CEN14FA369

The pilot's inadvertent visual flight into instrument meteorological conditions, which resulted in a loss of helicopter control.

After the commercial pilot received an emergency medical services helicopter flight request, he quickly (in about 20 seconds) assessed the weather conditions and accepted the flight. No records were found indicating that the pilot obtained an official weather briefing before departing on the flight, and the investigation could not determine which weather resources the pilot used to assess the weather. About 8 minutes later, the pilot called the company's operations center to report that the flight was departing; this was the last communication received from the pilot. The helicopter was operating in an area that was known by company pilots, including the accident pilot, to have the potential for low visibility, even though there were no airport weather reporting facilities or Doppler radar coverage in the area. A review of GPS data showed that, while en route to pick up the patient, the helicopter performed a slight descending 360° turn before continuing toward the hospital. Weather overlays with the GPS track indicated that the helicopter made the 360° turn about the same time that an outflow boundary wave, which could have increased the potential for windshear and strong updrafts and downdrafts and reduced ceilings and visibility. Following the 360° turn, the helicopter proceeded toward the destination. About 14 minutes later, the helicopter turned right and began flying toward a major highway. It is likely that, due to the reduced visibility in the area, the pilot was flying toward the highway to follow the lights toward the city. The helicopter then turned further right and began to climb. As the helicopter entered another outflow boundary wave, it turned left. The left turn tightened, and the helicopter began to rapidly descend into terrain. The helicopter impacted a mesa in a near-level attitude. A review of a company communication recording showed that, about 17 minutes after the estimated accident time, the operations center attempted to contact the flight crew and was unsuccessful. The company sent three company helicopters to the accident helicopter's last known position; one helicopter pilot flew near the helicopter's site but was unable to see anything, and the two other pilots could not proceed close to the accident site due to clouds and low visibility. The wreckage was subsequently located by local law enforcement. A postaccident examination of the helicopter and engine did not reveal any anomalies that would have prevented normal operation. Due to mid- and low-level cloud cover, it is likely that no lunar or celestial lighting was available for amplification by the pilot's night vision goggles (NVG). Since the helicopter was not equipped with an infrared spotlight, only cultural light would have been available for NVG amplification. However, the helicopter was operating in a remote, sparsely populated area with minimal cultural light. Although the pilot's recurrent training included recovery procedures from inadvertent entry into instrument meteorological conditions (IMC), and his training records showed that he satisfactorily completed this item on his most recent training flight about 8 months before the accident, the circumstances of the accident are consistent with the pilot's inadvertent visual flight into IMC, which resulted in a loss of helicopter control.

TriState CareFlight LLC Operations The helicopter was operated by TriState CareFlight LLC. The helicopter was tasked in accordance with the company's standard operating procedure. Telephone recordings were provided which revealed information about the flight. At 0018, a hospital in Tucumcari, New Mexico, telephoned TSCF's operations center to request a patient transfer from the hospital to another hospital in Albuquerque, New Mexico. The helicopter stationed at Tucumcari had been recently tasked with another flight, so the operations center contacted the pilot of the closest helicopter which had landed in Amarillo, Texas to refuel. The pilot declined the flight due to thunderstorms between Amarillo and Tucumcari. At 0042, TSCF's operation center contacted the accident pilot at Santa Fe, New Mexico and provided the flight request details. After being given the route of flight, the pilot assessed the weather for about 20 seconds before accepting the flight. It is unclear what weather resources the pilot may have consulted prior to the accident flight. At 0050, the pilot called the operations center and informed them that he was departing for the flight. That was the last transmission made from the accident crew. When the helicopter stopped tracking, the operations center received a notification that the helicopter's progress had stopped. At 0200, the operations center attempted to contact the accident crew via satellite communications and cellphones and was unsuccessful. At 0209, the operations center contacted the on-call supervisor and informed him that a helicopter was dispatched to Tucumcari and was overdue. At 0215, a teleconference was held with multiple supervisors from the company attempting to locate and contact the accident crew. They contacted local law enforcement and asked for officers to respond to the last known location. At 0234, TSCF called the local flight service station and asked to begin search and rescue procedures for the helicopter and its crew. TSCF tasked several company helicopters to fly to the last known coordinates of the accident helicopter to see if they could locate the helicopter or contact the crew on the radios. Three helicopters flew towards the accident site and two of the helicopters were unable to proceed due to low visibility. One helicopter flew near the helicopter's site but was unable to see anything, could not reach the crew on the radio, and did not hear an emergency locator transmitter beacon. At 0322, TSCF was informed that the local land owner's ranch hand spotted a fire on the property near the last coordinates and responded to investigate. At 0355, New Mexico State Police confirmed that the wreckage of a helicopter had been located. Operations Specifications In reference to the accident flight, the following specifications would have been valid for the flight: The Agusta 109 helicopters were authorized to perform visual flight rules (VFR) flight en route and could operate both day and night. Flights at night in designated mountainous terrain must have a minimum ceiling of 1,000 ft. Night "local" flights needed 3 miles visibility and "cross country" flights needed 5 miles visibility. Local flying areas are those areas in which the pilot has demonstrated a level of familiarity which allows the use of lower VFR operating minima. Prior to conducting VFR operations, the pilot must determine the minimum safe altitudes along the planned en route phase of flight to include the minimum safe cruise altitude. The pilot must clear all terrain and obstacles for the route of flight by at least 500 ft for night operations. All night or NVG en route cruise operations require a minimum altitude of 500 ft agl. Prior to each flight, the pilot assesses the risk for the flight through the completion of a risk assessment form. Only the risk assessment form for the previous flight was located. The form for the accident flight was likely onboard the helicopter and was destroyed in the accident. TSCF used the SkyConnect satellite communication system to communicate between their California based operations center and the accident helicopter. At 0050:48, the pilot called the operations center to report that he had departed for Tucumcari. No further communications were made from the helicopter. The helicopter was operating under a company visual flight rules flight plan and was not in communication with air traffic control. SkyConnect Data The onboard SkyConnect system allowed for tracking of the company's helicopters at their operations center. The data track began at 0052 with the helicopter on the company's helipad at SAF. The helicopter briefly taxied southwest on taxiway Charlie before it departed the airport. While en route, the system reported the helicopter's position about every 30 seconds. The helicopter tracked on a 100° heading at 9,500 ft msl (about 3,800 ft agl) and 160 knots groundspeed until about 25 miles southeast of Las Vegas, New Mexico. At 0120:13 the Garmin GPSmap 396's data began recording and provided better data resolution than the SkyConnect data. The two tracks followed very closely to each other with the Garmin data being captured about every 10-20 seconds. This report will focus primarily on the data provided by the Garmin. Garmin GPSmap 396 The data from the panel mounted GPS was downloaded and found to retain the accident flight. Flight data began recording at 0120:13 when the helicopter was already en route to Tucumcari. The first complete data point from the accident flight occurred at 0120:26 as the helicopter tracked 106° at 9,237 ft msl with a groundspeed of 158 knots. At 0121, the helicopter began a slight descending left 360° turn. The helicopter descended as low as 1,225 ft agl before it resumed a course towards Tucumcari. The helicopter flew about 6,600 ft msl (about 1,200-1,800 ft agl) with a groundspeed of about 130 knots. At 0136:17, about 30 miles west from Tucumcari, the helicopter turned right and flew south-southeast. The helicopter descended to 6,000 ft msl and the groundspeed increased to 160 knots and then reduced to 140 knots. At 0140:09 the helicopter continued the right turn and flew south-southwest while climbing to 7,763 ft msl. At 0140:49, the helicopter turned left. As the helicopter passed through a 90 degree heading change, the helicopter began to descend. At 0141:21 the helicopter began a 940 ft per minute (fpm) descent, which increased until the last reporting point. The helicopter continued a left 360° turn that tightened as the turn progressed. The last reporting point occurred at 0141:47 with the helicopter at 4,840 ft msl (200 ft agl) and groundspeed of 93 knots. The estimated final descent rate was 14,760 fpm. Weather overlays with GPS flight track Due to weather radar beam angles and distance to the accident site from the weather radar sites, the radar beam likely missed the outflow boundary around the accident time. Using known weather information, modelling of the outflow boundary waves was performed. Weather associated with these outflow boundary waves would be consistent with increased wind shear, strong updrafts and downdrafts, reduced ceilings, and reduced visibility. When the helicopter flew east-southeast and performed a slight descending 360° turn at 0121, it was directly near the estimated location of an outflow boundary wave. The boundary wave was the second wave that moved through the area from the north-northwest to the south-southeast. The helicopter accelerated past the second boundary wave and continued to the east-southeast. At 0136, when the helicopter maneuvered to the south-southeast it was between the first and second boundary wave. At 0141, the helicopter likely flew into the first boundary wave about the time it began the left turn and descent toward the terrain. Agusta Engineering Data Engineers from Augusta Helicopters assessed the Garmin GPS data to evaluate the ability of a helicopter to