Accident Details
Probable Cause and Findings
The pilot’s decision to continue the visual flight rules flight into instrument meteorological conditions, which resulted in the pilot’s spatial disorientation and loss of control. Contributing to the accident was the company’s inadequate oversight of its safety management processes, including ensuring the pilots were accurately completing and updating the flight risk analysis, logging maintenance discrepancies, and ensuring the helicopter met Part 135 regulations before departure.
Aircraft Information
Registered Owner (Current)
Analysis
HISTORY OF FLIGHTOn February 9, 2024, about 2208 Pacific standard time, an Airbus Helicopters EC 130B4 helicopter, N130CZ, was destroyed when it was involved in an accident near Halloran Springs, California. The two pilots and four passengers were fatally injured. The helicopter was operated by Orbic Air, LLC, as a Title 14 Code of Federal Regulations (CFR) Part 135 on-demand flight.
According to company records, in the days preceding the accident, Orbic Air coordinated two charter flights with a broker. As per the agreement, Orbic Air would conduct a charter flight to transport passengers from the Palm Springs International Airport (PSP), Palm Springs, California, to the Boulder City Municipal Airport (BVU), Boulder City, Nevada. Three days later, Orbic Air would conduct a charter flight to pick up the passengers from BVU and fly them back to PSP. During the agreement discussions, the broker initially requested a twin-engine aircraft with an instrument-rated pilot; however, Orbic Air’s capability was limited to a single-engine aircraft and VFR operations. According to Orbic Air’s flight operations employee, during the broker discussions, he mentioned to the broker the addition of a second pilot for the nighttime flights, which was a standard company precaution for flights to Las Vegas, Nevada, due to the route and timing considerations. The charter flights were confirmed with the broker on February 8th.
At 1405 on the day of the accident, the pilot and another company pilot/mechanic traveled by train to the Camarillo Airport (CMA), Camarillo, California, to pick up the helicopter from their maintenance base. According to the DOM, about a week and a half before the accident, the helicopter had been placed into their maintenance facility for maintenance that included an installation of a Garmin GTN 650 navigator avionics device and repair to the radar altimeter. The maintenance had been completed, and on February 9th the DOM conducted a test flight, which started about 1615, lasted about 4 minutes, and consisted of one traffic pattern at CMA. The DOM placed an entry into the maintenance logbook that there were no deficiencies noted.
An FRA form was completed by the pilot at 1613 for the Part 135 leg of the planned flight. The Part 135 leg was scheduled from PSP to BVU, and all other legs were operated under Part 91. The pilot’s FRA total trip score was 12, indicating a low-risk flight (a score above 15 would indicate an elevated risk and require review by management and risk mitigation, and a score above 20 would be a possible no-go for the flight).
At 1727, the pilot and company pilot/mechanic departed CMA and arrived at Bob Hope Airport (BUR), Burbank, California, at 1743, which was Orbic Air’s flight operations base. During the flight, the accident pilot texted the DOM to report that the radar altimeter was inoperative. After arrival at BUR, the company pilot/mechanic attempted to troubleshoot and fix the radar altimeter via multiple phone communications with the DOM, who was located at CMA. Following the phone calls, the DOM was unsure if the radar altimeter was fixed and operative. The DOM reported that during the discussion, he told the company mechanic to bring the helicopter back to CMA. The company mechanic reported that the two accident pilots (pilot-in-command [PIC] and safety pilot) were in a hurry to depart so the mechanic did some “small troubleshooting.” The mechanic could not rectify the issue, so he packed up his tools and the helicopter departed to PSP. The mechanic had no further contact with the pilots.
According to the company flight follower for the charter flight, who was also Orbic Air’s president, after arriving at BUR, the accident pilot told him they were having issues with the radar altimeter. The flight follower reported that he explained to the pilot, “if it’s working, I think you’re okay, but if it’s not working, don’t take the flight.” The flight follower also had discussions about the weather for the entire planned flight with the pilot and safety pilot. According to the flight follower, neither he, the pilot, or the safety pilot had any concerns about adverse weather along the planned route of flight to BVU.
According to ADS-B data, at 1822, the helicopter departed BUR to PSP, and the flight follower did not know the status of the radar altimeter at the time of departure. At 1907, after the helicopter arrived at PSP, the flight follower had a phone conversation and exchanged text messages with the pilot, but neither discussed the status of the radar altimeter during the conversation. Surveillance video at the fixed-based operator showed the pilots in the lobby for about 50 minutes using their cellphones while waiting for the passengers as one passenger had misplaced their passport. It was not known if the pilots checked the weather on their cellphones during that time, and there was no evidence the pilot updated the FRA form.
After refueling with 41 gallons of fuel, the Part 135 flight departed PSP at 2045 under night VFR and flew a northwesterly heading for about 2 miles before following US Highway 111 to Interstate (I-)10 at altitudes varying between 2,500 and 3,000 ft above mean sea level (msl). The helicopter continued along I-10, crossed over San Bernadino International Airport, San Bernadino, California, and then followed I-215 to I-15.
The helicopter followed I-15 toward the planned destination of BVU. After passing east of the Cajon Pass, the altitude of the helicopter varied between about 3,300 and 5,500 ft msl, and the ground speed varied between about 93 knots (kts) and 155 kts but maintained between 130 and140 kts for most of the time. About 2146, ADS-B data was lost while the helicopter was about 24 miles east of Barstow, California, which was likely due to lower altitudes and terrain interference. The ADS-B lost data gap was about 47.5 miles long, and ADS-B data resumed about 2206 near the Halloran Springs/I-15 freeway exit west of the accident location. The last ADS-B data points for the flight tracked east-southeast, gradually descended in altitude, and then increased in a rapid descent and airspeed (see figures 1 and 2). The accident site was located 0.31 miles east-southeast of the last ADS-B data point at an elevation of about 3,360 ft msl.
Figure 1. Overhead view of ADS-B accident flight track.
Figure 2. Final segment of flight track data with time, altitude (msl), ground speed, and heading information.
The helicopter was equipped with SpiderTracks GPS technology tracking software that captured most of the flight, except for the last several seconds. SpiderTracks data was consistent with the ADS-B data and included the area of the ADS-B lost data gap. According to SpiderTracks data, while the helicopter was in the ADS-B lost data gap it continued to follow I-15 from altitudes that ranged from about 4,850 ft msl to about 2,199 ft msl (about 1,172 ft above ground level [agl]). About 2200, when the helicopter was near Baker, California, the pilot began to slow the helicopter’s airspeed from 130 to 140 kts, down to a low of 90 kts, and then maintained airspeed below 120 kts until the descending right turn. The data showed that after the helicopter passed Baker, it turned left (north) and deviated away from its course over I-15 by a lateral distance of about 3,100 ft, before returning over I-15 and continuing until the SpiderTracks data ended.
According to law enforcement, several witnesses who were traveling in vehicles on I-15 called 911 to report observing a “fireball” to the south of I-15. The witnesses reported the weather conditions in the area were not good as it was raining with a snow mix. The accident site was located by law enforcement at 2346. PERSONNEL INFORMATIONOrbic Air hired the pilot in 2021, and he completed his initial competency check in accordance with 14 CFR Part 135.293 (which specifies initial and recurrent pilot testing requirements) on September 8, 2022, in the Robinson R-44 helicopter.
According to the pilot’s resume, dated April 4, 2023, the pilot had about 6.2 hours of turbine flight time; 117 hours of instrument time, which included 69.4 hours in simulators; 48.8 hours while flying under simulated IMC; and 0 hours in actual IMC.
The pilot completed his initial competency check in accordance with 14 CFR Part 135.293 in the accident helicopter on July 10, 2023. The check included demonstrating satisfactory flying maneuvers required for IIMC to VFR conditions and unusual attitude recovery.
According to the pilot’s fiancée, in the days preceding the accident, he woke up between 0500 and 0630 and went to bed around 2000 and 2030. On the morning of the accident, the pilot woke up at 0620 and went back to bed from about 0730 to 0900 before resuming his activities.
Orbic Air hired the safety pilot in 2022, and he completed his initial competency check in accordance with 14 CFR Part 135.293 in the Robinson R-44 helicopter on May 17, 2023. The check included demonstrating satisfactory flying maneuvers required for IIMC recovery and unusual attitude recovery. The safety pilot was assigned to operate as a Part 135 PIC in the Robinson R-44 helicopter. AIRCRAFT INFORMATIONAccident Helicopter Information
The helicopter, was manufactured in 2006 by Airbus Helicopters (previously Eurocopter) (see figure 3), and Orbic Air purchased the helicopter on March 16, 2022.
FAA airworthiness documents showed equipment changes from the original manufactured configuration that included, but were not limited to,: the Bendix King KR87 automatic direction finder (ADF) system had been removed and a FreeFlight TRA3500 radar altimeter had been installed.
Figure 3. Undated photograph of the accident helicopter (Source: Internet).
Maintenance and Radar Altimeter Information
The maintenance records showed four radar altimeter issues between June 2022 and the accident flight. The following maintenance entry was noted for February 9, 2024:
Main rotor (MR) pin inspect...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CEN24MA111