WPR23LA200

NTSB accident investigation · Eurocopter AS 350 B3 · San Diego, CA · May 24, 2023

Accident · No injuriesClass 4 · LimitedFinal report
Date
May 23, 2023, 22:10 local (May 24, 2023, 05:10 UTC)
Place
San Diego, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Taxi
Aircraft
N791AMEurocopter AS 350 B3
Defining event
Taxi-from runway: Loss of control in flight
Weather
Visual (VMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 4 - Basic report with no Prelim publish
NTSB office
Western Pacific Region
Parties
FAA, CBP
FAA report
20230523011049A
Case key
192242

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’s failure to maintain altitude during a hover taxi due to distraction resulting from the unanticipated activation of strobing lights while using night vision googles.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotEurocopter AS 350 B3: 14 casesAll aircraft: 9,295 casesProbable cause
Light condition: bright lightEnvironmental issues › Conditions/weather/phenomena · Response/compensationEurocopter AS 350 B3: 1 caseAll aircraft: 28 cases
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedEurocopter AS 350 B3: 4 casesAll aircraft: 1,310 casesProbable cause
Attention/monitoring: attentionPersonnel issues › Psychological · PilotEurocopter AS 350 B3: 1 caseAll aircraft: 226 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot of the helicopter reported that he had completed an operational mission, during which he was wearing Night Vision Goggles (NVGs), and returned to the airport. While hover taxiing to parking using the NVGs, an aircraft approaching the airport to land triggered the Traffic Collision Avoidance System (TCAS), causing the helicopter’s strobing “wig-wag” lights to activate and impact the pilot’s visibility. The pilot looked down to locate the light switch and removed his hand from the collective to deactivate the lights. The helicopter descended and contacted the ground before the pilot could stop the descent. The helicopter subsequently became airborne again and the pilot was able to regain control and continue hover taxiing to parking. Substantial damage to the tail boom was discovered after the flight. The pilot reported that there were no preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operation.

Aircraft

Registration
N791AM
Reported as
Eurocopter AS 350 B3
Category
Helicopter
Serial number
4335
Built
2007
Airframe hours
11,500
Engine
Turbomeca ARRIEL 2B1, 747 horsepower, turbo shaft
Damage
Substantial damage
Flight
Public aircraft - federal · Part 91
Operator
US Department Of Homeland Security
Registered owner
US Department Of Homeland Security
Airworthiness certificate
Standard, Normal
Last inspection
April 28, 2023 · 69 hours before
Destination
Same as departure
Flight plan
Company VFR
Airport
SDM · Brown Fld Muni, runway 26R, 7,972 × 150 ft, concrete
Equipment
Satellite tracking device, Electronic multifunction display, Electronic flight bag or handheld device, ADS-B

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
42
Injuries
None
Certificates
Military, Commercial
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
March 20, 2023
Seat
Right
Restraint
4-point
Flight hours
1,900 total · 200 in this make and model · 560 as pilot in command · 23 in the last 30 days
Role
Co-pilot
Age
44
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
March 30, 2023
Seat
Left
Restraint
4-point
Flight hours
1,388 total · 190 in this make and model · 914 as pilot in command · 56 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Night
Wind
260° at 6 knots
Visibility
10 statute miles
Lowest ceiling
1,400 ft overcast
Temperature
57 °F, dew point 54 °F
Altimeter
29.95 inHg
Observed at
KSDM, 1 nm away
METAR
KSDM 240453Z AUTO 26006KT 10SM OVC014 14/12 A2995 RMK AO2 SLP140 T01440117

Docket · 2

The files NTSB released with the investigation on October 20, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.3 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.