The NTSB will hold a public hearing on December 10 regarding the fatal doors-off helitour photo flight that crashed into New York’s East River on March 11, 2018.
The NTSB’s exhaustive accident document docket related to the crash paints a complex mosaic of an air charter provider under seasonal economic pressure, evidence of an inconsistent safety culture, malfunctioning emergency equipment, thin FAA oversight, flashes of mercurial and sometimes loose management, and an intoxicated front seat passenger that all combined to create one of the most dramatic and high-profile U.S. helitour accidents in recent years.
The accident helicopter, N350LH, was a 2013 Airbus Helicopters AS350B2 owned by Meridian I Consulting and operated by Liberty Helicopters for FlyNYon. FlyNYon operated its own helicopters, but at the time relied on Liberty to provide supplemental lift under a year-long arrangement that began in September 2017. The accident helicopter was operating under the Part 91 section 119 aerial photography exemption, with five passengers and one pilot aboard when it crashed at approximately 7:08 p.m., 11 minutes after takeoff from the Helo Kearny (65NJ) heliport in Kearny, New Jersey. Moments after being cleared into Class B airspace at 2,000 feet, pilot Richard Vance, 33, radioed a mayday call and indicated an engine failure.
East River Impact
Amateur video showed Vance performing an autorotation into the East River in low light, glassy water conditions and making a slightly nose-high, hard landing. The impact point was just north of Roosevelt Island at 86th Street. The helicopter immediately rolled right with main blades churning into the water, where it rolled inverted. The water temperature at the time was estimated to be below 40 degrees F and the river current was five knots.
Vance emerged from the wreckage within 90 seconds and was taken aboard a passing tug. However, it took rescuers considerably longer to free the passengers—all in their 20s and 30s—described as “tightly harnessed” by New York’s Fire Department (FDNY), and all were pronounced dead either at the scene or later at area hospitals. The passengers were identified as Daniel Thompson, 34; Tristan Hill, 29; Carla Vallejos-Blanco, 29; Brian McDaniel, 26; and Trevor Cadigan, 26.
A preliminary FAA report on the accident indicated that the right-side emergency tri-floats appear to have not been fully inflated at the time of impact. The emergency floats had previously failed to inflate during three separate hangar tests at Liberty, as well as during inspections at other operators, according to the NTSB. A post-crash examination of the floats showed damage to three of them and a kink in a pressurization hose. A Liberty mechanic said floats can be damaged as passengers repeatedly mistake them for steps. The cyclic-mounted float activation handle was also notoriously difficult to use, requiring some pilots to use both hands. Vance, in fact, injured his hand while pulling the handle on the accident flight.
Vance said that, after experiencing what he thought was engine failure, during the autorotation sequence he noticed that the emergency fuel shutoff lever was already in the off position and that a portion of the front seat passenger tether was underneath the lever. At that point, the pilot said he had insufficient altitude to effect an engine restart.
An NTSB analysis of GoPro camera footage taken aboard the accident helicopter shows that passenger Cadigan was seated on the front bench passenger seat in the (far-left) number-two passenger position and identified as PS-2 in NTSB documents. The number-one (middle) passenger position, next to the pilot, was unoccupied. Four passengers were seated on the rear bench. Video footage shows pilot Vance repeatedly either trying to block Cadigan, who leaned/reclined back across seat number-one with his head crossing the center pedestal while taking photos, or gesturing to him to refasten his factory-installed lap belt.
Initially, the tether tail from Cadigan’s supplemental harness appeared loose but hanging in the area of the floor-mounted controls. Later in the flight, the tether tail appeared taut. According to the NTSB, “Contact with the floor-mounted controls was not visible, but the tautness of the tether tail led directly to that area.” Immediately thereafter, video shows that “the pilot’s left hand and arm motion were consistent with lowering the collective,” a motion consistent with autorotation entry.
The coroner’s report showed that Cadigan had a blood alcohol level of 0.18, more than twice the legal limit for operating a motor vehicle. Post-mortem blood draws from other passengers showed either no alcohol or trace amounts. Preflight banter captured by the GoPro recorded a passenger talking about “liquid courage” and consuming “five bloody marys.” Pilot Vance joked about drinking before flying, “They tell us we're not supposed to drink before we fly too, but I mean, come on.” (Vance’s post-crash toxicology was clean.)
A FlyNYon passenger on another flight who stood next to Cadigan in the terminal during check-in, aviation journalist Eric Adams, told the NTSB that Cadigan had a “very pronounced whiff of alcohol on his breath” that was very noticeable to him. According to Adams’s NTSB interview, “everyone in the room knew [about the odor]” including FlyNYon staff. Adams also said Cadigan did not seem drunk, merely having a good time.
Liberty, which flies its own traditional doors-on helitours and is a charter provider for the Blade per-seat, on-demand service, has a formal policy of not boarding impaired passengers. FlyNYon’s policy pre-crash was to deny boarding to obviously intoxicated passengers but to leave the assessment of compliant but impaired passengers up to the pilots.
Passenger Harnesses
The passenger harnesses used by FlyNYon on the accident flight had created concern and potential floor-control flight issues before, according to company pilots interviewed by the NTSB. Pilot Vance told investigators there had been previous events with harness tethers “inadvertent or otherwise” as well as with purses and cameras—and the passengers themselves—when they are on the cabin floor and get close to the controls. Liberty’s director of training Brent Duca echoed this concern to investigators. He said the safety culture at FlyNYon “sucked.”
“If it wasn’t cool, if it didn’t support the brand, if you weren’t a team player, it didn’t fly,” he told the NTSB. “Guys [Liberty pilots] were chastised. You knew not to challenge NYon.”
There were also concerns about passengers unbuckling from the standard factory seatbelts. According to the NTSB, minutes from a November 2017 pilots’ meeting noted, “Vigilance about seatbelt: please be continually watchful regarding passengers removing their seatbelt during flights, either on purpose or accidentally. Winter clothing can be cumbersome and it's easy to bump the seatbelt off. Also note if passengers do not speak English and are having a hard time understanding instructions.”
The standard FlyNYon harnesses were described as of the yellow off-the-shelf rock climbing/construction variety that attached to interior aircraft cabin hardpoints via a carabiner. In the event of emergency egress, passengers were instructed to cut the harness away via a sheathed knife on the harness. The standard-provided knives on the yellow harnesses cut through the tethers, “but not easily,” one pilot reported. Scott Fabia, Liberty pilot and safety officer, told the NTSB that cutting through the yellow harnesses “took some work.”
During his preflight passenger briefing on the fatal flight, pilot Vance intimated the difficulty to disengage from the harnesses, telling his passengers, “When we come back, do me a favor-umm ya know-don’t worry about takin’ any gear off yet ya know or trying to get untethered. Let me shut down. We’ll get out and help you guys.” In fact, Liberty pilots had taken over the chore of securing passenger harnesses due to lack of faith in FlyNYon’s “customer experience representatives” to do the job properly. One of the last words recorded aboard the accident helicopter after it hit the water was from a back seat passenger. Referring to his harness, he asked, “How do I cut this [expletive]?”
Pilots began to voice concerns about the harnesses as early as October 2017, and FlyNYon had in fact ordered what are now FAA-compliant blue harnesses that offered superior passenger comfort and were viewed as safer. However, the number of blue harnesses delivered was insufficient to support operations and the old-style yellow construction harnesses continued to be widely used on FlyNYon flights, including the accident flight. At the time of the accident, a FlyNYon customer experience representative said the company had 30 to 40 yellow harnesses and 15 blue harnesses but could only use five of them because they did not have cutters for the other ten.
During peak load times, FlyNYon reportedly had shortages of key passenger components. In February 2018, Liberty’s training director complained in an email of a shortage of tethers, harnesses, carabiners, and headsets. “We need enough harnesses and equipment so we can have the six aircraft flying and the next six sets of pax ready to fly. We cannot be waiting for aircraft to land so we can scavenge parts off landing passengers so we can get the next group ready.”
Doors-off Concerns
Liberty pilots had expressed concerns about operating FlyNYon doors-off flights from their inception. Liberty management opposed the flights and then reversed course in mid-2017. The reversal was said to be fueled by financial considerations: Liberty saw 50 percent of its tour flights from the Wall Street heliport slashed under a 2016 “voluntary” agreement between the New York City Economic Development Corporation and the Helicopter Tourism and Jobs Council. Helitourism had accounted for 75 percent of Liberty’s flights over the last 20 years before the agreement. The deal eliminated nearly 30,000 New York City-originated helitour flights annually and all flights on Sundays effective January 2017 for all operators including Liberty. New York City officials had been pushing for a complete ban on helitour flights.
The deal prompted some helitour operators, including Liberty, to establish passenger terminals in New Jersey, but that still did not completely compensate for the loss of business triggered by the deal. The resulting revenue decline forced belt-tightening at Liberty including its withdrawal from the Tour Operators Program of Safety (TOPS), a voluntary helitour industry association that conducts safety audits and promulgates best practices among its members. Liberty executives told the NTSB that FlyNYon flights contributed only 7 to 8 percent of the company’s total annual revenues in 2017 and was expected to generate a little over $1 million for the company in 2018; however, during the lean winter helitour months, they comprised a larger share of Liberty’s bottom line. FlyNYon paid Liberty a flat rate of $1,200 per flight hour and flew 11,000 to 12,000 passengers in 2017.
John Simone, Liberty’s former helicopter safety officer, told the NTSB that he thought doors-off flights “were ridiculous” and that doing them at night “added to the madness.” Simone said veteran pilots did not want to do the flights because they understood the risks, and that often left flights to low-time pilots who did not. Pilot Fabia said he was concerned that wind from doors-off flights could blow passenger headsets into a tailrotor, that a cell phone could be inadvertently dropped from a helicopter, that passengers risked direct impact from bird strikes, or that a suicidal passenger could easily jump. Indeed, the NTSB discovered that a fire extinguisher had flown out of a FlyNYon flight in New York and a passenger's shoe fell from a flight in Miami.
When pilots complained about having to fly doors-off in cold weather they were told to “suck it up.” Pilots also reported that the minimum allowable temperature for doors-off flights kept falling, beginning at 45 degrees F and ending at the time of the crash at 30 degrees F. Tour helicopter forward speeds varied typically from 60 to 100 knots. Pilot Vance described to investigators his clothing on the day of the crash: boots, Hanes socks, winter socks, boxer shorts, cold-weather compression pants, jeans, a long-sleeve thermal shirt, a hoodie, a nylon jacket with an inner and outer shell, and thin gloves (not ski gloves) that provided him with sufficient dexterity. Vance said the weight of his clothing impacted his decision not to attempt to rescue his trapped passengers by swimming into the submerged helicopter cabin. Other Liberty pilots expressed concerns about how the cold would impact their dexterity and ability to control the helicopter. Liberty did give pilots the option to alternate with other pilots and fly every other doors-off tour flight to rewarm when temperatures were sufficiently cold.
The CEO of FlyNYon, Patrick Kevin Day, a former line pilot who had once served as Liberty’s marketing director, sometimes reacted to critical pilot feedback with profanity-laced email rants, which the NTSB included in the docket, some of which surfaced as early as April 2018 in the New York Times. By then some New York-based FlyNYon pilots had retained the Washington, D.C. law firm of Katz, Marshall, and Banks to represent them and provide whistleblower protection. Firm attorney Joseph Abboud told AIN at the time, “We are representing a group of pilots who have strong concerns about a lax safety culture at FlyNYon and who have provided information to the FAA and the New York State Attorney General's (AG) Office relating to their concerns.”
In the emails, Day defended the old-style yellow harnesses, those employed on the crash flight, as safe and described Liberty pilots who had safety concerns about the doors-off flights as “dinosaurs,” pointing out that FlyNYon’s doors-off flights had grown by 400 percent “when operators in Vegas shrunk by 28 percent and operators in NY shrunk below the 50 percent line the government cut them.” In his interview with the NTSB, Day persistently maintained that FlyNYon’s operations were safe, but admitted that a formal risk assessment of the harnesses used by the company had not been performed. Day denied that the company boarded intoxicated passengers.
But the NTSB uncovered significant safety concerns with regard to implementation of widely accepted industry best practices at both Liberty and FlyNYon. Liberty’s director of operations, Patrick Day, Sr., father of the FlyNYon CEO, told investigators that the company did not use a flight-risk assessment tool, calling it “a bureaucratic morass.” Scott Fabia, a line pilot and Liberty’s safety officer, said his responsibilities for the latter did not include anything “formally” and that he had no knowledge of any safety management system at the company. Meanwhile, Liberty’s chief pilot, Paul Tramontana, told the NTSB that FlyNYon’s safety culture was not comparable to Liberty’s and characterized it as all over the place with nothing really defined.
NTSB interviews of local FAA officials also uncovered safety gaps stemming from the lack of regulation pertaining to the doors-off helitour industry before the crash. Specifically, the NTSB found that, while certain agency inspectors had “concerns” about what was going on at FlyNYon, the FAA did not scrutinize FlyNYon operations largely because they were conducted under Part 91, as opposed to Part 135. While inspectors did “look at” the yellow, old-style FlyNYon harnesses, they avoided “any specific evaluation because there was no rule, policy, or guidance that would provide any inspector with what the standard should be during surveillance or inspection.”
Eight days after the crash, the FAA banned doors-off flights that do not employ quick-release harnesses. The agency now requires operators of all doors-off flights for compensation to obtain an FAA letter of authorization (LOA) for the use of supplemental passenger restraint systems (SPRS). “The LOA will be issued after determining that the restraints to be used can be quickly released by a passenger with minimal difficulty and without impeding egress from the aircraft in an emergency,” it noted. The FAA did not specify the type of restraint to be used but rather its characteristics, including that the “SPRS must not require the use of a knife to cut the restraint, the use of any other additional tool, or the assistance of any other person. An SPRS also must not require passenger training beyond what would be provided in a preflight briefing."
In the wake of the crash, Liberty CEO Drew Schaefer resigned. FlyNYon no longer uses Liberty for supplemental lift. Patrick Day, Sr. is no longer director of operations at Liberty. FlyNYon now uses only the newer, more robust blue harnesses on flights that are FAA-compliant.
In September 2018, FlyNYon dismissed its chief pilot Michael Campbell after he was arrested on charges of smuggling more than four pounds of cocaine.
In August 2019, FlyNYon came under fresh criticism for offering doors-off flights to customers and their pets. In the wake of this criticism, FlyNYon no longer allows pets on flights. The company said its half-price ticket campaign aimed at pet owners raised $25,000 for animal charities.
U.S. Senate majority leader Chuck Schumer (D-NY), criticized the pet flights and FlyNYon. “It is outrageous that despite the death of five innocent people in a dangerous doors-off chopper flight and two active federal investigations into lapsed safety that FlyNYon is still operating those same flights at desperate discounts. But now, it is a sheer jaw-drop to know that the same company is strapping in dogs for people to snap pictures of while the animals all but dangle high above New York skies, experiencing the sound of the rotors and who knows what other cruel things.” Schumer called on the FAA to tighten the Part 91 photo flight exemption and make it unavailable for airtourism flights. Leading industry trade groups, including the Helicopter Association International (HAI), have long opposed the practice.
The March 2018 crash triggered a firestorm of litigation. One of the first lawsuits was brought by the parents of front-seat passenger Trevor Cadigan.
FlyNYon and other operators continue to offer doors-off “tours.” FlyNYon is currently offering 30-minute “shoe selfie” flights for $250 in New York using Bell LongRangers.