CEN12FA670

The loss of helicopter control after an in-flight upset, which occurred when the pilot selected the autopilot’s altitude hold mode; the reason for the reported in-flight control anomaly could not be determined during postaccident helicopter examinations. Contributing to the accident was the pilot's delay in transitioning to instrument flight rules flight before entering instrument meteorological conditions.

The emergency medical service helicopter was dispatched on a 30-minute flight to pick up a patient at a hospital. Due to area weather forecasts of marginal visual meteorological conditions (VMC) to instrument meteorological conditions (IMC) conditions, the pilot had the flight dispatcher file an instrument flight rules (IFR) flight plan in the event that he had to execute an IFR approach at his destination. The first 20 minutes of the flight were conducted in VMC about 2,500 ft mean sea level (msl) and were uneventful. During the final 10 minutes of the flight, the helicopter was nearing IMC, which included high overcast and midlevel scattered to broken clouds with light to moderate rain showers and reduced visibility. The pilot began a climb to 4,000 ft msl and then contacted an air traffic controller to activate the IFR flight plan. During this time, both the flight paramedic and flight nurse told the pilot that they were not comfortable entering the worsening weather conditions. Upon reaching 4,000 ft msl, the pilot engaged the autopilot in altitude hold mode, and the helicopter then abruptly pitched down 90 degrees and began spinning with the airspeed increasing. The pilot identified a disagreement between the pilot and copilot attitude director indicators, turned the autopilot off, and moved his scan to the backup attitude director indicator. The pilot then attempted an unusual attitude recovery by initiating back pressure on the cyclic control; however, the helicopter continued to descend rapidly through the bottom of the cloud base very close to the ground. The helicopter subsequently touched down in a level attitude, bounced several times, and skidded to a stop. All three occupants were assisted from the wreckage by ground personnel. Examination of the flight control systems did not reveal any anomalies that might have contributed to the accident. A review of the helicopter's maintenance history revealed that other company pilots had reported several occurrences of uncommanded pitch-and-roll anomalies with the helicopter during the previous several years. Maintenance inspections after these occurrences could not duplicate the reported problems, and the helicopter was always returned to service after successful flight control systems check flights. After the accident, the autopilot system, gyros, and servo components were examined, and no preimpact anomalies were found; however, the solid-state components could not be tested for functionality due to damage. The reason for the reported in-flight control anomaly could not be determined. The flight paramedic and flight nurse said that they lost visual reference to the ground during the in-flight upset. Therefore, it is possible that the transition from VMC to IMC led to the pilot becoming spatially disoriented while he was trying to recover from the reported upset and that this prevented him from recovering from it; however, investigators could not definitively determine if the pilot became spatially disoriented. Regardless, it is likely that an earlier transition from VFR to IFR flight before encountering IMC would have given the pilot a better chance to recover from the reported autopilot system-induced anomaly and would have reduced the possibility of his becoming spatially disoriented.

HISTORY OF FLIGHT On September 30, 2012, approximately 0932 central daylight time, an Augusta 109E Emergency Medical Service (EMS) helicopter, N144CF, registered to Wells Fargo Bank NW NA Trustee, Salt Lake City, Utah, crashed after an uneventful 26 minute cross-country flight. The crash occurred while the helicopter was being maneuvered to avoid local weather prior to setting up for an instrument approach to the Eastland Airport, Eastland, Texas. All three occupants, the airline transport rated pilot, flight nurse, and a flight paramedic, sustained serious injuries. The flight was being operated by CareFlite of Grand Prairie, Texas, and was conducted under the provisions of 14 CFR Part 91 as a repositioning flight to pick up a patient. The helicopter departed the CareFlite base located at Granbury Airport (GDJ), Granbury, Texas, at 0906. Its intended destination was the Eastland Airport (ETN), Eastland, Texas. Visual meteorological conditions prevailed along the route of flight from Granbury to Eastland, however, marginal visual meteorological conditions or instrument conditions were reported in the vicinity of the accident site. A company VFR flight plan was activated upon departure from Granbury and an IFR flight plan was placed on file with ATC, but was not activated. According to first responders to the accident site, the helicopter impacted the ground in an open field, approximately 4.4 miles south of Eastland Airport. Emergency responders transported the occupants to a nearby hospital. The helicopter was transported to a secure facility for detailed examination. Flight Nurse was located in the rear cabin, Aft-facing seat which is located on the right side of the aircraft. The Flight Paramedic was seated in the Co-Pilots seat. All three crew members' observations/recollections of the flight/event are as follows: Flight Paramedic According to the Paramedic, the crew received a call from CareFlite dispatch and the pilot accepted the mission. The pilot checked the weather and asked the CareFlite communications center to put an IFR flight plan on file and requested that the helicopter be topped off with fuel prior to departure. After preflight, the helicopter took off and began the flight in visual meteorological conditions (VMC). As we approached Eastland, visibility toward the north appeared to be decreasing. The pilot made the decision to continue the flight under IFR and stated to the Paramedic and Flight Nurse that he would slow down the helicopter's airspeed and follow a roadway below while he set up the autopilot to fly an instrument approach to the airport. The Paramedic felt the airspeed decrease and the pilot handed him a book with the approach plate for Eastland. The Paramedic held the book open to reference as needed. The Paramedic then became a little concerned with the situation. He looked back over his left shoulder at the weather conditions and made a statement to the pilot that he did not like the situation that we were getting into. The Paramedic then watched the navigational instruments and tried to remain calm. He noticed the pilot activate and deactivate different autopilot settings. During this time, the Paramedic noticed that the airspeed was continually decreasing as the altitude increased and at this point the helicopter was in complete IMC. The paramedic then noticed some fluctuation in the artificial horizon but it didn't seem too severe. He then felt a vibration, similar to that of an aircraft accelerating. He looked at the altimeter and it was spinning extremely fast and told the pilot that he felt as if the helicopter was in a steep dive. He stated that the pilot did not reply. The Paramedic then looked at the artificial horizon on the pilot side and observed that it was in an extremely askew orientation. At this point the pilot frantically stated that we were about to crash. Seconds later, the helicopter broke through the clouds pointing straight down at the ground. The Paramedic recalled seeing the pilot using the collective to attempt to pull up. The next thing he recalled was moments after the helicopter came to rest, he was still was still in his seat, the flight nurse had exited the helicopter, and the pilot was turned sideways and appeared to be standing in front of him inside the helicopter as it rested on its side. He recalled that at least one engine was still running. The Paramedic then saw the pilot turn both engine switches to the 'OFF" position. At this point, a bystander helped the pilot exit the helicopter through the pilot door and helped me exit through the window just above the co-pilot door. Flight Nurse The Flight Nurse had been with CareFlite for 16 years and had was familiar and trained in the company's IFR program for flight crewmembers. According to the Flight Nurse, the crew was initially notified that the flights destination was to be directly to the Eastland Hospital. The flight destination was then changed to the Eastland Airport due to the pilot having stated he did not have weather reporting available in Eastland prior to the flight, and in case of the need for IFR flight into Eastland Municipal Airport. She stated that the pilot had filed an IFR flight plan as a back-up. While preparing to go out to the aircraft, the Flight Nurse discussed the flight with the Flight Paramedic. The paramedic was not a permanent crewmember at the CareFlite base in Granbury, TX, but was called in to work from a different base. During their conversation, the Flight Nurse mentioned to the Flight Paramedic that she was concerned over the pilot's limited IFR experience in that particular helicopter (the Agusta 109). She understood that the pilot was one of the last pilots in the company to go through the certification of the IFR program. It was stated that as medical crewmembers that they would need to support the pilot in the event that the weather deteriorated and the flight plan would require IFR. During the crew duties before take-off the Flight Nurse remembered that the pilot mentioned that he had programmed the flight data into the aircraft in the event that an IFR approach was necessary going into Eastland. She stated that takeoff and departure was normal. The Flight Nurse was speaking with Eastland EMS on the progress of the flight and stated that they had an ETA of approximately 4-5 mins to the airport. Over the intercom, the Flight Nurse heard the Flight Paramedic state that, "I'm not comfortable with this." At that time, the Flight Nurse turned to the right to look forward into the cockpit and the helicopter was in the clouds – totally "Whited Out." The Flight Nurse replied to the Paramedic, "Oh, I'm not either." She said that prior to the aircraft entering into the clouds the flight was normal, doing just fine and no issues. It seemed to be a direct route. The Flight Nurse asked the pilot if there was anything that they could do to help and the pilot did not reply. She noted that the IFR Approach plates were out and that the Paramedic was assisting the pilot with them. She also noted that the pilot did not communicate much and said that there was no communication from the pilot on the possibility of entering the clouds. She said that the helicopter had been climbing and the altimeter instrument was reading approximately 4,500 feet. Pilot did state that "we should be fine here." The Flight Nurse heard the pilot make an attempt to contact the tower. Flight Nurse observed the pilot push a button up front on the panel. Almost immediately the aircraft seemed to go out of control, rolling to the left and right, and seemed to be pitching up and down at times. She stated that the upset was very scary and disorienting to her, and that she could not tell whether the aircraft was going up or down from her seat. The helicopter seemed to be out of control. The helicopter seemed to be not responding to the pilot's inputs and was descending at a rapid rate. She s