Pilot Debrief

ROBINSON HELICOPTER COMPANY R44 II near Panacea, FL — 2014-02-09

Final reportERA14FA115
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Date
2014-02-09
Location
Panacea, FL, USA
Airport
2J0
Aircraft
ROBINSON HELICOPTER COMPANY R44 II
Registration
N571AC
Category
Helicopter
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The pilot’s failure to maintain adequate clearance from trees during a takeoff at night. Contributing to the accident was the pilot’s lack of recent night flight experience.

Contributing factors

Contributing to the accident was the pilot's lack of recent night flight experience.

NTSB narrative

The pilot and two passengers departed on a local flight to a nearby airport. They arrived near sunset, dined at a local restaurant, and returned about 1 hour later. Multiple witnesses reported that the area where the helicopter was parked was dark on the night of the accident; the airport manager stated that the runway lights did not illuminate the trees at the end of the runway. After a preflight inspection, the pilot started the helicopter and announced his position and intentions over the common traffic advisory frequency. A passenger reported that she heard the pilot say, "here we go." The helicopter then impacted the tops of 50-ft-tall trees about 350 ft from the departure location. Examination of the airframe and wreckage revealed no mechanical malfunctions or anomalies that would have precluded normal operation. The pilot had accumulated 1 hour of night flight experience in the 11 months before the accident flight. Given the dark night conditions at the time of departure and his lack of recent night flight experience, it is likely that the pilot was unaware of the trees and did not successfully navigate above the trees and away from the airport. Review of the pilot's medical records and toxicology report revealed that he had been taking a disqualifying medication (pramipexole) since 2006. He reported the use of the medication during his aviation medical exam in 2012, and, although the medication should have been disqualifying, the aviation medical examiner issued the pilot a medical certificate. While symptoms of the disqualifying medication included "falling asleep while engaged in activities of daily living, including operation of motor vehicles," witnesses reported no abnormalities in the pilot's sleep patterns or behavior, including on the day of the flight. Based on witness statements and the pilot's long history of using this medication, it is likely that he was not affected by the medication's published symptoms during the flight.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have delayed takeoff due to dark conditions and fog.

NTSB coding

Evidence available

  • Video
  • Photos
  • 20 docket documents
View NTSB final reportView NTSB docket

Docket documents20

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