Hurried Departure

This Canterbury West Coast Air Rescue helicopter departing Greymouth, New Zealand, illustrates the additional risk posed by taking off in dark-night conditions, with no external visual references, a causal factor in the 2019 Bahamas accident discussed in the article. (iStock/Lakeview Images)

Failure to prepare for a dark-night flight sends seven to their deaths.

Most of us can perform reasonably well in familiar situations. Recognizing previously observed patterns eases mental workload, freeing bandwidth and attention to devote to the larger picture.

Coping with strange circumstances has the opposite effect, particularly if they trigger discomfort or anxiety. In a high-stakes, high-stress flight operation, that combination can snowball, putting the pilot(s) further and further behind the aircraft. Given time and the altitude to maneuver, the results can be merely frightening; without those advantages, the outcome can be disastrous.

The Mission

Shortly before midnight on Jul. 3, 2019, a corporate pilot based at Florida’s Palm Beach International Airport (KPBI) received an urgent phone call from his employer. The company’s owner was hosting a gathering on Big Grand Cay, one of his private islands in the Bahamas. His daughter and one of her friends had taken ill—another attendee later described them as “groggy and unresponsive”—and he wanted to evacuate them to Fort Lauderdale for evaluation and treatment. The pilot then called a contract pilot who worked for the company and asked him to join the flight as second in command (SIC).

They departed Palm Beach at 12:55 am on Jul. 4 in the company’s AgustaWestland AW139. There were only a few clouds below 25,000 ft. and winds were light, but it was very dark: both the sun and moon were more than 15 degrees below the horizon, providing no illumination.

The cockpit voice recorder (CVR) captured the pilots’ discussion of the conditions; the SIC assured his colleague that he “was night current,” had “done a lot of night flying,” and was accustomed to making off-airport landings after dark. They arrived at Big Grand Cay at 1:42 am and landed on the island’s 40-by-40-ft. helipad. The pad was unlit, so floodlights mounted on golf carts had been positioned where they wouldn’t interfere with the pilots’ vision. They kept the engines running after landing to board the passengers without delay.

The Aircraft

The 2007-model helicopter had a five-bladed, fully articulated main rotor system and a four-bladed, fully articulated tail rotor powered by two Pratt & Whitney Canada PT6C-67C turboshaft engines, each rated for 1,531 shp. The aircraft was equipped with a Honeywell Primus Epic integrated avionics suite that included an automatic flight control system (AFCS) utilizing two four-axis auto­pilots, each capable of controlling the aircraft if the other failed.

Force trim release (FTR) switches on the cyclic and collective controls enabled either pilot to override the autopilot and hand-fly that control as long as the switch was depressed. The FTR switches could also be used to reset the autopilots’ input parameters. Depending on which autopilot mode was in use, the AFCS captured the indicated airspeed, vertical speed, or altitude at the moment the FTR was released. A Penny & Giles multipurpose flight recorder combined the functions of the flight data and cockpit voice recorders.

The helicopter had flown 2,158 hours as of the day of the flight. An extensive series of 25-, 50-, 300-, and 600-hour repetitive inspections had been completed on Jun. 28, just 4 flight hours earlier, along with annual oil changes in the main, intermediate, and tail gearboxes. Track and balance of the main- and tail-rotor systems was also checked, and repairs made to the landing gear and rotating scissor assemblies.

The Pilots

The 56-year-old pilot in command (PIC) was a longtime close friend of the owner. He held a commercial certificate with ratings for single-engine seaplanes and single- and multi-engine airplanes as well as an instrument rating for helicopters. In the National Transportation Safety Board (NTSB) report, his total flight experience in all aircraft was given as 2,241 hours, but his pilot log was kept on an iPad from which no data could be recovered, so his make-and-model time, night currency, and instrument currency couldn’t be determined. According to the operator’s chief pilot, the PIC exercised operational control over the helicopter. His second-class medical certificate was issued in December 2018.

The 52-year-old SIC held an airline transport certificate for helicopters with commercial privileges for gyroplanes and a flight instructor’s certificate for both classes of rotorcraft. He’d given the PIC, already a fixed-wing pilot, his initial helicopter instruction in 2004 and they’d been friends since, starting an aviation business together. The SIC had accumulated 12,200 hours of total flight time. Though the SIC held no US fixed-wing ratings, the chief pilot recalled hearing that he’d previously flown fighter jets for the Royal Air Force. His second-class medical certificate was issued in April 2019.

According to his girlfriend, the PIC didn’t like to fly at night and rarely did so, characterizing it as “a whole different ballgame.” She believed this was the first time he’d flown to the island after dark. The SIC’s wife reported that he enjoyed night flying and had logged about 1,450 hours at night, most recently on May 25, six weeks before the accident.

The two pilots had been paired during their initial type-rating training in the AW139, which included instrument takeoffs and unusual attitude recoveries. The SIC’s instructor commented that he showed “great understanding of instrument procedures and FMS [flight management systems], but not always using a checklist led to momentary loss of situational awareness.” He also noted that the SIC “struggled with [crew resource management] … wanting to fly single-pilot, especially during emergency training.”

Both pilots passed Part 61 checkrides and proficiency checks in November 2018, though the PIC was rated below average on airman’s skill-decisiveness as well as overall. His instructor wrote that “progressive training/checking was halted and changed to traditional 61.58 training due to the applicant not reaching the required proficiency.”

The Flight

The flight lasted less than 2 minutes and covered less than 2 miles.

At 1:45 am, the PIC used a ForeFlight integrated flight app to file an IFR flight plan requesting direct routing at a cruising altitude of 1,500 ft. and an airspeed of 140 kt. It was never activated. The CVR didn’t record any preflight briefing or discussion of the division of crew responsibilities or procedures for making a dark-night departure over water. At 1:50 am, the PIC said he’d enter the flight plan information into the FMS. Five passengers were boarded, including the owner, the two ailing guests, and two more of their friends, one of whom had just passed her nursing board exams and wanted to be available to help during the flight. The helicopter lifted off at 1:52:17.

Things began to fall apart almost at once. Both the cyclic and collective FTR switches were engaged immediately. The helicopter climbed vertically to 62 ft. above ground level at zero airspeed before the SIC advised “push that nose forward, get some airspeed.”

The collective FTR was released at 1:52:28. Nose-down cyclic inputs pushed the helicopter’s pitch attitude below horizontal, and it gained speed while continuing to climb. At 184 ft. and 53 kt. airspeed, the SIC warned, “Watch your altitude.” Pitch attitude was 12 degrees nose down. The helicopter reached 190 ft. at 68 kt., then began to descend while banking left. At 1:52:48, the CVR recorded automated warnings of “sink,” “warning terrain,” and “one hundred fifty feet” generated by the enhanced ground proximity warning system (EGPWS).

The helicopter was 110 ft. above the water and descending at 1,380 ft. per minute (fpm) when the autopilot was engaged in both the “altitude acquire” and “indicated airspeed” modes. Target altitude was set at 1,000 ft.

The collective FTR switch was briefly activated at the same time. Because the helicopter was below its target altitude and descending, this reset the autopilot’s target rate of climb from 1,000 to 100 fpm, a design feature of the system. The ship pitched up and reached an altitude of just 52 ft. before beginning to climb again as its left turn continued. In the 14 seconds from 1:52:51 to 1:53:05, the EGPWS issued nine separate terrain warnings. The cyclic remained under manual control with the FTR engaged.

Climbing through 78 ft., the PIC asked, “How high are you?” but the SIC didn’t reply. Three seconds later, passing through 116 ft., the PIC said, “Three hundred feet,” apparently having mistaken vertical speed for altitude: the helicopter was then climbing at 300 fpm.

The SIC replied, “We’re not,” to which the PIC answered, “That’s what it says here.” At 1:53:05, the SIC observed that they’d been “diving.” The EGPWS warnings ended once they reached 150 ft. Meanwhile, the autopilot began lowering collective in an attempt to reduce their rate of climb to its target of 100 fpm.

After 20 seconds of nose-up or nose-level flight, the helicopter pitched down again at 1:53:11. Two seconds later, it reached its maximum altitude of 212 ft. while banked 30 degrees left, then began descending again as the autopilot gradually raised the collective. EGPWS warnings resumed.

The SIC said, “There was a fatal accident in the United Kingdom, and this is exactly what happened there.” Descending nose-low with airspeed building, the PIC asked the SIC for headings several times and for altitude once but got no reply. Impact occurred at 1:53:22 in a 12-degree left bank and a pitch of 7 degrees nose-down.

Two witnesses about 1.6 nm to the southwest heard the impact and set out to search in a spotlight-equipped boat but couldn’t find the helicopter. The flight wasn’t reported missing until the following afternoon, when another company pilot learned that it had never reached Fort Lauderdale. The FAA was notified and issued an alert notice.

The company pilot set out to search in a float-equipped Cessna Caravan but was unsuccessful. The witness who’d heard the crash the night before also resumed searching and found the wreckage lying inverted in 16 ft. of water just 1.2 nm from the departure helipad. The retractable landing gear was still extended. Divers recovered the bodies of all seven occupants.

Bahamian authorities delegated the investigation to the NTSB. Having found no evidence of equipment failure, the board determined the probable cause of the accident to be “the pilots’ decision to take off over water in dark-night conditions with no external visual reference, which resulted in spatial disorientation and subsequent collision with the water. Also causal was the pilots’ failure to adequately monitor their instruments and respond to multiple EGPWS warnings to arrest the helicopter’s descent.”

External pressure to complete the flight, lack of night flying experience from the island, and inadequate crew resource management were all cited as contributory.

Unanswered Questions

Several aspects of the accident sequence remain difficult to explain. Especially puzzling is why the pilot who was both less experienced and, by his own admission, uncomfortable flying at night took the controls to lift off into utter blackness, with no ground lights or visible horizon. It’s possible the PIC’s uneventful departure from Palm Beach, where the lights of the airport environment and the Florida coastline provided visual references for their climb to the 2,500-ft. cruising altitude logged in the flight data recorder, led him to underestimate the challenge posed by this departure.

Before that, it’s not clear why two pilots consistently described as careful, competent, and safety-conscious didn’t perform any kind of departure briefing or formally assign responsibilities as pilot flying versus pilot monitoring. Perhaps concern for the ailing passengers led them to hurry their preparations, or perhaps their long-standing comfort flying together made a briefing seem redundant. Family members and colleagues interviewed by investigators agreed that they probably weren’t seriously fatigued.

Most baffling, though, is why the SIC didn’t take the controls once he realized his partner was struggling, especially after his comment about the nearly identical British accident (which also involved an AW139). At that point, the helicopter was less than 200 ft. above the ocean, descending at a rate accelerating through 1,000 fpm. Disaster might still have been averted in the nine seconds that remained. Given their prior relationship as instructor and student, a sharp callout of “My controls!” would almost surely have triggered an immediate transfer of command.

The Takeaway

Many accidents begin with flights that seem routine until they’re not, but some flight operations aren’t routine at any point and can’t be treated that way. A medical evacuation requiring a black-night departure over the ocean is among the situations that combine an extremely narrow margin for error with the most severe consequences should anything go wrong.

Regardless of weather, this is a pure instrument flight and must be handled as such. With no established departure procedure from an off-airport site, the takeoff and climb to cruising altitude require detailed and specific planning.

A hard check on the pilot’s current level of skill is also in order. Instrument flight requires regular recurrent training to maintain proficiency. Year after year, about one-third of all pilots killed attempting VFR flight in low-visibility conditions already held instrument ratings.

The two ailing passengers mightn’t have been better off had they waited until morning, but they certainly wouldn’t have fared any worse. Transporting patients to safety rests on safely transporting the patients.