Pilot Debrief

BELL HELICOPTER TEXTRON 407 near Nuevo, CA — 2023-03-24

Final reportANC23FA031
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Date
2023-03-24
Location
Nuevo, CA, USA
Aircraft
BELL HELICOPTER TEXTRON 407
Registration
N14Z
Category
Helicopter
Highest injury
Fatal
Fatalities
2
Phase of flight
Maneuvering

Probable cause

The pilot’s decision to maneuver in a steep bank at a low altitude, which resulted in his failure to maintain clearance with terrain.

NTSB narrative

The pilot and passenger departed in the helicopter on a personal flight over rough hilly terrain. The pilot’s cell phone was enabled with a crash notification feature, which initiated a call to a family member to notify them there may have been an accident. The family member notified first responders, and the wreckage was located near the peak of a rocky hilltop. Video recovered from cameras mounted on the outside of the helicopter shows the helicopter took off and made two low-level passes over terrain. As the pilot approached the crest of a ridgeline, he initiated a steep right turn. As the helicopter passed a rocky outcrop at the top of the hill, the main rotor blade contacted the terrain. Fragments of main rotor blades can be seen across the entire view of the camera. Reviewed medical evidence for the pilot and pilot-rated passenger indicated that they both had some risk factors for an impairing or incapacitating cardiovascular event. Although such an event cannot be excluded by autopsy evidence alone, there was no autopsy evidence that such an event occurred, and the accident circumstances were not consistent with a sudden medical event. Thus, it is unlikely that the pilot’s or pilot-rated passenger’s medical conditions contributed to the accident. Examination of the helicopter revealed no anomalies with the airframe or engine that would have precluded normal operation.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have avoided low-level maneuvering over elevated terrain.

NTSB coding

Evidence available

  • Video
  • FDR / data
  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

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