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ASN Wikibase Occurrence # 226646
Last updated: 2 June 2021
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Date:28-JUN-2019
Time:00:40 LT
Type:Silhouette image of generic A109 model; specific model in this crash may look slightly different
AgustaWestland AW109S Grand
Owner/operator:North Memorial Health
Registration: N11NM
MSN: 22075
Fatalities:Fatalities: 2 / Occupants: 3
Aircraft damage: Substantial
Category:Accident
Location:Brainerd Lakes Regional Airport (BRD), MN -   United States of America
Phase: Approach
Nature:Ambulance
Departure airport:Robbinsdale, MN (MY77)
Destination airport:Brainerd Lakes Regional Airport, MN (BRD/KBRD)
Investigating agency: NTSB
Narrative:
The crew of the helicopter air ambulance flight was approaching the airport for landing in dark night instrument meteorological conditions (IMC) after delivering a patient to the hospital. The reported weather conditions about the time the pilot initiated the instrument landing system (ILS) approach included 1/2-mile visibility with haze, which then deteriorated to 1/4 mile, which was within the operator's approved visibility approach minimums. The paramedic onboard reported that he saw the runway environment through a thin layer of fog as the helicopter descended toward the decision height (DH) of 200 ft above ground level during the approach.

After descending below the DH, with a power setting below 30% torque, the helicopter's pitch attitude increased from -3 (nose-down) to 20 (nose-up), its airspeed decreased from 100 to 50 knots, and the pilot declared a missed approach, likely due to a loss of visual contact with the runway environment. The pilot's increased collective input and the helicopter's decreasing airspeed resulted in an increase in torque, and the helicopter entered a right rotational yaw that accelerated into a spin. The helicopter subsequently impacted terrain near the runway.

The dark night conditions at the rural airport resulted in little to no visual references during the pilot's transition to landing and the attempted missed approach. It is likely that the pilot became spatially disoriented, which led to the excessive pitch attitude, slow airspeed, his failure to recognize and arrest the right yaw, and the subsequent loss of control.

Probable Cause: The pilot's spatial disorientation during an instrument approach in dark night instrument meteorological conditions, which resulted in a loss of control and subsequent impact with terrain.

Sources:

NTSB CEN19FA185

Accident investigation:
cover
  
Investigating agency: NTSB
Status: Investigation completed
Duration:
Download report: Final report
Location

Media:


Images:


Photo: NTSB

Revision history:

Date/timeContributorUpdates
28-Jun-2019 12:39 Iceman 29 Added
28-Jun-2019 12:41 Iceman 29 Updated [Location, Destination airport]
28-Jun-2019 12:55 Iceman 29 Updated [Embed code]
28-Jun-2019 13:15 Aerossurance Updated [Source, Narrative]
28-Jun-2019 13:18 Aerossurance Updated [Narrative]
28-Jun-2019 13:21 Captain Adam Updated [Aircraft type, Registration, Cn, Source, Damage]
28-Jun-2019 13:44 TB Updated [Location, Source, Embed code, Damage]
28-Jun-2019 13:45 TB Updated [Destination airport, Narrative]
28-Jun-2019 19:19 Captain Adam Updated [Damage, Narrative]
28-Jun-2019 19:35 Aerossurance Updated [Embed code]
28-Jun-2019 19:38 Aerossurance Updated [Source, Embed code]
29-Jun-2019 14:22 Aerossurance Updated [Source, Embed code, Narrative]
29-Jun-2019 15:06 Aerossurance Updated [Embed code, Narrative]
04-Dec-2020 19:27 Aerossurance Updated [Destination airport, Source]
05-Dec-2020 08:43 Aerossurance Updated [Embed code, Narrative]
27-Mar-2021 12:46 ASN Update Bot Updated [Time, Other fatalities, Nature, Destination airport, Source, Embed code, Damage, Narrative, Accident report]
27-Mar-2021 14:48 ASN Update Bot Updated [Departure airport, Destination airport, Embed code, Damage, Category, Accident report]
27-Mar-2021 15:25 harro Updated [Nature, Source, Embed code, Narrative]
27-Mar-2021 15:25 harro Updated [Photo]

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