# NTSB ERA22LA007: Bell Helicopter Textron Canada 429, N505TJ, Batavia, NY, October 7, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 4 · Limited · Final report - Date: October 6, 2021, 21:16 local (Oct 7, 2021, 01:16 UTC) - Place: Batavia, NY - Coordinates: 43.034158, -78.167864 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.0342&lon=-78.1679&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 104073 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22LA007 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104073/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104073 - Page: https://openairdocs.org/ntsb/ERA22LA007 ## Probable cause The pilot’s failure to disengage the autopilot prior to climbing out of a fog bank. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Bell Helicopter Textron Canada 429, 2 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=1182158), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Auto flight system: autopilot system](https://openairdocs.org/ntsb-findings/01022210): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Bell Helicopter Textron Canada 429, 1 case](https://openairdocs.org/ntsb-findings/01022210/cases.md?model=1182158), [All aircraft, 28 cases](https://openairdocs.org/ntsb-findings/01022210/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Bell Helicopter Textron Canada 429, 2 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=1182158), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Bell Helicopter Textron Canada 429, 3 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1182158), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Ceiling/visibility/precip: fog](https://openairdocs.org/ntsb-findings/03035055): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Bell Helicopter Textron Canada 429, 1 case](https://openairdocs.org/ntsb-findings/03035055/cases.md?model=1182158), [All aircraft, 78 cases](https://openairdocs.org/ntsb-findings/03035055/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Bell Helicopter Textron Canada 429, 1 case](https://openairdocs.org/ntsb-events/120/sequence.md?model=1182158), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The pilot reported that he decided to perform a practice approach to the runway using night vision goggles. He set up the approach and activated the autopilot. About 200 ft above the ground, the helicopter inadvertently entered a fog bank and the pilot lost visual reference to the runway. He attempted to perform a climbing right turn but forgot to deactivate the autopilot. The autopilot initiated a descent into the fog, the pilot maintained a level attitude, and shortly thereafter the helicopter impacted the ground and bounced. The pilot attempted to initiate a climb; however, the helicopter impacted the ground a second time, which resulted in substantial damage to the fuselage. The pilot reported no preimpact mechanical malfunctions or failures with the helicopter that would have precluded normal operation. ## Aircraft - Registration: [N505TJ](https://openairdocs.org/deregistered/N505TJ-2022-11-03), registration cancelled 2022-11-03, S/N 57029, built 2010 (OpenAirDocs) - Reported make and model: BELL HELICOPTER TEXTRON CANADA 429 - Registry model: [Bell Helicopter Textron Canada 429](https://openairdocs.org/model/bell-helicopter-textron-canada-429) (registry code 1182158) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PW207D](https://openairdocs.org/engine/pratt-whitney-canada-pw207d) (registry code 52156, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 57029 - Year built: 2010 - Airframe hours: 2860 - Engines: Pratt & Whitney PW207D1 550 horsepower turbo shaft; Pratt & Whitney PW207D1 550 horsepower turbo shaft - Damage: Substantial damage - Flight: Positioning, Part 135 - Operator: Mercy Flight Inc - Registered owner: Mercy Flight Inc - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, September 28, 2021 - Departed: ROC, Rochester, NY - Destination: Same as departure - Flight plan: Company VFR - Airport: GVQ, Genesee County, runway 10/28, 5,499 × 100 ft, asphalt - Equipment: Onboard weather, Electronic primary flight display, Electronic multifunction display, Data recorder, Satellite tracking device, Auto-pilot, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: none; flight engineer, private, commercial; airplane ratings: single-engine land; instrument ratings: helicopter; medical: class 2, with waivers/limitations; last flight review April 23, 2021; seat: right; restraint: 4-point; flight hours: 3,583 total, 621 in this make and model, 3,583 as pilot in command, 25 in the last 90 days, 9 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: calm - Lowest ceiling: none - Temperature: 50 °F, dew point 48 °F - Observed at: GVQ ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20211006017429A](https://openairdocs.org/incident/20211006017429A), Oct 6, 2021: Bell Helicopter Textron Canada 429, Batavia, NY, Substantial damage. On the evening of October 6th, 2021, approximately 2116 EDT, [privacy data omitted], N505TJ, a Bell 429 helicopter air ambulance, operating under 14 CFR 135 ?… ## Docket (3 files) The files NTSB released with the investigation on January 4, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104073. 5.0 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12900530&FileExtension=pdf&FileName=6120%20LA007_Redacted-Rel.pdf - Pilot record of interview (item 2, PDF, 3 pages, 175 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12900964&FileExtension=pdf&FileName=Record%20of%20Interview%20Pilot_Redacted-Rel.pdf - Investigative photographs (item 3, PDF, 3 pages, 3 photos, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12903971&FileExtension=pdf&FileName=Photo%20Array%20LA007-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.