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Casualties unknown

2005-09-28: Eurocopter Deutschland BK 117 B-2 — nahe Weilheim an der Teck, DE

nahe Weilheim an der Teck, DE

On September 28, 2005, an Eurocopter Deutschland BK 117 B-2 was involved in an aviation accident near nahe Weilheim an der Teck, DE. Investigators recorded the probable cause as: Immediate causes: A mutually reinforcing effect of various medications could have led to impaired perception and ability to act in the pilot during flight, though other organic causes could not be excluded; the climb to cruising altitude was terminated at a… This summary draws on records from the German Federal Bureau of Aircraft Accident Investigation (BFU).

Sourcesthe German Federal Bureau of Aircraft Accident Investigation (BFU)Primary reportUpdated 1785061435Data APIEditorial standards

On 28 September 2005, a BK 117 B-2 rescue helicopter struck a wooded slope near Weilheim an der Teck, Germany, resulting in the destruction of the aircraft and fatal injuries to all four occupants. The investigation identified multiple contributing factors including possible medication impairment and failure to maintain adequate terrain clearance.

Accident Overview

On 28 September 2005 at approximately 11:14 local time, a Eurocopter BK 117 B-2 helicopter, operated as a rescue aircraft, collided with a wooded steep slope of a 794-meter-high mountain near Weilheim an der Teck, Germany. The helicopter was destroyed in the impact, and all four occupants sustained fatal injuries. The accident was reported to the German Federal Bureau of Aircraft Accident Investigation (BFU) at 12:15, which immediately initiated an investigation.

Flight History

The helicopter departed from Klinikum Schillerhöhe in Gerlingen (Stuttgart) at 11:03 for a visual flight to transfer a patient to Klinikum München-Großhadern. Shortly after takeoff, the pilot contacted Stuttgart Airport's aerodrome control to transit the control zone. Due to arriving traffic, the helicopter initially remained north of the airport. Once traffic permitted, it crossed east of the airport on a southerly heading, then followed the A8 motorway eastbound. At 11:09:30, the pilot reported leaving the control zone near Wendlingen. No further radio communications occurred. The helicopter was cruising at approximately 60 meters below the mountain peak when it flew into the wooded slope.

Aircraft and Occupants

The helicopter, a BK 117 B-2, was carrying a pilot, a physician, a paramedic, and a patient. The paramedic was seated on a folding seat behind the left front seat, facing opposite the flight direction, to assist the physician with patient care during the flight.

Meteorological Conditions

At the time of the accident, the mountain peak was clear of clouds, and horizontal visibility exceeded 10 kilometers.

Injuries and Damage

All four occupants sustained fatal injuries. The helicopter was completely destroyed. Ground damage occurred as well.

Investigation and Causes

The BFU investigation concluded that the immediate causes of the accident were:

  • A mutually reinforcing effect of various medications might have impaired the pilot's perception and ability to act during the flight, though other organic causes could not be excluded.
  • The climb of the helicopter to cruising altitude was terminated at a height that, with the maintained heading, was insufficient to clear the clearly visible rising terrain ahead.
  • The collision hazard was not noticed by the paramedic because he was occupied with patient care and seated facing away from the flight direction.
  • The helicopter continued unpowered horizontal flight at unchanged speed and direction, even after descending below the minimum safe altitude over rising terrain, until it flew into the wooded slope.

Systemic causes identified included:

  • The pilot's overall workload from private circumstances and numerous duties during duty, rest, and leisure time likely led him to take sedatives or sleeping medications.
  • The pilot's decision not to avail himself of possible relief from station duties for additional tasks.
  • The company's failure to relieve the pilot from station duties for special tasks.
  • The medical environment, daily contact with injured persons and medications, potential professional consequences, and absence or non-perception of direct side effects likely contributed to the pilot not reporting the use of sedatives for fitness-to-fly assessment.
  • The reliability of the pilot's medical fitness examination was not ensured because systemically it did not require cross-checking the pilot's statements against an objectively diagnosed health status.
  • Control of medically conspicuous findings, derived examination procedures, and reporting obligations to the German Federal Aviation Office (LBA) were not provided for in the fitness examination regulations and thus did not occur.
  • The internal reporting system at the air rescue center was not used by employees for safety-relevant observations about the accident pilot, as they did not consider their identity reliably protected due to the pilot's role in the flight safety team.

Probable cause

Immediate causes: A mutually reinforcing effect of various medications could have led to impaired perception and ability to act in the pilot during flight, though other organic causes could not be excluded; the climb to cruising altitude was terminated at a height insufficient to clear the rising terrain; the paramedic did not notice the collision risk due to patient care duties and seating orientation; the helicopter continued horizontal flight at unchanged speed and direction until impact. Systemic causes: The pilot's overall workload likely led to use of sedatives or sleeping medications; the pilot declined relief from station duties for additional tasks; the company failed to relieve him; the medical environment and lack of reporting of medication use; lack of cross-checking in fitness examinations; inadequate control of medical findings; and non-use of the internal reporting system due to anonymity concerns.
Controlled flight into terrain

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