Medical Impairment and Terrain Collision Destroy Eurocopter BK 117

Casualties unknown • nahe Weilheim an der Teck, DE

A medical transport helicopter crashed into a wooded mountainside near Weilheim an der Teck, killing all four occupants after the pilot's perception was likely impaired by medication.

What happened

On September 28, 2005, at 11:14 AM, a Eurocopter BK 117 B-2 helicopter crashed into the wooded slope of a 794-meter mountain near Weilheim an der Teck. The aircraft was performing a medical transfer, transporting a patient from the Schillerhöhe Clinic in Gerlingen to the Munich-Großhadern Clinic.

The flight departed at 11:03 AM. After clearing the Stuttgart airport control zone, the helicopter maintained a constant heading and speed, likely utilizing autopilot. Despite the terrain rising ahead, the pilot ended the climb at an altitude of 2,300 feet AMSL, which was insufficient to clear the ascending landscape. The aircraft continued in level flight at a constant speed, eventually striking the mountainside approximately 60 meters below the peak. All four fatalities occurred on board, including the crew and the patient.

The investigation

The BFU investigation focused on the pilot's physiological state and the flight's operational circumstances. Investigators analyzed radar data, which showed the flight path remained unchanged despite the approaching terrain. Toxicological analysis of the pilot was conducted, and the investigation also examined the pilot's medical history, professional workload, and the company's safety reporting culture.

Findings

  • Drug impairment: Toxicological tests revealed high concentrations of Diphenhydramine in the pilot's system, along with Diazepam, Midazolam, and Sufentanil. The synergistic effect of these sedatives and analgesics likely caused a significant impairment of the pilot's perception and ability to react.
  • Inadequate climb profile: The pilot terminated the climb at a height that did not allow for the clearance of the rising terrain.
  • Lack of situational awareness: The paramedic was seated facing backward to assist with patient care, preventing him from noticing the impending collision. The doctor's view was also severely limited by the seating arrangement and the demands of medical care.
  • Systemic failures: The pilot was under significant personal and professional stress, which likely led to the use of sedatives. Furthermore, the company's internal reporting system was not utilized by colleagues to report safety concerns regarding the pilot, partly due to fears regarding anonymity.
  • Medical oversight: There were discrepancies in the pilot's medical self-reporting, and the existing medical examination process lacked the mechanisms to verify health claims against objective diagnostic findings.

Probable cause

The primary cause of the accident was the pilot's impaired perception and reaction capability, likely resulting from the synergistic effects of multiple sedatives and analgesics found in his system. This was compounded by a failure to maintain a sufficient climb profile to clear the rising terrain and a lack of situational awareness among the crew members focused on patient care.

Frequently asked questions

What happened in the 2005-09-28 Eurocopter Deutschland BK 117 B-2 accident near nahe Weilheim an der Teck, DE?

A medical transport helicopter crashed into a wooded mountainside near Weilheim an der Teck, killing all four occupants after the pilot's perception was likely impaired by medication.

What aircraft was involved and where did it happen?

The accident on 2005-09-28 involved a Eurocopter Deutschland BK 117 B-2, at nahe Weilheim an der Teck, DE.

What was the probable cause of the accident?

The primary cause of the accident was the pilot's impaired perception and reaction capability, likely resulting from the synergistic effects of multiple sedatives and analgesics found in his system. This was compounded by a failure to maintain a sufficient climb profile to clear the rising terrain and a lack of…

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