Accident Details
Probable Cause and Findings
The pilot’s decision to continue the visual flight rules flight into deteriorating weather conditions, which resulted in spatial disorientation and the loss of aircraft control.
Aircraft Information
Registered Owner (Current)
Analysis
HISTORY OF FLIGHTOn March 26, 2023, about 0238 central daylight time, a Robinson R44 II helicopter, N441PD, was destroyed when it was involved in an accident near Port Allen, Louisiana. The pilot and tactical flight officer sustained fatal injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 aerial observation flight.
According to Baton Rouge Police Department (BRPD) personnel and ADS-B data, the BRPD helicopter, call sign Air 1, departed the Baton Rouge Metropolitan Airport (BTR), Baton Rouge, Louisiana, about 0226, to provide aerial support to BRPD ground units that were conducting a high-speed pursuit of a fleeing vehicle. Air 1 advised dispatch and ground units via radio that they were assisting and requested updates to the vehicle movement and location. ADS-B data showed the helicopter depart BTR to the south, turned west, then overfly Highway 190, west of Baton Rouge. Unable to maintain a safe pursuit of the vehicle, BRPD dispatch terminated the pursuit to all BRPD units, including the helicopter, via radio at 0235. There were no further communications received from the helicopter. About that time, the data showed the helicopter executed a shallow left deviation to the south of Highway 190. Following the deviation, a left turn was initiated and the turn rate increased. The initial turn was followed by a series of turns and altitude changes (see Figures 1 and 2). The ADS-B data ended at 0238 at an altitude of about 1,450 agl. There were no witnesses to the accident.
Figure 1. ADS-B data overlayed on Google Earth.
Figure 2. ADS-B data overlayed on Google Earth with an altitude profile.
According to the West Baton Rouge Parish Sheriff’s Office, at 1049, a family member reported that the tactical flight officer had not returned home from his scheduled shift, and his cellular phone was sending a signal from a remote area in West Baton Rouge Parish. The sheriff’s department searched the area and located the helicopter at 1114. PERSONNEL INFORMATIONA review of the pilot’s original logbook, in which the last entry was dated December 23, 2018, revealed the pilot had accumulated 250.5 night flight hours, no simulated instrument flight hours, and 456.6 total flight hours. The pilot’s current logbook did not specify total night flight time or simulated instrument flight time; therefore, the pilot’s total night and simulated instrument time could not be determined.
On the day before the accident, the pilot and tactical flight officer participated in a local public relations event from 0900 to 1600, then began their normal work shift, which was scheduled from 1600 to 0400. The BRPD air support unit (ASU) base quarters had a couch available should the staff need to rest; however, BRPD policy typically did not allow rest periods while on shift.
The tactical flight officer held a commercial pilot certificate with rotorcraft-helicopter and remote pilot ratings. The tactical flight officer did not hold a current medical certificate. AIRCRAFT INFORMATIONOn January 2, 2023, a 2,200-hour airframe inspection was completed on the helicopter. During this maintenance, a new Lycoming engine, a Garmin GTN 750Xi, and other avionics upgrades were installed. The ASU stated the helicopter received the Garmin GTN 750Xi upgrade to assist the department pilots with traffic avoidance and weather information.
The police configuration helicopter had removable anti-torque pedals and removable collective control installed in the left seat position at the time of the accident. The configuration does not allow for a removable cyclic; the cyclic control is installed in the right seat position. METEOROLOGICAL INFORMATIONThe BTR Automated Surface Observing System observations around the time of the accident identified IFR to marginal VFR conditions.
Geostationary Operational Environmental Satellite Number 16 (GOES-16) visible and infrared data were reviewed for the period from 0000 to 0700, and the closest images to the time of the accident were documented. The imagery indicated the cloud cover above the accident site was a combination of low and very low-level water clouds with the cloud cover moving northward and expanding in area coverage with time.
The National Weather Service Aviation Weather Center had text Airmen’s Meteorological Information (AIRMET) advisory Sierra valid for the accident site at the accident time. The AIRMET was issued at about 5 hours before the accident on March 25, at 2145, and forecast IFR conditions due to mist and fog.
The Graphical Forecasts for Aviation (GFA) issued before the accident flight and valid from 0100 to 0700 indicated broken to overcast clouds at the accident site with bases between 300 and 600 ft agl.
A search of archived information indicated that the pilot did not request weather information from Leidos Flight Service or ForeFlight. It is unknown what weather information, if any, the pilot checked or received before or during the accident flight. According to the ASU standard operational procedures (SOPs), the pilot in command (PIC) will obtain and assess an official weather briefing upon beginning his tour of duty and/or as required. AIRPORT INFORMATIONOn January 2, 2023, a 2,200-hour airframe inspection was completed on the helicopter. During this maintenance, a new Lycoming engine, a Garmin GTN 750Xi, and other avionics upgrades were installed. The ASU stated the helicopter received the Garmin GTN 750Xi upgrade to assist the department pilots with traffic avoidance and weather information.
The police configuration helicopter had removable anti-torque pedals and removable collective control installed in the left seat position at the time of the accident. The configuration does not allow for a removable cyclic; the cyclic control is installed in the right seat position. WRECKAGE AND IMPACT INFORMATIONThe main wreckage, which consisted of the cockpit, fuselage, and tailcone, came to rest inverted next to an irrigation ditch at the edge of a sugar cane field (see Figure 3).
Figure 3. Main wreckage at accident site.
The main rotor transmission, mast, and sections of the main rotor blades came to rest in a wooded wetland area about 250 ft east of the main wreckage. Fragmented Plexiglass, forward and upper cockpit structure, instrument console components, and tactical flight officer station (left seat) equipment were scattered between the main rotor assembly and main wreckage. A majority of the helicopter was accounted for at the crash site except for the outboard 5 ft of one main rotor blade. The blade spar, skin, and honeycomb structure were missing; the blade separation location exhibited a pattern of scores on the blade lower surface area, consistent with contact with other helicopter structure.
The helicopter was equipped with a 406 MHz emergency locator transmitter that was found in the debris field and separated from the mounting structure. The antenna wire was severed about 4 inches from the transmitter.
Examination of the helicopter structure revealed impact signatures consistent with main rotor blade contact to the cabin structure above the forward looking infrared (FLIR) gimbal, to the top of the windshield bow and left seat passenger door frame. Main rotor blade leading edge damage and blade separation locations corresponded to the impact signatures on the cabin structure. Both elastomeric teeter stops were split horizontally through the middle. One main rotor blade spindle appeared to be straight or undamaged, and the other blade spindle was torn open at the coning bolt. The main rotor gearbox rotated one full revolution when it was manually rotated. The tail rotor gearbox was intact and free to rotate.
Flight control continuity could not be established due to the breaks in the system and small missing portions of the push-pull tubes; however, some breaks were matched and examined for evidence of malfunction or failure; none were found. All fractures and breaks were examined and exhibited characteristics consistent with overload fractures.
The pilot’s throttle twist grip was found in the full ON position, and the collective was near the full UP position.
The engine cooling fan rear inlet lip exhibited scoring on the aft-most surface. The cooling fan scroll inlet rings exhibited rotational scoring in a circular arc pattern, on both the upper and lower halves of the scroll.
Postaccident examination of the helicopter revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.
The helicopter was equipped with a Garmin GTN 750Xi, which will log up to 100 hours of flight data in the unit’s internal memory, and an AeroComputers UC-5300 tactical mapping system. The Garmin unit, without its display, exterior SD card, and exhibiting minor exterior damage, and the AeroComputers unit, were recovered from the accident site and sent to the National Transportation Safety Board (NTSB) Vehicle Recorders Laboratory for potential data extraction.
Examination of the Garmin device revealed the device did not contain an internally mounted SD card. Due to the damage and missing data cards, the manufacturer was contacted for additional support. The manufacturer indicated the unit contained a multi-media card chip on the main circuit board that stored limited GPS data. Due to the existence of ADS-B data for the accident flight, attempts to recover the limited GPS data were not pursued, and no data was recovered from the device.
Examination of the AeroComputers unit revealed the unit and the internal solid-state drive (SSD) sustained impact related damage. When attached to the NTSB laboratory computer via a write blocker device, the SSD did not have a recognizable filesystem. Due to the extent of damage, the SSD was sent to a third-party laboratory that specializes in recovering data from SSDs. The third-party laboratory indicated that their recovery attempts were unsuccessful. Despite multiple recovery attempts, no d...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CEN23FA142