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NTSB releases report on fatal N.Y. medical helicopter crash

Investigators focused on pilot errors involving the vortex ring state during the second training flight of the Mercy Flight helicopter

By Jon Harris
The Buffalo News

ELBA, N.Y. — April 26, 2022, was an annual training day for Mercy Flight’s pilots.

A Bell Helicopter flight instructor was in town to provide factory training of the Bell 429 helicopter, intended to give an extra layer of comfort and security for the pilots of the Cheektowaga-based nonprofit provider of emergency air medical transport.

But on the second training flight of the day, something went terribly wrong just before 1 p.m. while over rural Genesee County.

[RELATED: 2 killed in copter crash ID’d as Mercy Flight pilot, Bell Helicopter employee/pilot]

A just completed final report from the National Transportation Safety Board — released nearly 20 months after the double-fatal accident — sheds light on what was Mercy Flight’s darkest day, when one of its pilots, James E. Sauer, and Bell flight instructor Stewart M. Dietrick were killed when their helicopter crashed in the Town of Elba. Sauer and Dietrick were longtime pilots with thousands of hours of flight experience.

In the report, the NTSB said the cause of the crash boiled down to errors made by one or both of the pilots — the helicopter had dual controls — during a training maneuver that required the pilot to pull the aircraft out of an unstable flight condition known as a “vortex ring state.” In a matter of seconds, the helicopter’s main rotor blades struck the aircraft’s tail, causing it to break up in flight. Also causal, the agency noted, was the “flight instructor’s inadequate monitoring of the flight.”

NTSB investigators keyed in on an 18-second window from 12:59:26 to 12:59:44 that day, when the helicopter entered into vortex ring state, which is characterized by an “unstable condition in which a helicopter experiences uncommanded pitch-and-roll oscillations, has little or no collective authority” and reaches a rapid descent rate.

The NTSB’s report noted that, on the first training flight that day, Dietrick had another Mercy Flight pilot perform a vortex ring state recovery maneuver. The information gathered, the NTSB said, indicates Dietrick also had Sauer enter into vortex ring state for training purposes.

At 12:59:47 — 13 seconds shy of 1 p.m. — recovered flight data show there were “multiple abrupt control inputs” recorded, with the cyclic nearly full forward and to the left, with right antitorque pedal applied.

The NTSB determined it was these abrupt, inappropriate moves that resulted in the helicopter’s main rotor blades contacting the tail boom.

When main rotors — which spin above the helicopter to lift and push it forward — flex or dip down and essentially slice the helicopter in two while in midair, it is called a tail-boom strike.

The NTSB’s preliminary report released in May 2022 noted a fracture in the tail was consistent with main rotor blade contact, but it wasn’t until the final report released late last week that investigators determined what had likely caused the crash.

The agency’s investigation found no evidence of any mechanical malfunctions or failures of the helicopter that would have precluded recovery from vortex ring state.

The NTSB said it could not determine “why the pilot(s) might have applied these abrupt control inputs” inside the cockpit.

‘Questions that remain unanswered’

In an interview with The Buffalo News, Mercy Flight Executive Vice President Scott Wooton said the report confirms the assumption the organization had that this was a “maneuver that went wrong and caused, somehow, for the main rotors to come in contact with the tail boom.”

Since there were dual controls in the helicopter for the training flight, with both Sauer and Dietrick sitting up front in the cockpit, Wooton said it is hard to know whether it was Sauer or Dietrick — or both of them — who made the abrupt control inputs that led to the crash.

“We’ll just never know what caused those abrupt maneuvers,” Wooton said. “Who was doing what, at what time? Those are the things that we’ll never know. So there’s always going to be questions that remain unanswered here.”

NTSB spokesperson Peter Knudson confirmed it is unclear who made the abrupt inputs.

In a statement Wednesday evening, Bell did not comment specifically on the report but said it is “extremely saddened by the accident that resulted in the loss of two pilots, including one of our Bell teammates.”

“Out of respect for the privacy of the families involved, we are unable to answer questions or share additional information,” Bell said, echoing a statement the company made on April 26, 2022.

Wooton stressed that Mercy Flight has never sought to point the finger at anyone in particular and has moved past any kind of assignment of blame for the crash. Instead, the organization has focused more on healing from the incident and staying in contact with the affected families, particularly the Sauer family.

“Mercy’s Flight standpoint on that is it’s a terrible tragedy,” Wooton said. “And as far as assigning any sort of blame to it, that’s for others to decide or be interested in. Both of those gentlemen were very experienced pilots, very capable pilots. Both just really top-class aviators and, you know, the loss of either of them, individually, is great, but the both of them together, it’s just a terrible tragedy.”

Both Sauer, from the Rochester suburb of Churchville, and Dietrick, of Prosper, Texas, were 60 years old and died of multiple blunt force injuries from the crash.

Sauer, who served in the U.S. Army, flew for the State Police for nearly 20 years until his retirement in 2020, which is when he began to work as a pilot for Mercy Flight.

Dietrick also had a long career as a pilot, including serving in the U.S. Coast Guard and working for an air ambulance before joining Bell, according to published reports.

The NTSB report notes that Sauer had 6,030 total aircraft hours, including 580 in the helicopter make and model he flew that day. Dietrick had an estimated 2,850 aircraft hours, including 500 in that same helicopter make and model.

That day’s first training flight

Another key to the NTSB’s investigation into the crash was information collected from the first training flight of the day on April 26, 2022, which involved another Mercy Flight pilot and the same flight instructor, Dietrick.

NTSB investigators interviewed that pilot on May 17, 2022, and he described how Dietrick also had him perform a vortex ring state recovery maneuver, also known as “settling with power.”

The pilot accomplished the maneuver and told the NTSB that he thought the descent rate was maybe 500 feet per minute, but not more than 1,000 feet per minute.

But shortly after, the instructor asked the pilot if he had ever “really gotten into” vortex ring state, adding that the helicopter could go a lot deeper than they had just gone in the prior maneuver, according to a record of the NTSB’s conversation with the first pilot.

Dietrick requested the pilot do the maneuver again.

During the next entry into vortex ring state, the pilot told the NTSB that the helicopter developed a very high descent rate, possibly as much as 1,800 feet per minute. The NTSB, in the report, said flight data recovered confirmed a “very high descent rate.”

The pilot said he was surprised that Dietrick did not intervene as the helicopter got deeper into the state.

While in vortex ring state, “the pilot stated that he didn’t know why they were going so deep” into the state and “that the instructor was just sitting there, ‘hands on his lap,’ ” according to the report.

“So, the pilot, feeling uncomfortable at that point, had to exit this very high descent rate on his own rather than waiting for further guidance from the instructor pilot,” NTSB investigators wrote in the report.

The remainder of the first flight was uneventful, the NTSB noted in its report. After the pilot flew out of the settling-with-power state, they worked on auto rotations and flew back to Genesee County Airport in the Town of Batavia.

Based on the comments from the first pilot that day, the NTSB concluded that “it is likely the flight instructor did not provide adequate information to the accident pilot on how he would receive training for” vortex ring state, including how they would identify, enter and exit that state.

‘A step toward closure’

Wooton, Mercy Flight’s executive vice president, said the report confirmed some of the organization’s assumptions. But its release made for a tough day, with many difficult conversations.

Wooton said he called Sauer’s son, Josh, after the report came out on Friday and expressed his condolences again.

“It’s tough to relive the day, and that’s kind of just what you do when you read that final report,” Wooton said. “You’re going over all the facts, and you go right back to that same place that you were when it happened, and it’s tough to do. But it is a step toward closure.”

As an organization, Mercy Flight is back to its full fleet of four helicopters. For more than a year, the organization was down to two helicopters following the crash in Elba and a hard landing in October 2021 , when a pilot lost visual reference to the ground in a fog just north of Genesee County Airport.

One of the two new helicopters was publicly introduced in June, with the pilot’s door featuring a decal that reads “in honor and remembrance of pilot James E. Sauer .”

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