Pilot Debrief

Guimbal CABRI near Kent Island, MD — 2019-05-04

Final reportERA19FA163
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Date
2019-05-04
Location
Kent Island, MD, USA
Aircraft
Guimbal CABRI
Registration
N572MD
Category
Helicopter
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The noninstrument-rated pilot's continued visual flight into instrument meteorological conditions, which resulted in an inadvertent descent into the water. Contributing to the accident was the pilot's decision to conduct the flight at a low altitude without sufficient cues to aid in the perception of attitude and altitude.

Contributing factors

Contributing to the accident was the pilot's decision to conduct the flight at a low altitude without sufficient cues to aid in the perception of attitude and altitude.

NTSB narrative

The non-instrument-rated pilot and passenger intended to fly the helicopter, which was not equipped for instrument flight, in order to photograph the passenger's family member fishing, despite a forecast of instrument meteorological conditions. The helicopter flew for about 11 minutes, making several left and right turns in the vicinity of where the family member was fishing at an altitude of about 175 ft. The passenger was texting the family member, and at one point asked "Can you see us? We are hitting the wall that we can't fly through." The family member responded, "not really," and the passenger sent one last text message stating, "Give me one more [GPS] pin to try." After the last message, the helicopter began to fly south over water and away from land and any natural horizon. The wreckage was located in the water about 1.5 miles from the shoreline. Examination of the wreckage revealed no evidence of any preimpact mechanical anomaly. Analyses of weather information, witness statements, and photographs taken by the passenger were consistent with conditions of limited visibility and a lack of a visible horizon. In these limited visibility conditions, especially when flying away from shore, the pilot's workload would have increased as he divided his attention between maintaining control of the helicopter and an adequate altitude above the water using poor visual cues and positioning of the helicopter laterally while looking for the fishing vessel. These conditions were conducive to the both the development of spatial disorientation and loss of control, or an inadvertent descent into the water (due to distraction or a visual illusion). The ability of the pilot to detect any loss of control or a trajectory towards the water was significantly reduced as a result of the extremely low altitude in which the flight over water was conducted, the low visibility, the lack of instruments on board to allow for instrument flight, and his lack of instrument training and experience.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot should have aborted the flight due to IMC conditions after weather briefing.

NTSB coding

Evidence available

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

Docket documents19

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