Pilot Debrief

ROBINSON HELICOPTER COMPANY R44 near Port O'Connor, TX — 2023-03-07

Final reportCEN23FA125
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Date
2023-03-07
Location
Port O'Connor, TX, USA
Aircraft
ROBINSON HELICOPTER COMPANY R44
Registration
N494SH
Category
Helicopter
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The pilot’s initiation of the visual flight into instrument meteorological conditions, which resulted in spatial disorientation and a subsequent loss of helicopter control. Contributing to the accident was the pilot’s flicker vertigo during the flight.

Contributing factors

Contributing to the accident was the pilot’s flicker vertigo during the flight.

NTSB narrative

The helicopter impacted terrain shortly after the non-instrument-rated pilot took off from his residence for the night flight. A neighbor observed the helicopter’s red anti-collision (strobe) light operating as it departed. The neighbor reported that it was extremely foggy and she could “barely see” her boat dock, which was about 75 ft away. There were no known witnesses to the accident. The helicopter impacted the terrain and a postimpact fire ensued. Recorded data from on board the helicopter showed that it departed from a road next to the pilot’s residence and traveled toward a swamp area that contained little to no ground reference lighting. ADS-B data for the accident flight showed a fight path starting from an area near the pilot’s residence. The helicopter traveled to the east, passed over a lake, and then performed a turn to the north. The helicopter climbed and then descended toward the south. The ADS-B data terminated over an open field next to a home. The direct distance from where the helicopter departed from to the accident site was about 0.25 miles. While a postimpact fire consumed most of the wreckage, an examination revealed no preimpact mechanical malfunctions or failures with the airframe or the engine. The helicopter was found to be equipped for instrument flight; however, the helicopter was not certified for instrument flight rules. A search revealed that the pilot did not receive an official weather briefing before initiating the flight. The pilot’s toxicological testing detected ethanol at a very low level in cavity blood. Ethanol was not detected in vitreous fluid or urine. These results indicate that some or all of the detected ethanol may have been from postmortem production. It is unlikely that ethanol contributed to the accident. The toxicological evidence also indicates that the pilot had used cetirizine. Whether the pilot was experiencing some sedating effects of this medication at the time of the accident is uncertain. Based upon the pilot’s initiation of flight at night in instrument meteorological conditions (IMC), it is unlikely that the pilot’s use of cetirizine contributed to the accident. The autopsy’s cardiac findings are non-specific and unlikely of significance to the accident. The pilot had the anti-collision (strobe) light activated during the flight. Usage of an anti-collision (strobe) light during flight through clouds can cause flicker vertigo and subsequent spatial disorientation. In addition to spatial disorientation, the pilot likely also experienced flicker vertigo before the impact with terrain. It is likely the non-instrument-rated pilot’s decision to initiate flight in night IMC resulted in spatial disorientation, a loss of control during the initial climb, and a subsequent impact with terrain.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot could have delayed takeoff due to extremely foggy conditions.

NTSB coding

Evidence available

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

Docket documents27

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