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NTSB investigation record

ERA09FA417

Completed

Robinson helicopter R44· N7189W

Date
July 24, 2009
Location
Boonsboro, MD
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot’s improper decision to depart on a visual flight rules (VFR) flight at night in adverse weather conditions in close proximity to rising mountainous terrain in a helicopter that was only certified to be operated under VFR and his subsequent failure to maintain adequate clearance with wires.

Investigator assessment

Analysis narrative

The helicopter arrived at Hagerstown Regional Airport, Hagerstown, Maryland, from Frederick Municipal Airport (FDK), Frederick, Maryland, about 1815, which was almost 2 hours later than scheduled, because of adverse weather. About 2000, the pilot and three passengers boarded the helicopter for the return flight to FDK; however, they subsequently returned to the airport terminal because of poor weather conditions. According to witnesses at the airport, the pilot checked the weather while at the terminal several times. Further, he called a fellow employee of Advanced Helicopter Concepts (the operator of the helicopter), who lived about 4 miles from FDK, twice to ask about weather conditions at the airport. About 2100, the employee informed the pilot that the weather conditions were “miserable” with severe thunderstorms in the area. Sometime between 2200 and 2215, the employee told the pilot that the rain had stopped; however, he stated that it was still foggy and windy with lightning in the area. On both occasions, the employee offered to drive the helicopter occupants back to FDK; however, the pilot declined the offers. A 2210 weather observation taken at FDK, located about 15 miles southeast of the accident site at an elevation of 303 feet above mean sea level (msl), indicated the following: visibility of 10 statute miles, thunderstorms and light intensity rain, and scattered clouds at 800 and 8,000 feet. A witness on the ground near the accident site reported that it was a “dark night” (civil twilight ended at 2101, and only 4 percent of the moon’s visible disk was illuminated) and that fog was present about 50 feet above the roadway surface. Given that the helicopter was only certified to be operated under visual flight rules, the pilot exercised poor judgment when he chose to fly back to FDK in dark night and adverse weather conditions. The helicopter took off about 2215 and was flying over an interstate highway toward FDK when it entered an area of reduced visibility. The helicopter subsequently struck an unmarked, steel guy-wire that extended perpendicularly over the interstate, near the top of a mountain, and then crashed. During the final 2 minutes of the flight, the helicopter was flying at level flight about 1,100 feet above msl as the terrain elevation rose from about 600 to 1,200 feet above msl. A witness observed the helicopter fly into clouds and reverse direction just before impact. The accident sequence is consistent with controlled flight into an obstacle that the pilot most likely did not see because of the dark night conditions and reduced visibility. The helicopter was equipped with a radar altimeter. Further, Robinson Helicopter Safety Notice SN-16 advises pilots to constantly be on alert for power lines because “flying into wires, cables, and other objects is by far the number one cause of fatal accidents in helicopters” and to “always maintain at least 500 feet AGL [above ground level], except during take-off and landing.” Safety Notice SN-26 states, “Many fatal accidents have occurred at night when the pilot attempted to fly in marginal weather...when it is dark, the pilot cannot see wires…Even when he does see it, he is unable to judge its altitude because there is no horizon for reference.”

Source record

Factual narrative

HISTORY OF FLIGHT On July 23, 2009, at 2226 eastern daylight time, a Robinson R44 helicopter, N7189W, was substantially damaged when it struck a guy-wire and impacted the ground while in cruise flight near Boonsboro, Maryland. The certificated commercial pilot and three passengers were killed. Night visual meteorological conditions prevailed and no flight plan had been filed for the Title 14 Code of Federal Regulations Part 91 business flight. The flight originated from Hagerstown Regional Airport (HGR), Hagerstown, Maryland, and was en route to Frederick Municipal Airport (FDK), Frederick, Maryland, when the accident occurred. The helicopter was based at FDK and maintained by Advanced Helicopter Concepts (AHC), an operator of five Robinson R22 helicopters. The helicopter was privately owned by a trustee of Advanced Helicopter Youth Foundation, a non-profit charity founded by the President of AHC. According to witnesses, on the day of the accident, the helicopter flew from FDK to HGR, to transport a Director of Advanced Helicopter Youth Foundation, and another passenger to a business association meeting. In addition, the pilot was scheduled to give rides in the helicopter, in conjunction with that meeting. The pilot and the third passenger were employees of AHC. The helicopter arrived at HGR at approximately 1812. It was originally scheduled to arrive at 1630, but was delayed due to weather. The pilot then gave rides in the helicopter, until about 2000. The rides consisted of a flight around the traffic pattern and lasted less than 5 minutes each. After the business meeting and the rides, the pilot and passengers boarded the helicopter; however, it was shut-down shortly thereafter and the occupants returned to the terminal. An airport employee reported that one of the passengers stated that the weather was "pretty bad" and that the pilot thought they would be delayed about 1 hour. At approximately 2100, the pilot called an employee of AHC, to ask about the weather conditions for the return flight to FDK. The employee lived about 4 miles from FDK, near the base of South Mountain, and informed the pilot that the weather conditions were "miserable" with severe thunderstorms in the area. He offered to drive in his car to HGR to return the occupants to FDK; however, the pilot stated they would "wait out" the weather. The pilot called back "sometime between 2200 and 2215," to again ask about the weather conditions. The employee told the pilot that the rain had stopped; however, it was still foggy, and windy with lightning in the area. He again offered to drive to HGR, and the pilot stated that he would wait for the weather conditions to improve. He also mentioned that a wife of one of the passengers owned a minivan, and could pick them up if needed. It was estimated that the helicopter departed HGR about 2215. The HGR air traffic control tower closed at 2200, and there were no known communications with the helicopter. A witness, driving east on Interstate 70 (I-70), stated that he observed the helicopter pass over his right side. It was a "dark night," and there was fog present about 50 feet above the roadway surface. The helicopter appeared to fly into "low clouds," turned around, and was heading back toward the west, when it contacted power lines just as his car passed under them. The helicopter impacted the ground and "burst into flames." Another witness, driving on I-70, reported that the helicopter was flying parallel with the interstate, and "seemed to be getting lower." It then disappeared from view, which was followed by "sparks in the sky." He then observed the helicopter descend toward the roadway. PERSONNEL INFORMATION The pilot, age 24, was hired by AHC in January 2009. He held a flight instructor certificate, with ratings for rotorcraft and instrument helicopter. He also held a commercial pilot certificate, with ratings for airplane single-engine land, rotorcraft, instrument airplane, and instrument helicopter. Review of the pilot's logbooks revealed that as of July 18, 2009, he had accumulated about 645 hours of total flight experience, which included about 440 hours in helicopters. Of the 440 hours, about 20 hours were logged in the same make and model as the accident helicopter, with the remaining time logged in R22 series helicopters. The pilot received a "checkout" in the R44 on December 24, 2008. In addition, the pilot had logged about 70 and 160 hours during the 30 and 90 days preceding the accident; respectively. The pilot had accumulated about 25 hours of night flight experience, which included about 12 hours at night in helicopters. During the 90 days preceding the accident, the pilot had logged .3 hours of night flight experience. According to company records, the pilot flew 3.2 hours on the day prior to the accident, and 2.7 hours on July 20, 2010. On the day of the accident, the pilot had one flight scheduled at 1200, which consisted of a 1.9 hour photography flight. The pilot completed a Robinson Helicopter Company Pilot Safety Course on February 5, 2009. The pilot's most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on July 13, 2009. The other AHC employee onboard was hired in 2009, and worked at the "front desk" as an office manager. He held a rotorcraft private pilot certificate, which was issued on March 31, 2009. At that time, he reported about 90 hours of rotorcraft flight experience. AIRCRAFT INFORMATION The four-seat, single main rotor, single-engine helicopter, serial number 847, was constructed primarily of metal, and manufactured during September 2000. The primary structure of the fuselage was welded steel tubing and riveted aluminum sheet. The tailcone was a monocoque structure in which aluminum skins carried most of the primary loads. Fiberglass and thermoplastics were used in the secondary structure of the cabin, engine cooling system, and in various other ducts and fairings. The helicopter was powered by a 260-horsepower Lycoming O-540-F1B5 series engine, with a maximum continuous rating of 205-horsepower at 2,718 rpm. Review of maintenance records revealed that the helicopter had been operated for about 60 hours since its most recent annual inspection, which was performed on March 16, 2009. At the time of the annual inspection, the airframe and engine had been operated for about 1,730 hours since new. Prior to the accident date, the helicopter was flown from Lexington, South Carolina, to FDK, on July 13, 2009. The pilot of that flight described the flight as "uneventful." According to the Pilot's Operating Handbook, the helicopter was certified to be operated under visual flight rules flight only. METEOROLOGICAL INFORMATION Witnesses at the airport reported that the pilot and AHC employee both checked the weather conditions several times while they were at HGR. The following weather observations were recorded at HGR, which was located about 13 miles northwest of the accident site, at an elevation of 692 feet mean sea level (msl): At 2153, wind from 310 degrees at 5 knots; visibility 10 statute miles; few clouds at 2,300 feet, broken clouds at 8,000 feet; temperature 24 degrees Celsius (C), dew point 19 degrees C; altimeter 29.87 inches of mercury (in/hg). At 2253, wind from 320 degrees at 5 knots; visibility 10 statute miles; sky clear; temperature 23 degrees C, dew point 19 degrees C; altimeter 29.88 in/hg. The following weather observations were recorded at FDK, which was located about 15 miles southeast of the accident site, at an elevation of 303 feet msl: At 2210, wind from 130 degrees at 11 knots; visibility 1.5 statute miles, with thunderstorms and heavy intensity rain; broken clouds at 600 and 1,000 feet, overcast clouds at 1,500 feet; temperature 21 degrees C, dew point 20 degrees C; altimeter 29.89 in/hg. At 2232, wind from 200 degrees at 6 knots; visibility 10 statut

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