ATL04LA055

NTSB accident investigation · MBB BK117A3 · Okeechobee, FL · December 17, 2003

Accident · Minor injuriesLimited investigationFinal report
Date
December 16, 2003, 19:08 local (Dec 17, 2003, 00:08 UTC)
Place
Okeechobee, FL
Injuries
3 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N911WJMBB BK117A3
Weather
Visual (VMC) · Night/dark
Status
Completed · report June 30, 2004
Report
Approved by Office Director
Parties
Orlando FSDO-15
FAA report
20031216036839A
Case key
58496

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot continued visual flight into instrument meteorological conditions and experienced spatial disorientation, loss of aircraft control, and in-flight collision with trees and terrain. Factors in the accident were the pilot's failure to follow company procedures, total lack of instrument flight time, and a dark night.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherManeuvering
Light condition - dark nightFactor
Vfr flight into imc - encounteredPilot in commandCause
Weather condition - rain
Loss of control - in flightManeuvering
Spatial disorientationPilot in command
Aircraft control - not maintainedPilot in command
Lack of total instrument timePilot in commandFactor
Procedures/directives - not followedPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled
Object - tree(s)
Terrain condition - ground

Analysis

The pilot was conducting a night positioning flight and encountered instrument flight conditions. The pilot did not follow company procedures for instrument flight conditions, and lost control of the helicopter due to spatial disorientation. The helicopter entered a spiraling decent and collided with trees and ground. There were no mechanical anomalies with the helicopter. The pilot had logged 200 hours total time in the make and model helicopter, and no actual instrument time in any type of helicopter except for simulated instrument flight time. According to the company written procedures the pilot was required to follow the checklist which stated in part, "Fly the aircraft, climb to altitude, do not get in a hurry, and contact approach or center."

Factual narrative

On December 16, 2003, at 1908 eastern standard time, a MBB, BK117A3, N911WJ, registered to Merrill Lynch Business Financial SE, operated by C J Systems Aviation Group Inc., as a 14 CFR Part 91 positioning flight, collided with trees and the ground during an inadvertent encounter with instrument flight conditions in cruise flight. No flight plan was filed and a computer weather briefing was obtained. The helicopter sustained substantial damage. The commercial pilot and two paramedics reported minor injuries. The flight originated from a heliport located at Sebring Hartland Hospital, Sebring, Florida, on December 16, 2003, at 1850.

The pilot stated he departed the hospital, climbed to 1,000 feet, and was in visual flight conditions on a heading of 120-degrees magnetic with a ceiling of 1,500 feet and 8 to 10 miles visibility. He passed Okeechobee to the northeast and encountered instrument meteorological conditions (IMC). He observed some highway lights to the east and started a left turn to get a reference on the lights and "lost total visibility due to heavy rain". He slowed the helicopter down and lost sight of the lights. He made a right turn to the south and "encountered vertigo". He immediately looked down at his flight instruments and observed the artificial horizon was above the horizon, and the airspeed was decreasing. He lowered the nose of the helicopter to regain airspeed and the helicopter began to settle. The nose of the helicopter went to the right and down. He looked back at his flight instruments, the attitude indicator showed the helicopter was inverted, and the vertical speed indicator indicated a 1,000-foot a minute descent. He immediately applied cyclic pitch and rolled the helicopter to the upright position and pulled collective pitch to increase power. The front seat paramedic made a mayday call on the radio. The helicopter collided with the trees in an upright position and fell to the ground. The pilot stated there were no mechanical deficiencies with the helicopter.

A paramedic located in the left front seat of the helicopter stated they had just cleared a rain shower when the pilot stated he wanted to follow State Road 70 due to the headlights of the cars. It was dark except for the lights of a few distant houses and the lights of the cars. The pilot started a turn. "During this bank our descent became increased and sharp." He reached over and grabbed the pilot's leg and said his name three times with no response. "We then came to a level attitude and began to fish back and forth from nose to tail and back. This increased in intensity until we entered a right hand downward spiral and impacted the ground."

A St. Lucie County Sheriff's helicopter pilot dispatched to search for the accident helicopter stated he encountered increasingly deteriorating weather and they were using night vision goggles (NVG) which allowed them to continue at a reduced airspeed. The ceiling was 500 feet with light to moderate rain showers and the visibility with NVG's was 3 to 5 miles. They descended down to 300 feet and observed a "black line of low level scud to the northeast about a 1/2 mile away." They started receiving emergency locator signals while they were conducting a grid search. They turned off their anti-collision strobes due to the light refracting the flashes in their NVG's. They immediately observed a light source about a mile away. They flew towards the light source and located the downed helicopter.

Training records provided by CJ Systems Aviation Group revealed the pilot received training on inadvertent IMC on October 6, 2000. The training syllabus states that every pilot is authorized one hour of inadvertent IMC flight training per quarter. The Inadvertent Instrument Meteorological Conditions Checklist (IIMC) instructs the pilot to:

1. Fly the aircraft

2. Climb to altitude

3. Do not get in a hurry

4. CONTACT APPROACH or CENTER

"The first three items should be committed to memory." The pilot had 200 hours in the BK117A3, and no actual instrument flight time.

Review of FAA Advisory Circular 60-4A, PILOT"S SPATIAL DISORIENTATION, states, "The attitude of an aircraft is generally determined by reference to the natural horizon or other visual references with the surface. If neither horizon nor surface reference exists, the attitude of an aircraft must be determined by artificial means from the flight instruments. Sight, supported by other senses, allows the pilot to maintain orientation. However, during periods of low visibility, the supporting senses sometimes conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. The degree of disorientation may vary considerably with individual pilots. Spatial disorientation to a pilot means simply the inability to tell which way is up.

Aircraft

Registration
N911WJ
Reported as
MBB BK117A3
Category
Helicopter
Serial number
7050
Airframe hours
5,533
Engine
Honeywell LTS101-650-B1, 600 horsepower, turbo shaft
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
C J Systems Aviation Group
Registered owner
Merrill Lynch Business Financial SE
Airworthiness certificate
Standard, Utility
Last inspection
Annual · December 15, 2003 · 1 hours before
Departed
Sebring, FL
Destination
SUA · Stuart, FL

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
31
Injuries
Minor
Certificates
Commercial, Flight instructor
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
October 1, 2003
Seat
Right
Flight hours
3,100 total · 200 in this make and model · 3,050 as pilot in command · 16 in the last 90 days · 12 in the last 30 days

Weather

Conditions
Visual (VMC) · Night/dark
Wind
210° at 6 knots
Visibility
8 statute miles
Lowest ceiling
1,700 ft broken
Temperature
72 °F, dew point 70 °F
Altimeter
30.04 inHg
Observed at
FPR, 29 nm away

Docket · 5

The files NTSB released with the investigation on May 4, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.4 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.