CEN24MA111

The pilot’s decision to continue the visual flight rules flight into instrument meteorological conditions, which resulted in the pilot’s spatial disorientation and loss of control. Contributing to the accident was the company’s inadequate oversight of its safety management processes, including ensuring the pilots were accurately completing and updating the flight risk analysis, logging maintenance discrepancies, and ensuring the helicopter met Part 135 regulations before departure.

In preparation for the Part 135 on-demand charter flight, there was no record that the pilot or safety pilot obtained a formal preflight weather briefing for the accident flight either directly from a flight services provider, through the ForeFlight application, or from a third-party vendor. No data were available to determine what weather information the pilots may have accessed using the ForeFlight application or some other source. The flight risk analysis (FRA) form the pilot completed about 4 1/2 hours before the accident flight’s departure included risk items related to maintenance, weather, duty hours, and a second pilot. Based on the form’s risk scoring criteria, the pilot’s score of 12 for the accident flight was in the company’s low risk category (the maximum score for the flight to remain in the low risk category was 15). In the days preceding the accident, the helicopter had been undergoing routine maintenance that involved work on the radar altimeter, which was a required instrument for Part 135 flight operations. About 1727 on the day of the accident, the accident pilot and a company mechanic/pilot repositioned the helicopter from the maintenance facility to the company’s flight operations base, and during the flight the accident pilot noted the radar altimeter was not functioning. During the return flight, the pilot texted the director of maintenance (DOM) about the issue. After arriving at the company’s flight operations base, the pilot discussed the issue with the company flight follower (who was also the company’s president). According to the flight follower, who also held operational control of the charter flight, during the discussions he told the pilot that the flight could not depart if the radar altimeter was not functioning. A company mechanic performed some troubleshooting on the radar altimeter; however, he was unable to rectify the issue and the radar altimeter remained non- functional. The mechanic reported that the pilots and the DOM were aware that the radar altimeter was not functioning, yet they departed at 1822 on the positioning flight to pick up the passengers. About 40 minutes later, the positioning flight landed at the airport to pick up the charter passengers. After arrival, the pilot and flight follower had a phone conversation and exchanged text messages, but they did not discuss the status of the radar altimeter or weather conditions. The accident leg departure was delayed about 50 minutes due to a passenger’s lost passport. A review of surveillance video at the fixed-based operator showed the pilots in the lobby using their cellphones; it is not known if the pilots checked the weather on their cellphones during that departure delay. In addition, the pilot did not complete an update to the FRA (which was internet accessible) while waiting at the airport. There was no evidence that the radar altimeter began functioning normally before the accident flight. During the time between the pilot completing the FRA and the accident flight leg departure, the National Weather Service issued weather updates involving the planned flight route area. The updates included lower ceilings and precipitation with rain and snow showers across the region. The accident flight departed in dark night visual flight rules (VFR) conditions and no moon illumination with a planned route to follow freeways to the destination airport. The freeway lights, vehicle lights, and various ground lights along the route of flight would have provided the light sources for VFR orientation. ADS-B and company flight tracking data showed the helicopter following the freeways at various altitudes and airspeeds toward the destination airport. About 10 miles west of the accident site, with mainly freeway vehicle lights available, the pilot began operating the helicopter at lower and slower airspeeds, deviated to the north of the freeway about 3,100 ft laterally, then returned back over the freeway. The lower altitude, slower airspeed, and deviation were likely due to encountering low ceilings and reduced visibility related to precipitation. Generally, helicopter pilots are trained to slow down and descend, if prudent, when negotiating or encountering deteriorating weather conditions. This can allow a pilot more time to safely maneuver the helicopter to avoid the conditions. The accident site area included hilly terrain that was rising on both sides of the freeway and in front of the helicopter. About 2 minutes before the accident, the helicopter’s airspeed and altitude increased, with a slight deviation to the south of the freeway. It is unclear if the pilot was attempting an inadvertent instrument meteorological conditions (IIMC) recovery maneuver. The helicopter continued the right turn for about 10 seconds when the helicopter began a rapid descent into terrain while maintaining the right turn. Witnesses, who were traveling in their vehicles, reported observing a fireball to the south of the freeway. The witnesses reported that the weather conditions in the area were not good as it was raining with a snow mix. Search and rescue efforts were difficult due to weather conditions that included low visibility, rain, snow, and high winds. The helicopter wreckage, which was highly fragmented and not survivable, was located about 1 hour and 40 minutes after the accident. Postaccident examination of the airframe, engine, rotor blades, flight controls, rotor drive, main rotor, and fenestron components identified no evidence of preimpact malfunction or failure that would have precluded normal operation. The engine displayed rotational damage signatures and resolidified metal deposits consistent with powered operation at impact. All recovered instruments, avionics, and portable/personal electronic devices sustained damage that prevented data extraction. The helicopter wreckage was consistent with a high-energy, right-side-low attitude impact with terrain. The accident pilot was trained that, to recover from entry into instrument meteorological conditions (IMC), he should first level the wings on the artificial horizon indicator, maintain heading, adjust torque and airspeed for best rate of climb, and climb to an altitude that will avoid obstacles. The gradual right turn, increased airspeed, and increased descent rate were inconsistent with the training to recover from entry into IMC. The pilot may have been susceptible to the Coriolis illusion when maintaining a constant turn if he moved his head, for example, to look from inside the cockpit to outside the cockpit. In addition, the helicopter also began to accelerate as it descended, which could have resulted in a somatogravic (false climb) illusion that led the pilot to believe the helicopter was climbing. The pilot likely experienced spatial disorientation while maneuvering the helicopter in IMC, which led to his loss of helicopter control and the resulting collision with terrain. The accident occurred at 2208; while this time is not typically associated with extreme fatigue, it is a time when melatonin is increasing, and the body is preparing for sleep. Additionally, based on information from the pilot’s fiancée, the accident occurred during a time when the pilot would normally have been sleeping. Although the pilot had only been awake about 13 hours and on duty about 8 hours at the time of the accident, given the time of day and the body’s biological desire to sleep, the role of fatigue could not be ruled out. While the exact actions of the pilot before his spatial disorientation are unknown, fatigue has been shown to reduce one’s judgement, decrease reaction time, and degrade performance, all affecting the pilot’s ability to respond to deteriorating weather conditions. Recognizing that opportunities exist to identify hazards or deficiencies before an accident occurs is a vital component of the safety management system (SMS). However, Orbic Air missed several opportunities t

Orbic Air hired the pilot in 2021, and he completed his initial competency check in accordance with 14 CFR Part 135.293 (which specifies initial and recurrent pilot testing requirements) on September 8, 2022, in the Robinson R-44 helicopter. According to the pilot’s resume, dated April 4, 2023, the pilot had about 6.2 hours of turbine flight time; 117 hours of instrument time, which included 69.4 hours in simulators; 48.8 hours while flying under simulated IMC; and 0 hours in actual IMC. The pilot completed his initial competency check in accordance with 14 CFR Part 135.293 in the accident helicopter on July 10, 2023. The check included demonstrating satisfactory flying maneuvers required for IIMC to VFR conditions and unusual attitude recovery. According to the pilot’s fiancée, in the days preceding the accident, he woke up between 0500 and 0630 and went to bed around 2000 and 2030. On the morning of the accident, the pilot woke up at 0620 and went back to bed from about 0730 to 0900 before resuming his activities. Orbic Air hired the safety pilot in 2022, and he completed his initial competency check in accordance with 14 CFR Part 135.293 in the Robinson R-44 helicopter on May 17, 2023. The check included demonstrating satisfactory flying maneuvers required for IIMC recovery and unusual attitude recovery. The safety pilot was assigned to operate as a Part 135 PIC in the Robinson R-44 helicopter. Accident Helicopter Information The helicopter, was manufactured in 2006 by Airbus Helicopters (previously Eurocopter) (see figure 3), and Orbic Air purchased the helicopter on March 16, 2022. FAA airworthiness documents showed equipment changes from the original manufactured configuration that included, but were not limited to,: the Bendix King KR87 automatic direction finder (ADF) system had been removed and a FreeFlight TRA3500 radar altimeter had been installed. Figure 3. Undated photograph of the accident helicopter (Source: Internet). Maintenance and Radar Altimeter Information The maintenance records showed four radar altimeter issues between June 2022 and the accident flight. The following maintenance entry was noted for February 9, 2024: Main rotor (MR) pin inspection, 7-day/10-hour inspection, MR pitch rod Airworthiness Directive, Engine 300-hour inspection, Radar Altimeter (RadAlt) repair (repaired coax, reinstalled antennas), Unibal repair, Instrument lights inoperative and repaired, Oil cooler leak repair, Removed GNS 430 and installed GTN650Xi, Removed GTX300 and installed GTX 345. Ground run and test flight completed. According to the DOM, the radar altimeter exhibited intermitted issues depending on the power sequence to the unit. In some instances, if the radar altimeter was turned on with just battery power, the radar altimeter would “flash at you and then sort of…it would nuke it.” In other instances, if the radar altimeter was turned on while the helicopter engine and generator were running and supplying constant voltage, the unit would typically function without an issue. As a result, the DOM then instructed the company pilots to leave the radar altimeter off during the start sequence and turn it on when the generator had come online to 28 volts. Equipment Discrepancy Reporting and Records The aluminum document storage clipboard that contained helicopter and maintenance information onboard the helicopter was located intact in the wreckage debris area. A catalog of the contents was as follows: 1) flight log, 2) recurring maintenance compliance log, 3) dual control removal/installation log, and 4) aircraft status report (created January 11, 2024). Not present in the clipboard was an aircraft discrepancy log. The DOM stated that if there was an aircraft discrepancy identified by the flight crew that it would be reported via text message or phone call by the pilot to the DOM. The DOM would then instruct the flight crew how to proceed. There was no written (paper) record kept of these discrepancies. If the discrepancy required maintenance action, the maintenance department would make the repair and enter it into the internet-based tracking system. Recent maintenance would be included in the aircraft status sheet that goes into the aircraft clipboard. Typically, the pilots did not review the maintenance records before accepting an aircraft for flight. If there was any recent maintenance performed, the DOM would convey the work done to the pilot verbally. The Orbic Air GOM (Revision 11), Section F, Chapter 6, stated that when a pilot found a defective piece of equipment they should: Check the Aircraft Discrepancy Log in the aircraft and see if the item has been previously reported and properly deferred. If the item has not been previously written up, the PIC will record the pertinent information on the company Aircraft Discrepancy Record. The Aircraft Discrepancy Log will remain in the aircraft until the affected part is repaired or replaced and an entry to that effect is made in the aircraft permanent maintenance records. Title 14 CFR Part 135.65, Reporting mechanical irregularities, states that: (a) Each certificate holder shall provide an aircraft maintenance log to be carried on board each aircraft for recording or deferring mechanical irregularities and their correction. (b) The pilot in command shall enter or have entered in the aircraft maintenance log each mechanical irregularity that comes to the pilot's attention during flight time. Before each flight, the pilot in command shall, if the pilot does not already know, determine the status of each irregularity entered in the maintenance log at the end of the preceding flight. (c) Each person who takes corrective action or defers action concerning a reported or observed failure or malfunction of an airframe, powerplant, propeller, rotor, or applicable, shall record the action taken in the aircraft maintenance log under the applicable maintenance requirements of this chapter. (d) Each certificate holder shall establish a procedure for keeping copies of the aircraft maintenance log required by this section in the aircraft for access by appropriate personnel and shall include that procedure in the manual required by Sec. 135.21. The pilot and safety pilot reported no medical conditions on their most recent FAA airman medical applications. The FAA Forensic Sciences Laboratory performed toxicology testing on postmortem specimens. The results were negative for ethanol and all tested-for substances. The San Bernardino County Sheriff’s Department Coroner Division, San Bernardino, California, performed autopsies on the pilot and safety pilot. The pilots’ causes of death were multiple blunt force injuries. On February 9, 2024, about 2208 Pacific standard time, an Airbus Helicopters EC 130B4 helicopter, N130CZ, was destroyed when it was involved in an accident near Halloran Springs, California. The two pilots and four passengers were fatally injured. The helicopter was operated by Orbic Air, LLC, as a Title 14 Code of Federal Regulations (CFR) Part 135 on-demand flight. According to company records, in the days preceding the accident, Orbic Air coordinated two charter flights with a broker. As per the agreement, Orbic Air would conduct a charter flight to transport passengers from the Palm Springs International Airport (PSP), Palm Springs, California, to the Boulder City Municipal Airport (BVU), Boulder City, Nevada. Three days later, Orbic Air would conduct a charter flight to pick up the passengers from BVU and fly them back to PSP. During the agreement discussions, the broker initially requested a twin-engine aircraft with an instrument-rated pilot; however, Orbic Air’s capability was limited to a single-engine aircraft and VFR operations. According to Orbic Air’s flight operations employee, during the broker discussions, he mentioned to the broker the addition of a second pilot for the nighttime flights, which was a standard company prec