N32CC

HISTORY OF FLIGHTOn July 4, 2019, about 0153 eastern daylight time, an Agusta S.p.A. AW139 helicopter, N32CC, was substantially damaged when it was involved in an accident near Big Grand Cay, Abaco, Bahamas. The two pilots and five passengers were fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

According to pilot-in-command’s (PIC) cellphone records, the owner of helicopter (who also owned the company the PIC flew for) called him about 2324 on July 3. The owner reportedly called the PIC to inform him that he needed the PIC to fly his daughter and her friend from the Bahamas to the United States for medical treatment. About 8 minutes later, the PIC contacted a friend of the owner who was also on the Island. The friend reported that the PIC told him that he would be flying from Florida to Big Grand Cay and that he would need lights to illuminate the private helipad at Big Grand Cay. About 2338, the PIC called back the friend and reported that he had "to get someone to come with him" for the flight. The PIC called the second-in-command (SIC) about 2343 to notify him that he was needed for the flight. The SIC's wife reported that, after being notified about the flight, the SIC began to check the weather and looked at landing sites.

According to data from the combination cockpit voice recorder (CVR) and flight data recorder (FDR), the flight departed Palm Beach International Airport (PBI), West Palm Beach, Florida, about 0055 on July 4, destined for Big Grand Cay. During the flight, the PIC was the pilot flying (PF) from the right seat, and the SIC was the pilot monitoring (PM) from the left seat. At 0059:09, the PIC stated, "ah, it's gonna be darker than # out here," and the SIC responded that he was trying to dim some of the cockpit lights. (The symbol # in quotes from the CVR indicate an expletive.) At 0101:52, the SIC asked the PIC if he had ever flown to the island at night, and the PIC replied, “no.” At 0103:02, the PIC again asked the SIC to dim the lights. While en route to Big Grand Cay, the SIC stated that he “was night current” and had “done a lot of night flying” and that he had landed “off airport” at night and was used to doing it. About 0124:13 the SIC mentioned not to “fixate on one light and start to go spa…” but the word was not completed; about 5 seconds later he stated “you won’t get spatially disoriented with two of us on board.” He then added that a night landing in a black hole “can be tricky.”

The friend of the owner who had spoken to the PIC before the flight reported that he arranged two golf carts with flood lights to light the helipad but had them pointed so they would not distract the pilots. According to the FDR data, the helicopter landed at the private helipad at Big Grand Cay about 0142. While the helicopter was on the ground with the engines running, the CVR recorded the PIC discussing flying into Fort Lauderdale/Hollywood International Airport (FLL), Fort Lauderdale, Florida; flight plan information; and the need for an ambulance to meet the flight. The individual who arranged to light the helipad reported that three of the five passengers self-boarded the helicopter while the remaining two passengers were carried and loaded into the helicopter and strapped into their seats. He told the owner that medical help would be waiting at FLL when they landed.

At 0145, the PIC filed an instrument flight rules (IFR) flight plan with ForeFlight for a flight from Walker's Cay Airport (MYAW), Walker's Cay, Abaco, Bahamas, about 5 nautical miles (nm) west-northwest of the departure helipad, to FLL. The flight plan noted that the flight would depart at 0200, that five people were onboard (although there were actually seven people on board), and that sufficient fuel was onboard for 2 hours 16 minutes of flight. The flight plan was not activated.

About 0150, the CVR recorded the SIC talking about initial altitude and heading information, and the PIC responding that he would enter the flight plan information into the flight management system (FMS). At 0152:13, the SIC stated, "our initial heading is going to be one eight zero….” According to FDR data, at 0152:17, the helicopter lifted off; the cyclic force trim release (FTR) switch was engaged and remained engaged for the entire flight and the collective FTR switch was engaged until 0152:28 when the collective stabilized about 70%.

At 0152:31, while the helicopter was about 62 ft above the ground, with no forward airspeed and in a slight nose-up pitch attitude, the SIC stated, "alright airspeed coming up no it’s not coming up so push that nose forward get some airspeed." Shortly thereafter, while the helicopter was climbing, the FDR recorded nose-down cyclic control input and changes in pitch attitude that became negative about 0152:36; the helicopter continued to climb and began to gain forward airspeed.

At 0152:42, while at 184 ft, 53 knots forward airspeed, and a pitch attitude about 12° nose down, the SIC stated, "watch your altitude." The helicopter climbed to 190 ft at an indicated airspeed of 68 knots; the collective position was 72%. At 0152:44, the helicopter began to descend with a nose-down pitch attitude, the airspeed increasing, and the collective relatively constant near 72%. It also began a left turn and twice momentarily returned to a no bank condition before continuing until water impact. At 0152:48, while in a descent with the cyclic positioned about 69% forward, the CVR recorded a “sink,” “warning terrain,” and “one fifty feet” from the enhanced ground proximity warning system (EGPWS). About 0152:50, at an altitude of about 110 ft while descending about 1,380 ft per minute (fpm) with the collective pitch at 75%, the autopilot flight director was engaged in altitude acquire (ALTA) and indicated airspeed (IAS) modes while the FTR switch on the cyclic was active; this indicated the PIC was manually commanding cyclic movement throughout the flight. The selected altitude for ALTA to capture was 1,000 ft and the default rate of climb was 1,000 fpm. IAS mode automatically engages with ALTA and is meant to generate pitch commands to maintain airspeed. (See the “Helicopter Information” section of this report for more information about ALTA mode.) Nearly simultaneous to the ALTA mode activation, the collective FTR switch was momentarily activated. Because the helicopter was descending when the collective FTR switch was activated, and the target altitude for ALTA was above the current altitude, the ALTA rate of climb was reset to +100 fpm (per system design) and remained at that value for the remainder of the flight. The cyclic was pulled back to 52% at 0152:51 and the helicopter pitched up, reaching a minimum altitude of 52 ft before beginning to climb. From 0152:51 to 0153:05, the EGPWS issued nine “warning terrain” warnings.

At 0152:56 while climbing through 78 ft, the PIC asked, "how high are you," but the SIC did not reply (At 0152:58 the helicopter’s vertical speed was +300 fpm). About three seconds later while at 116 ft, the PIC stated, "three hundred feet." Subsequently, the SIC stated, "we're not," to which the PIC replied, "that's what it says over here." At 0153:05, the SIC stated that the helicopter had been "diving," followed by an expletive from the PIC and the continuation of multiple EGPWS warnings until the helicopter climbed above 150 ft. As the helicopter climbed, the collective input lowered from 75% at 0152:53 to a minimum value of 46% at 0153:09 as the autopilot attempted to limit the vertical speed to ALTA reference target.

During the second climb, the longitudinal cyclic had been moving forward to near 68%, and at 0153:11, the helicopter, which had been nose up or level since 0152:51, again pitched nose down. The helicopter’s rate of climb dropped below 100 fpm and collective began to increase at a rate of about 5% per second. The helicopter reached a maximum altitude of 212 ft while banking left 30° then began descending with EGPWS warnings occurring.

At 0153:13, the helicopter again began to descend, and the SIC stated, “there was a fatal accident in the United Kingdom and this is exactly what happened there." (EGPWS warnings continued through this time.) Two seconds later, with the collective control about 70%, the rate of collective increase slowed as power index (PI) values increased to about 80%. Over the next 8 seconds, the collective position gradually increased to about 75% and PI values increased to about 86%. While descending in a nose-down attitude with the airspeed increasing, the PIC asked the SIC multiple times for headings and once for altitude, but the SIC did not respond. According to an NTSB performance study, the helicopter impacted the water about 0153:22 while in a 7°-nose-down and 12°-left-bank attitude. The CVR recorded no aural master cautions or warning annunciations during the flight. Figure 1 shows the cockpit annunciations recorded on the CVR and select times and altitudes.

Figure 1. Cockpit annunciations recorded on CVR with select times and altitudes (Figure contained in the NTSB Performance Study)

A witness located about 1.6 nm southwest of the wreckage location reported that there was no moon visible when the helicopter departed. He also reported that, as the helicopter began descending, he heard a "whoosh whoosh whoosh" sound and then lost sight of the helicopter. He heard the helicopter impact the water and said that the engines sounded good. He immediately called the "caregiver" at Big Grand Cay and described what he had seen and heard then he and another individual departed in his spotlight-equipped boat between 0205 and 0207 to where he had thought the helicopter had crashed. They searched for the wreckage but did not locate it. He called the caregiver about 0400 and was told the helicopter would have made it to the United States safely.

At 1415, a company pilot was notified that the helicopter had ...