# NTSB WPR23LA200: Eurocopter AS 350 B3, N791AM, San Diego, CA, May 24, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 4 · Limited · Final report - Date: May 23, 2023, 22:10 local (May 24, 2023, 05:10 UTC) - Place: San Diego, CA - Coordinates: 32.570396, -116.98481 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.5704&lon=-116.9848&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Defining event: [Taxi-from runway: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: No injuries - Injuries: 2 uninjured - 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 - NTSB case key (mKey): 192242 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR23LA200 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192242/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192242 - Page: https://openairdocs.org/ntsb/WPR23LA200 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Eurocopter AS 350 B3, 14 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=8680954), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Light condition: bright light](https://openairdocs.org/ntsb-findings/03036010): Environmental issues › Conditions/weather/phenomena · Response/compensation; cases with it: [Eurocopter AS 350 B3, 1 case](https://openairdocs.org/ntsb-findings/03036010/cases.md?model=8680954), [All aircraft, 28 cases](https://openairdocs.org/ntsb-findings/03036010/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Eurocopter AS 350 B3, 4 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=8680954), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Attention/monitoring: attention](https://openairdocs.org/ntsb-findings/02021510): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Eurocopter AS 350 B3, 1 case](https://openairdocs.org/ntsb-findings/02021510/cases.md?model=8680954), [All aircraft, 226 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Taxi-from runway: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Eurocopter AS 350 B3, 9 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=8680954), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## 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](https://openairdocs.org/aircraft/N791AM), registered now, S/N 4335, built 2007 (OpenAirDocs) - Reported make and model: EUROCOPTER AS 350 B3 - Registry model: [Eurocopter AS 350 B3](https://openairdocs.org/model/eurocopter-as-350-b3) (registry code 8680954) (OpenAirDocs) - Registry engine: [Turbomeca ARRIEL-2B1](https://openairdocs.org/engine/turbomeca-arriel-2b1) (registry code 60056, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 4335 - Year built: 2007 - Airframe hours: 11500 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; injuries: none; 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 - Co-pilot; age 44; injuries: none; 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 ## 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 20230523011049A](https://openairdocs.org/incident/20230523011049A), May 23, 2023: Eurocopter AS350B3, San Diego, CA, Minor damage. On may 23, 2023, [privacy data omitted] helicopter call sign “troy 161” with two crew members onboard experienced a hard landing. The aircraft departed brown… ## Docket (2 files) The files NTSB released with the investigation on October 20, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192242. 3.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 13 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15669066&FileExtension=pdf&FileName=WPR23LA200%20NTSB%206120%20combined%202nd%20Pilot%20stmt_Redacted-Rel.pdf - Photos (item 2, PDF, 2 pages, 599 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15722277&FileExtension=pdf&FileName=WPR23LA200%20Docket%20photos-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.