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Cal-Ore Life Flight - Non-injury incident



Date: 12-26-2010 17:30 

Program: Cal-Ore Life Flight
	311 Cove Road
	Brookings, OR 97415
	541-469-7911

Type: Cessna 421C
Tail #: N31CU
Operator/Vendor: none

Team: Pilot, RN, Paramedic. No injuries reported. Patient on board. 

Description: 
	The interfacility flight originated in Crescent City, CA (CEC), and
	was destined for Medford, OR (MFR).  The weather was IFR with marginal
	VFR ceilings at both departure and destination, along with mountain
	obscuration, rain and forecast light to moderate icing.  All preflight
	checks were normal, including deice equipment, and the risk assessment
	matrix was within the acceptable range. The flight proceeded normally
	with the pilot reporting some ice at 11,000' in cruise, which was
	easily removed with the deice equipment.  
	
	On descent into MFR, ice accumulation increased, and when leveling off
	at approximately 8,000', the pilot experienced a vibration followed by
	the elevator control oscillations. Suspecting tail ice, the pilot
	continued to select the deice boots. Though he confirmed the wing
	boots were expanding and breaking off the ice, he did not get the
	proper cockpit annunciation indicating that the tail was being deiced.
	The pilot then confirmed a tailplane ice issue. The oscillations
	continued on descent. 
	
	The pilot elected to declare an emergency and asked for vectors direct
	to the airport. He was vectored to a lower and warmer altitude at
	which time the ice begin to depart the aircraft and the elevator
	control smoothed out. The pilot then accepted the ILS approach and
	made a normal "no-flap" landing. The aircraft was met by the ground
	ambulance and the patient was transported without incident. The
	aircraft was taken out of service and all appropriate calls and
	notifications made.

Additional Info: 
	Maintenance personnel have determined that a faulty pressure air line
	in the deice boot had shifted, allowing expanded air to escape
	overboard on the left vertical stabilizer deice boot edge.  This
	caused the tail deice boots to not inflate properly.  
	
	A follow-up discussion was conducted with all of  the crew members and
	personnel involved, and the incident is being referred to the QM
	committee for review and comment. 

Source: Dan Brattain, Program Director

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programs when an accident / incident has occurred. Please share the above
information with your program staff. If you have further questions, please
contact the CONCERN Coordinator, David Kearns at 800 525 3712 or email:
coordinator@concern-network.org.

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