By Jon Harris
The Buffalo News
ELBA, N.Y. 鈥� April 26, 2022, was an annual training day for Mercy Flight鈥檚 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鈥檇 as Mercy Flight pilot, Bell Helicopter employee/pilot]
A just completed final report from the National Transportation Safety Board 鈥� released nearly 20 months after the double-fatal accident 鈥� sheds light on what was Mercy Flight鈥檚 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 鈥� the helicopter had dual controls 鈥� during a training maneuver that required the pilot to pull the aircraft out of an unstable flight condition known as a 鈥渧ortex ring state.鈥� In a matter of seconds, the helicopter鈥檚 main rotor blades struck the aircraft鈥檚 tail, causing it to break up in flight. Also causal, the agency noted, was the 鈥渇light instructor鈥檚 inadequate monitoring of the flight.鈥�
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 鈥渦nstable condition in which a helicopter experiences uncommanded pitch-and-roll oscillations, has little or no collective authority鈥� and reaches a rapid descent rate.
The NTSB鈥檚 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 鈥� 13 seconds shy of 1 p.m. 鈥� recovered flight data show there were 鈥渕ultiple abrupt control inputs鈥� 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鈥檚 main rotor blades contacting the tail boom.
When main rotors 鈥� which spin above the helicopter to lift and push it forward 鈥� flex or dip down and essentially slice the helicopter in two while in midair, it is called a tail-boom strike.
The NTSB鈥檚 preliminary report released in May 2022 noted a fracture in the tail was consistent with main rotor blade contact, but it wasn鈥檛 until the final report released late last week that investigators determined what had likely caused the crash.
The agency鈥檚 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 鈥渨hy the pilot(s) might have applied these abrupt control inputs鈥� inside the cockpit.
鈥楺uestions that remain unanswered鈥�
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 鈥渕aneuver that went wrong and caused, somehow, for the main rotors to come in contact with the tail boom.鈥�
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 鈥� or both of them 鈥� who made the abrupt control inputs that led to the crash.
鈥淲e鈥檒l just never know what caused those abrupt maneuvers,鈥� Wooton said. 鈥淲ho was doing what, at what time? Those are the things that we鈥檒l never know. So there鈥檚 always going to be questions that remain unanswered here.鈥�
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 鈥渆xtremely saddened by the accident that resulted in the loss of two pilots, including one of our Bell teammates.鈥�
鈥淥ut of respect for the privacy of the families involved, we are unable to answer questions or share additional information,鈥� 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.
鈥淢ercy鈥檚 Flight standpoint on that is it鈥檚 a terrible tragedy,鈥� Wooton said. 鈥淎nd as far as assigning any sort of blame to it, that鈥檚 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鈥檚 just a terrible tragedy.鈥�
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鈥檚 first training flight
Another key to the NTSB鈥檚 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 鈥渟ettling with power.鈥�
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 鈥渞eally gotten into鈥� 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鈥檚 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 鈥渧ery high descent rate.鈥�
The pilot said he was surprised that Dietrick did not intervene as the helicopter got deeper into the state.
While in vortex ring state, 鈥渢he pilot stated that he didn鈥檛 know why they were going so deep鈥� into the state and 鈥渢hat the instructor was just sitting there, 鈥榟ands on his lap,鈥� 鈥� according to the report.
鈥淪o, 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,鈥� 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 鈥渋t is likely the flight instructor did not provide adequate information to the accident pilot on how he would receive training for鈥� vortex ring state, including how they would identify, enter and exit that state.
鈥楢 step toward closure鈥�
Wooton, Mercy Flight鈥檚 executive vice president, said the report confirmed some of the organization鈥檚 assumptions. But its release made for a tough day, with many difficult conversations.
Wooton said he called Sauer鈥檚 son, Josh, after the report came out on Friday and expressed his condolences again.
鈥淚t鈥檚 tough to relive the day, and that鈥檚 kind of just what you do when you read that final report,鈥� Wooton said. 鈥淵ou鈥檙e going over all the facts, and you go right back to that same place that you were when it happened, and it鈥檚 tough to do. But it is a step toward closure.鈥�
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鈥檚 door featuring a decal that reads 鈥渋n honor and remembrance of pilot James E. Sauer .鈥�
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