Investigation Summary
The accident occurred while Mercy Air 2 was returning to its base in Victorville after transporting a patient to Loma Linda. The pilot had flown the same route five times earlier that day, but the accident flight was the first conducted in darkness. Although the destination and departure points reported VFR conditions, an AIRMET had been issued for the Cajon Pass warning of mountain obscuration, fog, and mist. Satellite tracking data showed the helicopter followed Interstate 15 until near the summit of the pass, where it inexplicably turned northeast, diverging from the highway by 0.7 nautical miles. Investigators found no evidence of mechanical failure. The pilot was not IFR current and was not authorized to use night vision goggles (NVGs) or the aircraft's autopilot for IFR flight. The crash site was characterized by intermittent waves of fog that rolled in at 4,000 feet, which likely disoriented the pilot as he transitioned from the well-lit basin toward the dark, rising terrain of the pass.
Final Conclusions
The NTSB determined the probable cause was the pilot's inadvertent encounter with instrument meteorological conditions and subsequent failure to maintain terrain clearance. Contributing factors included the dark night conditions, fog, and mountainous terrain. The investigation highlighted the risks of Part 91 positioning flights, which at the time allowed for less stringent weather minimums than Part 135 flights with patients on board.
Photographic Evidence (1)
Video Analysis
The Dangers of HEMS Operations: Mercy Air 2 — A detailed look at the 2006 Mercy Air Bell 412 crash in the Cajon Pass, examining the challenges of night VFR operations in mountainous terrain and the impact of weather on medical helicopter safety.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Total hours reflect NTSB narrative (3,371) including military and civilian time. Experience in last 90 days: 87 hours; 30 days: 38 hours; 24 hours: 7 hours. Pilot was not IFR current.
Systems & Failure Modes
OuterLink Automatic Flight Following System
A satellite-based tracking system that reported GPS location every 30 seconds; however, the altitude and airspeed recording software had not yet been installed.
3-axis Autopilot
The Bell 412SP was equipped with an autopilot and stability augmentation system (SAS), though the pilot's check ride specifically noted he was not authorized for its use under IFR.
Interesting Facts
- 01The pilot had over 3,000 hours of military helicopter experience but was not IFR current.
- 02The aircraft was equipped with a 3-axis autopilot, but the pilot was not authorized to use it for IFR flight.
- 03The helicopter was not yet equipped with night vision goggles (NVGs), though the company was in the process of fleet-wide installation.
- 04The accident occurred during a Part 91 positioning flight, which had less restrictive weather minimums than Part 135 patient transport flights.
- 05Post-crash fire consumed approximately 2 acres of the mountainside.
- 06The Cajon Pass is known for erratic winds and sudden fog due to marine layer incursions.
Safety Actions & Advisories
NTSB HEMS Recommendations
The NTSB recommended that the FAA require all medical helicopter operations with medical personnel on board to be conducted under the more restrictive Part 135 regulations, regardless of whether a patient is present.
Night Vision Goggle Implementation
Mercy Air continued its program to equip all helicopters and pilots with night vision goggles (NVGs) to improve situational awareness during night operations.