Pilot Debrief

Agusta A109 near New York, NY — 2019-06-10

Final reportERA19FA191
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Date
2019-06-10
Location
New York, NY, USA
Airport
6N5
Aircraft
Agusta A109
Registration
N200BK
Category
Helicopter
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

The non-instrument-rated pilot’s decision to initiate the flight into marginal visual flight rules and instrument meteorological conditions, which resulted in spatial disorientation and a subsequent loss of control.

NTSB narrative

After dropping off a passenger during a routine weekly commuting flight, the noninstrument-rated pilot of the helicopter remained at the fixed-base operator (FBO) for about 2 hours, reviewing weather information before departing on the planned repositioning flight, which was the last flight leg of the commute. Before he departed, the pilot informed FBO staff that he saw a “twenty-minute window to make it out.” Had the pilot remained at the heliport, the helicopter owner would have incurred hourly, overnight, and landing fees depending on the length of stay. The extent to which those fees or other factors, such as the pilot’s obligation to reposition the helicopter as part of the normal commute, influenced his decision to depart could not be determined. The pilot departed into marginal visual flight rules (MVFR) conditions, and soon after takeoff, encountered instrument meteorological conditions (IMC). Although the pilot communicated that he was attempting to return to the departure heliport; shortly thereafter, he transmitted to heliport staff that he “didn’t know where he was.” Flight track data depicted an erratic flight path after takeoff, during which the helicopter climbed above the reported cloud base of 500 ft above ground level, and witness video recordings showed the helicopter flying in and out of clouds. About 8 minutes after takeoff, the helicopter descended rapidly and impacted the roof of a building. Examination of the airframe and engines revealed no evidence of any preimpact anomalies. The pilot’s decision to depart into MVFR conditions and the helicopter’s subsequent encounter with IMC were conducive to the development of spatial disorientation, and the helicopter’s erratic flight path and rapid descent were consistent with a loss of control due to spatial disorientation.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot should have canceled the flight due to poor weather conditions.

NTSB coding

Evidence available

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

Docket documents19

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