Pilot Debrief

EUROCOPTER DEUTSCHLAND GMBH EC-145 near North Captiva Island, FL — 2009-08-17

Final reportERA09LA464
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Date
2009-08-17
Location
North Captiva Island, FL, USA
Airport
FL90
Aircraft
EUROCOPTER DEUTSCHLAND GMBH EC-145
Registration
N911LZ
Category
Helicopter
Highest injury
None
Fatalities
0
Phase of flight
Descent

Probable cause

The pilot's failure to arrest the helicopter's descent, which resulted in controlled flight into terrain.

NTSB narrative

The emergency medical services (EMS) helicopter was on a night, over-water flight in visual meteorological conditions when the accident occurred. The pilot and two medical crewmembers were en route to pick up a patient on a barrier island. The pilot flew over the water with the autopilot engaged (altitude acquisition mode), at an altitude of 1,000 feet. While en route, the pilot unsuccessfully attempted to contact the fire department on the island to obtain landing zone information. When the helicopter was approximately 3 minutes from landing, the pilot selected 500 feet using the autopilot and the helicopter initiated a descent to that altitude. Unable to contact the fire department, the pilot likely became preoccupied with the task as well as the visual acquisition of the landing. The descent-power setting, which was manually controlled by the pilot, was not adequate to capture the selected altitude, and maintain 60 knots. As designed, the helicopter likely continued its descent with the autopilot engaged until it impacted the water. The pilot observed an amber indication on the primary flight display just before impact, which indicated the autopilot was engaged, and confirmed this most likely scenario. A post-accident examination of the helicopter revealed no pre-impact mechanical anomalies. After the impact, the dispatcher initiated a re-boot of her computer, rather than a search for the helicopter, when the helicopter's movement stopped on her screen. However, the fire department on scene initiated a search, and the crewmembers were rescued within a short timeframe. Had the crewmembers sustained serious injuries during the accident, the dispatcher's failure to initiate a search may have reduced the survivability of the accident.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have increased power to maintain altitude during descent.

NTSB coding

Evidence available

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

Docket documents28

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