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Cases › CEN19FA095 · Part 135 fatal · Class 2

BELL 407BRISTOW US LLC

Galliano, LA, USA · 2019-03-10·N577AL

2
fatal
0
serious
Fatal
highest injury
Destroyed
damage

What happened

NTSB summary, verbatim

The pilot of the helicopter departed on the flight to transport the passenger to an offshore platform; several minutes before the accident, he transmitted a pilot report describing a cloud ceiling about 700 ft above ground level and 6 statute miles visibility. Onboard data indicated that the helicopter entered a descending left turn from about 300 ft above ground level that continued until the helicopter impacted a marsh. The turn to the north was not consistent with the intended route of flight. The characteristics of the turn as it tightened over the last 25 seconds of the flight (increasing roll, decreasing pitch, and vertical descent rate) are consistent with the pilot experiencing spatial disorientation and loss of control. The restricted visual references resulting from the low cloud ceilings and flight over a body of water that lacked significant contrasting terrain features would have been conducive to the development of spatial disorientation; and the low altitude in which he was flying would have limited his available time to recover. Postaccident examination revealed no mechanical anomalies that would have precluded normal operation.

Photographs

5the aircraft, and what the investigators found
Wreckage and site documentation · 5 photographs from the docket

Photographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.

Probable cause

the Board's determination
The pilot's loss of control during cruise flight as a result of spatial disorientation while operating the helicopter in close proximity to terrain in marginal meteorological conditions.

Occurrence sequence

2 stepsNTSB coding · CICTT taxonomy
  1. 1 · Enroute-descent
    Course deviation
  2. 2 · Enroute-cruise
    Loss of control in flight
    defining event

Findings

5 causal · 0 contributing
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Aircraft control — Pilot
  • CAUSE
    Personnel issues › Psychological › Perception/orientation/illusion › Spatial disorientation — Pilot
  • CAUSE
    Aircraft › Aircraft oper/perf/capability › Performance/control parameters › Altitude — Not attained/maintained
  • CAUSE
    Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Low ceiling — Effect on operation
  • CAUSE
    Environmental issues › Physical environment › Terrain › Water — Effect on operation

NTSB analysis

from the final report

The pilot of the helicopter departed on the flight to transport the passenger to an offshore platform; several minutes before the accident, he transmitted a pilot report describing a cloud ceiling about 700 ft above ground level and 6 statute miles visibility. Onboard data indicated that the helicopter entered a descending left turn from about 300 ft above ground level that continued until the helicopter impacted a marsh. The turn to the north was not consistent with the intended route of flight. The characteristics of the turn as it tightened over the last 25 seconds of the flight (increasing roll, decreasing pitch, and vertical descent rate) are consistent with the pilot experiencing spatial disorientation and loss of control. The restricted visual references resulting from the low cloud ceilings and flight over a body of water that lacked significant contrasting terrain features would have been conducive to the development of spatial disorientation; and the low altitude in which he was flying would have limited his available time to recover. Postaccident examination revealed no mechanical anomalies that would have precluded normal operation.