N32CC
Agusta AW139
The pilot-in-command (PIC) and second-in-command (SIC) were conducting a personal flight from the Bahamas to Fort Lauderdale, Florida, with five passengers onboard. The night flight was conducted under visual flight rules. About 2324 the day before the accident, the helicopter and company owner contacted the PIC, who was his friend and confidante, and told him that he needed him to conduct the flight to transport his daughter and her friend from Big Grand Cay, Abaco, Bahamas, to the United States for medical treatment. About 20 minutes later, the PIC contacted the SIC telling him he needed him to conduct the flight with him. The flight from Florida landed in Big Grand Cay at 0142. At 0145, the PIC filed an instrument flight rules flight plan, but it was not activated. While the flight crew was on the ground, the cockpit voice recorder (CVR) did not record them conducting a formal preflight instrument flight briefing. The flight crew’s pretakeoff conversation was limited to discussing flight plan information, including altitude, heading, and navigation; programming the flight computer; and the number of passengers expected on board. They did not discuss how to take off in night, visual meteorological conditions over water or their roles and responsibilities. The flight crew had a short discussion about the use of the flight controls and their automated functions during takeoff. Thus, their limited planning and communication for the takeoff from Big Grand Cay was indicative of inadequate crew resource management (CRM). According to flight data recorder data, the helicopter departed about 0152. The helipad from which they departed was brightly lit with floodlights, but then the helicopter proceeded over water in dark night conditions with no visible moon, likely zero ambient illumination, and no visible horizon, which would necessitate the pilots’ reliance on the instruments in order to fly because of the very limited outside cues. After takeoff, the PIC, who was the pilot flying, manipulated the cyclic and antitorque control pedals, engaged the collective pitch trim, and began the helicopter’s first climb to about 190 ft. The cyclic force trim release (FTR) switch was engaged and remained engaged for the entire flight, indicating that the pilot was controlling the cyclic motion. Subsequently, the helicopter began to descend and the airspeed increased, all while the cyclic’s position continued to move forward to a more nose-down attitude. The first of numerous enhanced ground proximity warning system (EGPWS) warnings began and continued during the descent. About 0152:50, while at an altitude of about 110 ft descending about 1,380 ft per minute (fpm), one of the pilots engaged the autopilot in the altitude acquire (ALTA) mode with indicated airspeed hold, which set a vertical speed reference target of +1,000 fpm and an airspeed reference target of about 110 knots. Nearly simultaneous to the ALTA mode activation, the collective FTR switch was momentarily activated. Because the helicopter was descending at that time and the target altitude for ALTA was above the helicopter’s current altitude, the ALTA rate of climb was reset to +100 fpm (per system design), where it remained for the rest of the flight. Despite the repeated EGPWS warnings, the PIC continued commanding forward cyclic and the helicopter continued to descend. About 0152:51, with the helicopter about 52 ft above the water, the PIC pulled the cyclic back and initiated a second climb. He then asked the SIC for the altitude, and, not receiving a response, stated that the helicopter was at 300 ft, and the SIC advised him that the helicopter was not at 300 ft and that it was "diving." It is likely that the PIC confused the vertical speed indication with the altitude indication, as the helicopter was at 116 ft radio altitude but was climbing about 300 fpm at the time. Subsequently, multiple EGPWS warnings annunciated until the helicopter climbed above 150 ft and the warnings stopped. Although the PIC and SIC each made comments during the remainder of the flight, there did was no apparent coordination or troubleshooting between them, further indicative of a lack of CRM. When near the top of the climb, the collective pitch trim increased about 5% per second, with a corresponding increase in engine torque and power index (PI) values. After activation of ALTA mode, the PI levels began to increase to a point where the PI limiting function, as part of the flight director, began restricting collective movement, which prevented the ALTA mode from maintaining a positive vertical speed and climb to the set altitude. Because the PIC was manually controlling the cyclic, the flight director was unable to compensate for the high PI levels, such as reducing airspeed; thus, the flight director had to reduce collective to prevent a PI level exceedance. Given the lack of discussion about the negative vertical speed or any attempts by the PIC to manually manipulate the collective, it is likely neither pilot was adequately monitoring the vertical speed and altitude trends, which led to a loss of altitude. About 0153:13, as the helicopter began to descend from 212 ft because the cyclic was moved forward again to command a nose-down attitude and the EGPWS warnings began to annunciate again, the SIC stated that “this is exactly what happened” in a fatal accident in the United Kingdom in which the accident was caused by somatogravic illusion and subsequent spatial disorientation. The PIC did not respond to the SIC, likely due to his continued confusion about the helicopter’s position in space and his misunderstanding of the information on the helicopter’s flight instruments. The helicopter then entered a left descending turn in a nose-down attitude with airspeed and engine torque increasing, significant forward cyclic being applied, the descent rate increasing, and EGPWS warnings continuing. The PIC repeatedly asked for a heading and once for altitude, but the SIC did not respond. As the helicopter continued descending toward the water, the flight crew did not communicate the helicopter’s attitude, energy state, and steps needed to recover from the descent. Given that postaccident examination indicated the helicopter’s flight instruments were operational (and they were operational for the flight to the Bahamas), they had information available to them to understand the helicopter’s flightpath. However, about 0153:22, the helicopter impacted water at high speed while in a nose-down, left-bank attitude. As the pilot transitioned the helicopter to forward flight by commanding forward cyclic, the flight crew appeared initially unaware of the helicopter’s first descent until multiple EGPWS warnings annunciated. The PIC likely perceived that the accelerations associated with the helicopter’s increasing forward airspeed was the helicopter pitching up and he provided control inputs that caused the helicopter to descend. These improper control inputs during the second descent were consistent with the onset of a type of spatial disorientation known as somatogravic illusion, and the PIC likely did not effectively use his instrumentation during the departure to recognize the helicopter’s flightpath and orientation. The CVR indicated that the SIC recognized and announced the helicopter’s first descent to the PIC. In response, the PIC likely selected ALTA, which contributed to the recovery of the altitude lost from the first descent. However, the PIC continued to command forward cyclic (using the FTR switch), leading to the helicopter’s second descent. Again, numerous EGPWS warnings annunciated, but the PIC continued decreasing the helicopter’s pitch attitude while the airspeed and descent rate increased; these inputs were also consistent with spatial disorientation and a failure to rely on the helicopter’s instruments. Based on the sequence of events and the flight crew’s actions and comments, they lost awareness of the helicopter's flightpath after takeoff over water during dark night conditions, which likely led to spatial disorientation and the subsequent collision with water. The PIC’s night flight experience and instrument currency could not be determined. The SIC was reportedly night current but it could not be determined if he was night current in the helicopter make and model. Further, the PIC and the SIC had never flown to Big Grand Cay at night. Given both pilots’ many hours of flight experience, it is likely the PIC recognized the risk associated with the intended flight and contacted the SIC to make the flight with him. The PIC’s comfort flying with the SIC likely contributed to his decision to take the flight. Further, the urgency of the mission and the direct communication from the helicopter owner likely created external pressure on the flight crew, which can affect decision-making and create a sense of pressure to complete a flight. However, no records were found that the flight crew evaluated or planned for the impact of external pressure on their flights to and from Big Grand Cay in dark night conditions to transport ill passengers to a hospital. It is likely that they allowed the external pressure to affect their decision to conduct the flight even though neither of them had ever flown to Big Grand Cay at night. Examination of the helicopter’s flight control system including autopilot system, structures, main and tail rotor system, and engines revealed no evidence of any preimpact mechanical failures or malfunctions that precluded normal operation. Although one of the four separated sections of tail rotor blades was not recovered, analysis of the recorded flight data as well as the CVR showed no evidence of anomalous operation of the tail rotor prior to impact. All observed damage was consistent with the helicopter’s impact with the water.
HISTORY OF FLIGHTOn July 4, 2019, about 0153 eastern daylight time, an Agusta S.p.A. AW139 helicopter, N32CC, was substantially damaged when it was involved in an accident near Big Grand Cay, Abaco, Bahamas. The two pilots and five passengers were fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to pilot-in-command’s (PIC) cellphone records, the owner of helicopter (who also owned the company the PIC flew for) called him about 2324 on July 3. The owner reportedly called the PIC to inform him that he needed the PIC to fly his daughter and her friend from the Bahamas to the United States for medical treatment. About 8 minutes later, the PIC contacted a friend of the owner who was also on the Island. The friend reported that the PIC told him that he would be flying from Florida to Big Grand Cay and that he would need lights to illuminate the private helipad at Big Grand Cay. About 2338, the PIC called back the friend and reported that he had "to get someone to come with him" for the flight. The PIC called the second-in-command (SIC) about 2343 to notify him that he was needed for the flight. The SIC's wife reported that, after being notified about the flight, the SIC began to check the weather and looked at landing sites. According to data from the combination cockpit voice recorder (CVR) and flight data recorder (FDR), the flight departed Palm Beach International Airport (PBI), West Palm Beach, Florida, about 0055 on July 4, destined for Big Grand Cay. During the flight, the PIC was the pilot flying (PF) from the right seat, and the SIC was the pilot monitoring (PM) from the left seat. At 0059:09, the PIC stated, "ah, it's gonna be darker than # out here," and the SIC responded that he was trying to dim some of the cockpit lights. (The symbol # in quotes from the CVR indicate an expletive.) At 0101:52, the SIC asked the PIC if he had ever flown to the island at night, and the PIC replied, “no.” At 0103:02, the PIC again asked the SIC to dim the lights. While en route to Big Grand Cay, the SIC stated that he “was night current” and had “done a lot of night flying” and that he had landed “off airport” at night and was used to doing it. About 0124:13 the SIC mentioned not to “fixate on one light and start to go spa…” but the word was not completed; about 5 seconds later he stated “you won’t get spatially disoriented with two of us on board.” He then added that a night landing in a black hole “can be tricky.” The friend of the owner who had spoken to the PIC before the flight reported that he arranged two golf carts with flood lights to light the helipad but had them pointed so they would not distract the pilots. According to the FDR data, the helicopter landed at the private helipad at Big Grand Cay about 0142. While the helicopter was on the ground with the engines running, the CVR recorded the PIC discussing flying into Fort Lauderdale/Hollywood International Airport (FLL), Fort Lauderdale, Florida; flight plan information; and the need for an ambulance to meet the flight. The individual who arranged to light the helipad reported that three of the five passengers self-boarded the helicopter while the remaining two passengers were carried and loaded into the helicopter and strapped into their seats. He told the owner that medical help would be waiting at FLL when they landed. At 0145, the PIC filed an instrument flight rules (IFR) flight plan with ForeFlight for a flight from Walker's Cay Airport (MYAW), Walker's Cay, Abaco, Bahamas, about 5 nautical miles (nm) west-northwest of the departure helipad, to FLL. The flight plan noted that the flight would depart at 0200, that five people were onboard (although there were actually seven people on board), and that sufficient fuel was onboard for 2 hours 16 minutes of flight. The flight plan was not activated. About 0150, the CVR recorded the SIC talking about initial altitude and heading information, and the PIC responding that he would enter the flight plan information into the flight management system (FMS). At 0152:13, the SIC stated, "our initial heading is going to be one eight zero….” According to FDR data, at 0152:17, the helicopter lifted off; the cyclic force trim release (FTR) switch was engaged and remained engaged for the entire flight and the collective FTR switch was engaged until 0152:28 when the collective stabilized about 70%. At 0152:31, while the helicopter was about 62 ft above the ground, with no forward airspeed and in a slight nose-up pitch attitude, the SIC stated, "alright airspeed coming up no it’s not coming up so push that nose forward get some airspeed." Shortly thereafter, while the helicopter was climbing, the FDR recorded nose-down cyclic control input and changes in pitch attitude that became negative about 0152:36; the helicopter continued to climb and began to gain forward airspeed. At 0152:42, while at 184 ft, 53 knots forward airspeed, and a pitch attitude about 12° nose down, the SIC stated, "watch your altitude." The helicopter climbed to 190 ft at an indicated airspeed of 68 knots; the collective position was 72%. At 0152:44, the helicopter began to descend with a nose-down pitch attitude, the airspeed increasing, and the collective relatively constant near 72%. It also began a left turn and twice momentarily returned to a no bank condition before continuing until water impact. At 0152:48, while in a descent with the cyclic positioned about 69% forward, the CVR recorded a “sink,” “warning terrain,” and “one fifty feet” from the enhanced ground proximity warning system (EGPWS). About 0152:50, at an altitude of about 110 ft while descending about 1,380 ft per minute (fpm) with the collective pitch at 75%, the autopilot flight director was engaged in altitude acquire (ALTA) and indicated airspeed (IAS) modes while the FTR switch on the cyclic was active; this indicated the PIC was manually commanding cyclic movement throughout the flight. The selected altitude for ALTA to capture was 1,000 ft and the default rate of climb was 1,000 fpm. IAS mode automatically engages with ALTA and is meant to generate pitch commands to maintain airspeed. (See the “Helicopter Information” section of this report for more information about ALTA mode.) Nearly simultaneous to the ALTA mode activation, the collective FTR switch was momentarily activated. Because the helicopter was descending when the collective FTR switch was activated, and the target altitude for ALTA was above the current altitude, the ALTA rate of climb was reset to +100 fpm (per system design) and remained at that value for the remainder of the flight. The cyclic was pulled back to 52% at 0152:51 and the helicopter pitched up, reaching a minimum altitude of 52 ft before beginning to climb. From 0152:51 to 0153:05, the EGPWS issued nine “warning terrain” warnings. At 0152:56 while climbing through 78 ft, the PIC asked, "how high are you," but the SIC did not reply (At 0152:58 the helicopter’s vertical speed was +300 fpm). About three seconds later while at 116 ft, the PIC stated, "three hundred feet." Subsequently, the SIC stated, "we're not," to which the PIC replied, "that's what it says over here." At 0153:05, the SIC stated that the helicopter had been "diving," followed by an expletive from the PIC and the continuation of multiple EGPWS warnings until the helicopter climbed above 150 ft. As the helicopter climbed, the collective input lowered from 75% at 0152:53 to a minimum value of 46% at 0153:09 as the autopilot attempted to limit the vertical speed to ALTA reference target. During the second climb, the longitudinal cyclic had been moving forward to near 68%, and at 0153:11, the helicopter, which had been nose up or level since 0152:51, again pitched nose down. The helicopter’s rate of climb dropped below 100 fpm and collective began to increase at a rate of about 5% per second. The helicopter reached a maximum altitude of 212 ft while banking left 30° then began descending with EGPWS warnings occurring. At 0153:13, the helicopter again began to descend, and the SIC stated, “there was a fatal accident in the United Kingdom and this is exactly what happened there." (EGPWS warnings continued through this time.) Two seconds later, with the collective control about 70%, the rate of collective increase slowed as power index (PI) values increased to about 80%. Over the next 8 seconds, the collective position gradually increased to about 75% and PI values increased to about 86%. While descending in a nose-down attitude with the airspeed increasing, the PIC asked the SIC multiple times for headings and once for altitude, but the SIC did not respond. According to an NTSB performance study, the helicopter impacted the water about 0153:22 while in a 7°-nose-down and 12°-left-bank attitude. The CVR recorded no aural master cautions or warning annunciations during the flight. Figure 1 shows the cockpit annunciations recorded on the CVR and select times and altitudes. Figure 1. Cockpit annunciations recorded on CVR with select times and altitudes (Figure contained in the NTSB Performance Study) A witness located about 1.6 nm southwest of the wreckage location reported that there was no moon visible when the helicopter departed. He also reported that, as the helicopter began descending, he heard a "whoosh whoosh whoosh" sound and then lost sight of the helicopter. He heard the helicopter impact the water and said that the engines sounded good. He immediately called the "caregiver" at Big Grand Cay and described what he had seen and heard then he and another individual departed in his spotlight-equipped boat between 0205 and 0207 to where he had thought the helicopter had crashed. They searched for the wreckage but did not locate it. He called the caregiver about 0400 and was told the helicopter would have made it to the United States safely. At 1415, a company pilot was notified that the helicopter had not arrived at FLL. About 1 minute later, he called U.S. Customs and Border Protection at FLL and was advised that the helicopter had not cleared customs. At 1429, he called Leidos Flight Service and informed them that the flight was overdue, and the Federal Aviation Administration (FAA) issued an alert notice. The company pilot reported that he departed PBI in a company float-equipped airplane between 1600 and 1615 and searched a direct line from FLL to Big Grand Cay; however, he did not locate the wreckage. The witness who went out immediately after the accident again searched the area and found the wreckage between 1600 and 1700. According to Bahamas Air Navigation Services Division, the PIC requested no air traffic services nor did they provide any services between 2200 on July 3 and 0200 on July 4. The investigation was originally under the jurisdiction of the Air Accident Investigation Department (AAID) of the Bahamas. On July 6, 2019, the AAID requested delegation of the investigation to the NTSB, which the NTSB accepted on July 8, 2019. PERSONNEL INFORMATIONPIC Flight Experience According to the chief pilot of Challenger Management LLC, the company that operated the accident flight, the PIC was a friend and confidante of the helicopter owner. The PIC had operational control of the accident flight. According to the chief pilot, the PIC logged his flight time on an iPad. Two iPads were found in the wreckage; however, damage precluded accessing their data, and the company flight log sheets did not include the time of day for flights or whether they were conducted in instrument conditions; therefore, the PIC’s night flight experience and instrument currency could not be determined. The PIC's girlfriend reported that he did not like to fly at night and that he "rarely did it." To her knowledge, the accident flight was his first night flight to the Bahamas. She said the PIC told her that night flying was "a whole different ballgame." She added that he had informed her that the owner had been texting him all night and that he did not know if he had to fly to Big Grand Cay but that he hoped he did not have to return. The PIC's airman certificate application, dated October 17, 2017, indicated that he had received night flying experience in both rotorcraft and airplanes. At that time, he had reported that he received about 42 hours of night instruction, of which 3 hours were in rotorcraft; he had conducted 123 night takeoffs and landings, 103 of which were as PIC and 73 were in rotorcraft; and he had flown 157 hours at night as PIC, of which 110 hours were in rotorcraft. SIC Flight Experience The SIC's wife reported that he had accumulated more than 1,450 hours of night-flying experience and that, from November 21, 2018, to May 25, 2019 (which was when he conducted his last night flight before the flight to the Bahamas and the accident flight), he had accumulated about 27 hours of night-flying experience. It could not be determined how many of those hours were flown in the accident helicopter type. From November 29, 2017, to July 3, 2019, the PIC and SIC conducted 14 flights together in the accident helicopter; the last flight before the flight to Big Grand Cay occurred on February 22, 2019. Ten of the flights were flown to Big Grand Cay island during the day. During the 14 flights, the PIC was the PF, and the SIC was the PM. Flight Crew Training From August 28 to October 11, 2017, the PIC and SIC were paired together while receiving their initial type rating training in the AW139 helicopter, which included 60 hours of ground and flight training in the accident helicopter, which addressed basic flight maneuvers and various types of instrument procedures. The flight training consisted of 8 hours of visual flight rules (VFR) flight and 6 hours of simulated IFR flight. Both pilots received their type rating in the AW139 at the end of the training. During both their initial and recurrent flight training, the PIC and SIC conducted instrument takeoffs and unusual attitude recovery. The unusual attitude recovery exercises included training to recognize spatial disorientation. One instructor reported that he would give trainees "a lot of vectors” as a way to simulate the onset of spatial disorientation. The PIC and SIC were taught to complete the manufacturer recommended departure briefing (VFR/IFR), which included the departure profile to be flown; the actions required by each pilot, including appropriate callouts; the use of automation by whom and when; and the actions to be taken in the event of an emergency during the departure. In addition, they received training on the type of information to be briefed for an IFR departure, which included, in part, the profile to be followed, the automatic flight control system (AFCS)/flight director (FD) modes and IAS to be used during the departure, and a detailed description of the departure profile, including altitudes. PIC Training During the initial type rating training, the PIC was trained in the PF and PM roles. Regarding his first flight, the flight instructor commented, “steep turns were off on entry with nose up pitch causing airspeed and altitude to deviate.” Regarding his third flight, the instructor commented “flying and FMS is improving. Still slow with the FMS but gets there.” Regarding his fourth flight, the instructor commented, "needs to continue to fly dual pilot to get more comfortable with using copilot to supplement pilot duties." The PIC received a satisfactory rating for flight and instrument maneuvers. Between November 12 and 16, 2018, the PIC received recurrent training. The PIC’s training consisted of 12 hours of ground training and 8 hours of flight training in a level-D, full-flight simulator. The simulator training included 4.5 hours of flight time conducted under IFR and included night flying, and 3.5 hours of flight time conducted under VFR. He received a below average rating on Airman's Skill-Decisiveness. His overall evaluation was below average. During this time, he also received a Part 61 checkride and proficiency check, which included 3 hours of flight time in the AW139 simulator; he passed both on November 16. The instructor commented that the
The pilots’ decision to takeoff over water in dark night conditions with no external visual reference, which resulted in spatial disorientation and subsequent collision with the water. Also causal was the pilots’ failure to adequately monitor their instruments and respond to multiple EGPWS warnings to arrest the helicopter’s descent. Contributing to the pilots’ decision was external pressure to complete the flight. Contributing to the accident was the pilots’ lack of night flying experience from the island and their inadequate crew resource management.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
