Pilot Debrief

ROBINSON HELICOPTER COMPANY R44 II near Point Harbor, NC — 2021-07-19

Final reportERA21LA295
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Date
2021-07-19
Location
Point Harbor, NC, USA
Aircraft
ROBINSON HELICOPTER COMPANY R44 II
Registration
N4529J
Category
Helicopter
Highest injury
Fatal
Fatalities
2
Phase of flight
Climb

Probable cause

The noncertificated pilot’s decision to continue visual flight rules flight into instrument meteorological conditions, which resulted in spatial disorientation over a large body of water and a high velocity impact with the water. Contributing to the accident was the flight instructor’s inadequate oversight during their initial training and improperly signing off the student for solo flight when he lacked the proper student pilot and medical certificate.

Contributing factors

Contributing to the accident was the flight instructor’s inadequate oversight during their initial training and improperly signing off the student for solo flight when he lacked the proper student pilot and medical certificate.

NTSB narrative

The noncertificated pilot, who was the owner of the helicopter, originated the afternoon flight from a private residence, completed a brief fuel stop at an uncontrolled airport, and then continued toward the destination. Shortly after takeoff following the fuel stop, the pilot called a friend near the destination via video chat and informed him that he would arrive in an hour. The friend reported that everything seemed normal with the pilot, and he did not mention any concerns pertaining to the weather or helicopter. About an hour later, 27 miles northwest of the destination, a witness saw the helicopter land in a field. The helicopter remained on the ground for a few minutes and when the witness approached the helicopter in their car, the helicopter quickly took off toward a large body of water and continued a flight path that was consistent with a direction to the planned destination. About an hour after the helicopter was last seen by this witness, family members alerted the United States Coast Guard (USCG) that the helicopter had not arrived at the destination. The USCG conducted a search for the helicopter based upon cellphone location data and the next day small fragments of wreckage were located on the surface of the large body of water. The pilot and passenger were also recovered, and both had sustained fatal injuries. The small fragments of wreckage located were consistent with an impact at high velocity. Based upon planned route of flight data collected from a flight planning application, cellphone location data, and the debris area, it is likely that after the brief off-airport landing, the pilot continued the flight toward the destination. A witness described conditions at the time as low clouds, misty, with restricted visibility across the water. An NTSB weather study found that near the location of where debris was found, about the presumed time of the accident, widespread light to heavy precipitation, low clouds, and reduced visibility were present. There was no record that the pilot received an online or telephone weather briefing. Had the pilot received a weather briefing, forecasts would have alerted him of possible instrument meteorological conditions (IMC) and precipitation along his route. Given that the pilot informed his friend shortly after takeoff that he would arrive in 1 hour, and made no mention of the weather, it is likely that he was not aware of the IMC and precipitation. It is likely that the pilot performed an unplanned off-airport landing due to the weather conditions ahead, and instead of terminating the flight, he chose to continue in what had become IMC. The pilot’s attempted flight under visual flight rules in those conditions would have increased his likelihood of losing control of the helicopter due to spatial disorientation with no clear separation between the water surface and low clouds and obscuration of the horizon. The pilot was not qualified to operate the helicopter in IMC, the helicopter was not approved for flight into IMC, and in addition, he possessed limited training to operate the helicopter in general. These findings make a mechanical problem with the helicopter an unlikely factor in the accident, however, the limited amount of wreckage found precluded the investigation from examining the helicopter for any evidence of preimpact mechanical malfunctions or failures. The pilot’s flight instructor was aware of the accident cross-country flight; however, the pilot was not issued any of the required endorsements or prerequisite training to conduct the flight. The flight instructor reported that this was not the first flight the pilot conducted in which he was not properly endorsed or authorized for. The investigation was unable to determine if the pilot understood that he was not legally authorized to conduct solo cross-country flights or carry passengers. The flight instructor had authorized the pilot to perform solo flights, despite the student not holding the required student pilot and medical certificate. This deviation from regulations by the flight instructor likely contributed to the pilot’s subsequent deviations from regulations and his decision to conduct the accident flight despite not being properly trained or endorsed for the accident flight. Based on the pilot’s toxicology results, at least some of the detected ethanol was likely from sources other than consumption. Whether ethanol effects contributed to the accident cannot be determined from available evidence. Based on available medical and operational evidence, postmortem carbon monoxide production during prolonged water immersion likely increased the carboxyhemoglobin level in the pilot’s cavity blood after his death. It is unlikely that carbon monoxide effects contributed to the accident.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot did not check weather conditions before takeoff despite low visibility reported.

NTSB coding

Evidence available

  • Video
  • ADS-B / radar
  • Photos
  • 14 docket documents
View NTSB final reportView NTSB docket

Docket documents14

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