybody look at the exhaust stack, right side engine intake, or open any access panels prior to the operation of the helicopter.

An examination of the recorded Engine Control Unit (ECU) data revealed that during the flight, the helicopter’s engine experienced a momentary flameout followed by a successful relight. Although the engine power was increasing, due to the helicopter’s close proximity to the ground, the pilot was unable to recover main rotor rpm before ground impact. As part of the postaccident examination, the engine was removed from the airframe and an engine run was performed. There were no anomalies found with the airframe or engine that would have contributed to the loss of engine power. The operator’s procedure manual stated that the pilot must ensure that all ice, snow, and frost is removed from the engine inlet area. The helicopter manufacture’s flight manual stated that as part of the preflight inspection, the pilot must check that the engine inlet area is cleaned of all debris, accumulated snow and ice. The engine manufacturer’s Operation and Maintenance Manual gave a precaution that the accumulation of snow or ice may result in the engine experiencing a flameout.

Probable cause

The pilot's inadequate preflight inspection and the momentary loss of engine power due to snow or ice ingestion.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record CEN10LA078
Event ID
20091228X85137
Case number
CEN10LA078
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: investigation status. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.
  • API snapshot SHA-256: 9e739a3b7c56f55282c6291ef877923fa051cb43636d154b8835b33fe14fe896; retrieved 2026-09-15T13:35:38.447Z.