A109S Medevac Crash Brainerd Minnesota

[Airbubba]

Apparently N11NM.

Pilot, nurse killed in helicopter crash at Brainerd airportUpdated: June 28, 2019 09:53 AM

A pilot and a nurse died in an early-morning helicopter crash Friday at Brainerd Lakes Regional Airport, officials said.

According to a statement issued by North Memorial, three North Memorial Health crew members were on board at the time of the crash, which was about 1 a.m.

Officials said the helicopter's pilot and a nurse were reported dead at the scene. The third crew member was transported to St. Joseph's Medical Center.

No patients were on board when the crash happened

"The FAA and NTSB have been notified, and we will fully cooperate with both agencies during their investigation of the incident," a North Memorial spokeswoman said in a statement. "North Memorial Health is grateful for the expertise and efforts of the first responders who came to the accident scene including the Crow Wing County Sheriff's Office, Brainerd Police and Fire Departments and Baxter Police Department."

KSTP's Ashley Zilka spoke with Brainerd Lakes Regional Airport Director Steve Wright who said the helicopter was small and that there was no debris following the crash.


https://kstp.com/news/fatal-helicopter-crash-brainerd-airport/5406014/ (https://kstp.com/news/fatal-helicopter-crash-brainerd-airport/5406014/?cat=1&utm_source=dlvr.it&utm_medium=twitter)


https://cimg5.ibsrv.net/gimg/pprune.org-vbulletin/1920x1185/d_jzkoaxsaiibka_111abdb7675ec9281a73da172dc024bbc106f31c.jpg

[Airbubba]

A weather observation from another media outlet.

An airport employee confirms conditions were extremely foggy at the time of the incident. KARE 11 meteorologist Sven Sundgaard says ground fog was dense in the area, with visibility at two tenths of a mile or less.

https://www.kare11.com/article/news/local/north-memorial-helicopter-crashes-near-brainerd-2-dead/89-eb83ed75-170a-4139-bc48-9e114faa9d08

[Unregistered_]

What is it with US EMS crews and fog?
Is it the 'tow truck' mentality of tasking?

Sadly, no one EVER learns there. :ugh:
The hardest word in aviation? No.

[havoc]

North Memorial is a SPIFR no NVG program:

KBRD 281153Z AUTO 04005KT 1 3/4SM HZ OVC002 18/16 A3010 RMK AO2 SLP190 7//// T01830156 10200 20183 53005=left
KBRD 281144Z AUTO 04005KT 2SM HZ OVC002 18/16 A3011 RMK AO2 T01830156=left
KBRD 281120Z AUTO 05005KT 1SM HZ OVC002 18/16 A3010 RMK AO2 T01830156=left
KBRD 281053Z AUTO 05006KT 3/4SM HZ OVC002 18/16 A3009 RMK AO2 SLP187 T01830156=left
KBRD 281029Z AUTO 04005KT 1/4SM HZ VV002 18/16 A3008 RMK AO2 T01830156=left
KBRD 281014Z AUTO 06005KT 1/2SM HZ VV002 18/16 A3008 RMK AO2 T01830156=left
KBRD 281004Z AUTO 05005KT 1/4SM HZ VV002 19/16 A3008 RMK AO2 T01890156=left
KBRD 280953Z AUTO 06004KT 1/2SM HZ OVC002 19/16 A3008 RMK AO2 SLP182 T01890156=left
KBRD 280933Z AUTO 09003KT 1SM HZ OVC002 18/16 A3008 RMK AO2 T01830156=left
KBRD 280925Z AUTO 00000KT 1 3/4SM HZ OVC003 19/16 A3008 RMK AO2 T01890161=left
KBRD 280853Z AUTO 00000KT 8SM OVC003 19/16 A3009 RMK AO2 SLP184 T01890161 51004=left
KBRD 280824Z AUTO 08005KT 3SM HZ OVC002 19/17 A3008 RMK AO2 T01940167=left
KBRD 280815Z AUTO 09004KT 1 3/4SM HZ OVC002 19/17 A3008 RMK AO2 T01940167=left
KBRD 280753Z AUTO 06004KT 2SM HZ OVC002 19/17 A3008 RMK AO2 SLP181 T01940167=left
KBRD 280746Z AUTO 07004KT 2SM HZ OVC002 19/17 A3008 RMK AO2 T01940167=left
KBRD 280738Z AUTO 06006KT 1 1/2SM HZ OVC002 19/17 A3009 RMK AO2 T01940167=left
KBRD 280653Z AUTO VRB04KT 1/2SM HZ VV002 20/17 A3009 RMK AO2 SLP184 T02000172=left
KBRD 280642Z AUTO 05005KT 1/2SM HZ VV002 20/17 A3008 RMK AO2 T02000172=left
KBRD 280553Z AUTO 04003KT 1/4SM HZ VV002 19/17 A3007 RMK AO2 SLP181 60000 T01940167 10233 20178 402440178 50000=left
KBRD 280518Z AUTO 05004KT 1/4SM HZ BKN002 19/16 A3008 RMK AO2 T01890161=left
KBRD 280513Z AUTO 04003KT 1SM HZ BKN002 19/16 A3008 RMK AO2 VIS 1/4V5 T01890161=left
KBRD 280510Z AUTO 03003KT 2SM HZ BKN002 19/16 A3008 RMK AO2 VIS 1V5 T01890161=left
KBRD 280500Z AUTO 03003KT 1SM HZ VV002 19/17 A3008 RMK AO2 T01940167=left
KBRD 280458Z AUTO 03003KT 1 3/4SM HZ FEW002 19/17 A3008 RMK AO2 T01940167=left
KBRD 280453Z AUTO 03003KT 1 1/2SM HZ CLR 19/17 A3008 RMK AO2 SLP183 T01940167=left
KBRD 280430Z AUTO 05004KT 1SM HZ CLR 19/16 A3008 RMK AO2 T01940161=left
KBRD 280423Z AUTO 04004KT 1 1/2SM HZ FEW003 19/17 A3008 RMK AO2 T01940167=left
KBRD 280416Z AUTO 03003KT 1SM HZ VV003 20/17 A3008 RMK AO2 T02000172=left
KBRD 280413Z AUTO 00000KT 1 1/2SM HZ FEW003 20/17 A3008 RMK AO2 T02000172=left
KBRD 280401Z AUTO 03003KT 1 3/4SM HZ CLR 19/16 A3008 RMK AO2 T01940161=left
KBRD 280353Z AUTO 02003KT 9SM CLR 19/16 A3008 RMK AO2 RAE0254 SLP182 P0000 T01940161=left
KBRD 280253Z AUTO 04004KT 10SM -RA FEW095 21/17 A3007 RMK AO2 RAB34 SLP180 P0000 60000 T02060172 53006=left
KBRD 280153Z AUTO 08003KT 10SM SCT100 23/18 A3006 RMK AO2 RAB0057E12 SLP175 P0000 T02280178=left
KBRD 280053Z AUTO 08004KT 10SM BKN110 23/18 A3005 RMK AO2 SLP171 T02280178=left
KBRD 272353Z AUTO 07005KT 10SM SCT110 23/17 A3005 RMK AO2 RAE09 SLP173 P0000 6//// T02330172 10244 20222 56005=left
KBRD 272253Z AUTO 05007KT 10SM -RA OVC110 23/18 A3006 RMK AO2 RAB00 SLP175 P0000 T02330183=left
KBRD 272153Z AUTO 06006KT 10SM FEW044 SCT110 23/18 A3006 RMK AO2 SLP174 T02330178=left
KBRD 272053Z AUTO 03004KT 10SM OVC041 24/17 A3007 RMK AO2 SLP178 6//// T02390172 51037

[SASless]

Knowing what the OpSpecs Weather Minimums for the Operation are will be interesting reading when doing a comparison of the weather reporting in the forecast and actual weather being that existed at the time of the flight.

NVG's are not of much use if you are in cloud or fog.

Fog will straight up kill you.

[[email protected]]

Killer Fog!!!!?????

It's the impact with the ground whilst in the fog that seems to do the damage:ok:;)

[JimEli]

Via my quick check, wx was sufficient to file/fly the ILS with clear condition alternates within 30 minutes. Note my total speculation on this, did they complete the ILS and attempt a transition to the ramp, passing over top the PAPI? The aircraft heading is opposite this path but the impact looks near vertical with rotors intact.

And, I wouldn’t characterize NVGs as completely useless in fog and on an ILS.

[SASless]

How would you characterize the usefulness of NVG's on the night in question with the existing weather and Celestrial Lighting due to the Moon Phase, Overcast, and flight within Cloud or Fog?


http://www.aeromed-africa.com/sites/default/files/site_assets/documents/13%2030%20%20Aeromed%20NVIS_final.pdf

[Two's in]

The operator's website is interesting:

https://northmemorial.com/specialty/air-care/

Our pilots are certified to “fly by instrument,” making us agile enough to reach emergency scenes when weather has grounded other pilots.

A fascinating correlation between being instrument rated and landing at a random accident site in IMC.

[[email protected]]

A fascinating correlation between being instrument rated and landing at a random accident site in IMC. yes, that is a very worrying management mindset........

I have used NVG in very poor vis to get the required visual references at the bottom of an ILS once - not pretty or clever but we had no diversion options and a sick patient on board. You could see the lights at DH with the goggles but not without them and it was a two-pilot process.

[JimEli]

I have used NVG in very poor vis to get the required visual references at the bottom of an ILS once - not pretty or clever but we had no diversion options and a sick patient on board. You could see the lights at DH with the goggles but not without them and it was a two-pilot process.


Agreed. The transition from instruments/IMC to visual landing at night at/near ILS mins, is one of the most challenging maneuvers of IFR flight. The high intensity of the approach light system and runway lights can penetrate cloud and fog at the distances involved near DH. This amount of artificial lighting is sufficient for adequate NVG operation. It seems odd one could understand the benefits of NVGs, but dismiss their value during this phase of flight.

[Airbubba]

Pictures of the crash site by Steve Kohls of the Brainerd Dispatch:


https://cimg3.ibsrv.net/gimg/pprune.org-vbulletin/2000x1124/992e62_20190628_air_ambulance_helicopter_crash_02_ebf48eb69d 9f0308095ac20a00f0cc7262fdc30d.jpg
https://cimg5.ibsrv.net/gimg/pprune.org-vbulletin/2000x1124/9538a1_20190628_air_ambulance_helicopter_crash_03_db2743ae94 bf6b59907392e6e05e40cb0f3b704d.jpg

[SASless]

My experience with the Sperry Helipilot system on Bell 412's and S-76's demonstrated the aircraft could get you down to 50 feet AGL using the RadAlt and the system tracking the Localizer and Glide Slope....and do so at 60 Knots IAS.

On a fully instrumented runway approach system...with all the lights, strobes and such.....NVG's for a SINGLE Pilot Operation would be a benefit and a distraction.

Legal Approach Minima are well above the 50 foot number for ILS Approaches (all depends upon the OpSpecs for the Operator).


Now if you are doing a some sort of off airport approach or a Non-Precision Approach.....I can see a whole new degree of difficulty.

What kind of Instrument Approach was the Pilot performing?

But...back to the tragedy in question....the video of the crashed aircraft raises a lot of questions about what happened.

I did not see any lengthy skid marks or other signs of disturbance to the surrounding sod....all the Rotors were still attached, the aircraft certainly had a very hard vertical impact.....well off the Runway.

[LRP]

Appears to have impacted just short of the ILS antenna...altimeter problem?

[TeeS]

Appears to have impacted just short of the ILS antenna...altimeter problem?
Hi LRP
An altimeter problem on an ILS shouldn’t cause you to impact the ground early. Lots of other things might, including poor use of a three axis autopilot - but that is in the realms of pure conjecture!
Cheers
TeeS

LRP, my apologies - I didn’t look at the pictures and misunderstood your comment, that does look remarkably close to the glideslope antenna!

[JimEli]

Appears to have impacted just short of the ILS antenna...altimeter problem?

That would be just beyond the GS antenna, facing the opposite direction.

[ShyTorque]

My experience with the Sperry Helipilot system on Bell 412's and S-76's demonstrated the aircraft could get you down to 50 feet AGL using the RadAlt and the system tracking the Localizer and Glide Slope....and do so at 60 Knots IAS.

Unfortunately, the A109S autopilot isn't quite so sophisticated as that in the S-76.

The AP has no facility to carry out an ILS with the aircraft holding a set airspeed (the collective isn't coupled and there is no altitude pre-select facility). During the ILS the airspeed is controlled by the pilot using the collective and it can be counter-intuitive until you are used to it; it will easily go through Vne or VLE (max landing gear extended speed) as it couples to the G/S and noses down - it's a slippery beast and can get away from you. At lower IASs, with the AP fully coupled, the aircraft seems to "wallow" as if the AP is struggling - it's designed to fly fast.

The AP is capable of leveling the aircraft at the completion of the ILS but at that stage the airspeed still has to be controlled by the pilot using the collective. It's actually quite unnatural to significantly lower the lever - lowering the lever brings up the nose, rather than the possibly more usual expectation of it causing the nose to drop. If you are still in fog at that stage and not used to it, possibly more than a little disorientating.

[gulliBell]

Not withstanding the (lack of) sophistication of the A109S autopilot. Presumably it's sophisticated enough to enable the aircraft to be on the localizer and aligned with the runway center line. And in foggy conditions you stay on that localizer until DH, and at DH (with the required visibility) you continue down and land on the runway center line. And then ground taxi all the way to the dispersal point. 'Aint no way that helicopter was aligned with the runway center line when it met its demise.

And besides, there is absolutely no place for leveling off once established on an ILS approach prior to touchdown. The helicopter should be like a ping pong ball bouncing off a table at DH and carry out the missed approach if you don't have the required visibility (which is always to immediately add power at DH and climb). If you do have the required visibility at DH you continue the approach angle and alignment whilst slowing down until touch down. Either way, you never level off whilst in flight.

[ShyTorque]

gulliBell, I don't understand your reference to "leveling off" during an ILS.

Yes, the A109S flies a very good ILS. As you say, on reaching DA (or DH if using QFE), provided that sufficient visual reference has been seen and maintained there is a "transitional" period where the pilot has to take over, the aircraft has to be slowed down, either to a suitable hover taxi speed, or to a landing on the runway. The maximum run-on speed for an A109S is 40 kts. The autopilot has a "go-around" facility.

That sad photograph shows an aircraft that had impacted with little or no forward speed, but at a very high vertical velocity. Why it wasn't on the runway in fully serviceable condition remains to be seen.

[rotorspeed]

Strange one here. Be key to know what runway they were using and approach they were on. Not familiar with KBRD but seems there is an ILS on 23 and 34, and an RNAV on 05. N11NM was a 109S, so not the SP with 4 axis autopilot, so it would have been able to fully couple to an ILS but not, I suspect, the RNAV on 05. Given NE wind you'd ideally have chosen 05, but assuming it doesn't have an ILS and given the minimal 3kt tailwind, and advantage of having the terminal buildings at the end of the roll out with presumably some lighting, I'd have taken 23. Maybe 34 with a light crosswind. Either way, both have long 7000ft runways, so speed over the threshold not a big deal.

Looks like the pilot had 200ft and 1/4M (400m) at the time of the accident - not great, and may have been under legal limits (though before and after vis was better) - but assuming the runway lighting was fully serviceable and on, that should not have prevented a successful approach to the runway. Which is what I suspect he achieved. On the 109S the radalt will level at circa 50ft at the end of the approach with the ILS coupling keeping it over the runway, especially with no crosswind. And with say an approach speed of 100kts, stability is good, and with 7000ft you should have plenty of distance to slow it down to taxi speed without big pitch/power changes.

The wreckage appears to be about 200m SW of the 23 touchdown point, 60m south of the runway. It also shows no forward speed, and a pretty level vertical impact. So it really doesn't look like it crashed from continued descent on the ILS23 in virtually nil vis until it impacted the ground - that would have streaked it along with far more damage from surely at least 50 kts forward speed, even after 200m. In bad weather, it's unlikely you'd try and uncouple and flare enough to lose all airspeed just 200m after the threshold, especially when the terminal is over a mile ahead.

It seems to me a possible scenario is that the pilot completed whatever approach he was on, got visual and was at taxi speed, but then perhaps lost visual references in denser fog, and with minimal airspeed couldn't control the aircraft which started to go out of control so he dumped the lever to try and get back visual - but hit the ground before he did. But there again once he'd got visual over the runway you'd have thought he'd have run it on, given wheels, and been able to relax for the first time in a while, and work out his ground taxi route to wherever. But amongst the puzzles is why he actually crashed at the location he did.

[gulliBell]

gulliBell, I don't understand your reference to "leveling off" during an ILS..

Fly level to capture the GS, sure. Once the GS is captured there are only two choices. Down or Up. There is no leveling off.

[PANews]

And another question may be what seats were fitted. The answer to that question can turn an unfortunate hi-G injury accident where everyone walks away into a fatal.
The 109 is a legacy airframe and some of the original seat options are not crashworthy. The rear bench is no place to be but the pilots seat is usually stroking and modern.
It would not be the first time that an EMS 109/119 has simply killed by a lack of a stroking seat.

[SASless]

Once the GS is captured there are only two choices. Down or Up. There is no leveling off.

At what point does the ILS Procedure end?

We must assume you are using the criteria of the Pilot gaining adequate visual reference to allow for a decision to land as being part of the definition.

DH is the height above ground that the Pilot must declare his intention to land or go around....right?

In reality....it is far more common to make that decision well before DH if the existing weather conditions allow for an "early" decision.

I am thinking you are failing to understand my post where I described the Sperry system being able to fly the aircraft at a fixed height down the runway as being part of a legal IFR procedure....which it certainly is not.

The point was demonstrate most helicopter autopilot systems can provide better flight performance than is allowed by the Authorities.

In extreme cases....which sometimes we find ourselves in for any number of reasons outside our control...we might have to exceed those legal limitations to safely land the aircraft.

Knowing what your aircraft is capable of doing...and knowing how to use those capabilities might just save your Bacon when you need it.

As to all the jabber about aircraft attitude changes....again...knowing how to fly the machine is a good start on understanding what it is going to do when you move the controls.

If you set the aircraft up in a minimum safe airspeed configuration before intercepting the Glide Slope....(I used 60 Knots IAS)....upon intercepting the Glide Slope (I never had an autopilot that controlled the power) you reduce the Collective Setting to maintain the Glide Slope)...pitch attitude changes were minimal and only transient.....you certainly did not wait for the nose to dip upon intercepting the Glide Slope.

At the bottom....you had to increase Collective slightly to stop the descent and the autopilot took care of the Pitch Attitude changes needed to maintain that same IAS.

The key....is thinking outside the box...practicing the "new" procedure to see how it all works.

Nothing unsafe about it....and it adds another Tool in your box you might need to drag out and use some day.

When you fly in areas that can be invested by Fog over very large areas and see your planned but well distant Alternates go below minimums with scant notice....you start thinking about these kinds of things.

There are no helicopters in Orbit around the Earth....thus at some point you must land....no matter what the weather you find yourself dealing with.

[Devil 49]

Unfortunately, the A109S autopilot isn't quite so sophisticated as that in the S-76.

The AP has no facility to carry out an ILS with the aircraft holding a set airspeed (the collective isn't coupled and there is no altitude pre-select facility). During the ILS the airspeed is controlled by the pilot using the collective and it can be counter-intuitive until you are used to it; it will easily go through Vne or VLE (max landing gear extended speed) as it couples to the G/S and noses down - it's a slippery beast and can get away from you. At lower IASs, with the AP fully coupled, the aircraft seems to "wallow" as if the AP is struggling - it's designed to fly fast.

The AP is capable of leveling the aircraft at the completion of the ILS but at that stage the airspeed still has to be controlled by the pilot using the collective. It's actually quite unnatural to significantly lower the lever - lowering the lever brings up the nose, rather than the possibly more usual expectation of it causing the nose to drop. If you are still in fog at that stage and not used to it, possibly more than a little disorientating.

I remember an autopilot equipped BO105 accident some years ago that was attributed that was attributed to confusion as to how the collective interacted with the autopilot. I'll see if I can find that report, I don't recall specifics other than fatal, night, HEMS, pilot only on a short hop to the airport while the medicals packaged the patient for transport.

[ShyTorque]

Originally Posted by gulliBell https://www.pprune.org/images/buttons/viewpost.gif (https://www.pprune.org/rotorheads/622992-a109s-medevac-crash-brainerd-minnesota-post10506171.html#post10506171)Fly level to capture the GS, sure. Once the GS is captured there are only two choices. Down or Up. There is no leveling off.

No-one said or implied that one would level off during the approach on the GS per se.

But if visual after DA/DH you are no longer using the ILS, unless you have helicopters fitted with auto-land, which I don't think currently exist. The A109S certainly doesn't have that facility.

[JimEli]

...
I am thinking you are failing to understand my post where I described the Sperry system being able to fly the aircraft at a fixed height down the runway as being part of a legal IFR procedure....which it certainly is not.
...


No-one said or implied that one would level off during the approach on the GS per se.
But if visual after DA/DH you are no longer using the ILS, unless you have helicopters fitted with auto-land, which I don't think currently exist. The A109S certainly doesn't have that facility.


Absent a limitation, why decouple simply because the runway environment is in sight? Especially in low IFR conditions.

[JimEli]

Strange one here. Be key to know what runway they were using and approach they were on.
…


Under typical OpSpecs, I don’t think executing the GPS RWY 5 was legal given the weather, without an approach light system. However, it is usually allowed a straight-in reduction of visibility/RVR by one-half if flown at <90 knots. That would probably make ILS RWY 23 or 34 and LPV RWY 34 legal options. I didn’t find any NOTAM preventing those selections.

[SASless]

Absent a limitation, why decouple simply because the runway environment is in sight? Especially in low IFR conditions.

Who said anything about de-coupling the Auto-Pilot?

At some point one must do so....so where would you do that?

Some grist for the mill.....


https://www.faa.gov/air_traffic/publications/atpubs/aim_html/chap10_section_1.html

[ShyTorque]

Absent a limitation, why decouple simply because the runway environment is in sight? Especially in low IFR conditions.

Personal choice, but if you don't decouple, the AP will level the aircraft and fly it down the runway and the pilot will need to control the speed by lowering the collective....!!

As I already wrote:
The AP is capable of leveling the aircraft at the completion of the ILS but at that stage the airspeed still has to be controlled by the pilot using the collective. It's actually quite unnatural to significantly lower the lever - lowering the lever brings up the nose, rather than the possibly more usual expectation of it causing the nose to drop. If you are still in fog at that stage and not used to it, possibly more than a little disorientating.

[[email protected]]

Yes, perhaps one of the reasons for having a minimum of 200' DH for a Cat 1 ILS - the AP is capable of putting the pilot in a very uncomfortable situation.

Personally, I dislike 3 axis APs especially when used for approaches - it is too easy to forget that collective is controlling your IAS whether you are in IAS or VS mode and most counter-intuitive for many helicopter pilots.

[SASless]

As Attitude and Power equals airspeed or altitude/height.....and the Auto-Pilot is maintaining height (thinking of the bottom of the approach)....what is counter-intuitive about having to lower collective (reduce power) to slow down?

If you do not adjust power as the aircraft levels due to the auto-pilot attempting to maintain a height....the aircraft will pitch upwards and slow down.....fail to add some power and you might well get too slow, lose auto-pilot authority and see a downward trend on height.

If the basic laws of flight escape you....perhaps you might just be in the wrong profession.

A few minutes of practice now and then is a simple way to stay in touch with those basic relationships.

[ShyTorque]

Again, to clarify, in the A109S you can't be in IAS mode when fully coupled to the ILS. The AP maintains the LOC and GS but the pilot has to control the IAS by use of the collective.

If ATC are vectoring you to fit in with faster jet traffic at a busy airport they will usually expect you to fly at "best speed". I previously mentioned that because as the aircraft automatically captures and descends on the G/S, it will do it by lowering the nose. Unless you lower the lever promptly the AP will happily take you beyond VLE, or even VNE if you aren't careful. This can require a large power reduction = a large downward movement of the collective. On these aircraft the yaw pedals need to be respositioned by the pilot, even if AP inputs requires pedal position changes. The YAW pedal trim is released via the button on the cyclic. The pilot therefore has to allow the AP to fly the ILS but must manage the collective and the yaw trim. For those used to helicopters such as the S-76, where the AP also manages the yaw trim without any pilot intervention, it feels quite strange.

When I transferred from almost ten years on S-76s it took me quite a while to get used to the differences - I'd developed rather "lazy" feet.

By the way, SAS - I've never heard of anyone ever attempting to begin to fly an ILS in a A109S at 60 kts! 55kts is the minimum IFR speed for the type. From about 3,000 hours on type, I can tell you first hand that about double that speed works best. For me, after forty years of successfully flying RW instrument approaches, I'm probably a bit too old to change careers. :8

[SASless]

Shy,

Flexibility of thought as well as feet is a useful attribute in flying helicopters.

A casual reading of my posts should] surface adequate notice that the 60 Knot Speed I discussed was in conjunction with a "non-standard but quite legal ILS approach technique" that falls well within the capability of most auto-pilot equipped helicopters.

I would submit that if you fly a helicopter like a jet airliner then you deprive yourself of the unique aspects of the helicopter.

Where this particular 109 came to grief is not a busy airport....especially at the time of night it happened.

I have done ILS approaches at West Palm Beach in brand spanking new S-76's at speeds in excess of Boeing 727's....with ATC asking if they would speed up as there was overtaking traffic behind them......ask John Dixson about such happenings for verification.

I have also done them at the minimum speed as well.

At Malpensa International....I have even backed back up the ILS Approach in a Chinook on one occasion (not IMC but in solid Gin Clear conditions) ....but that is a yarn for another time.

You choose the speed that fits the occasion...considering traffic, weather, and technique that affords you the best chance of landing safely without having to resort to a missed approach.

In craggy weather I would rather transition from DH at a stately slow speed than streak down the runway trying to get stopped.


Why would you want to hit minimums at 120 KTS if you could do so at 60 KTS?

If you are going to do a Missed Approach at DH.....do you use Vbroc or your 120 Knot approach speed?

[[email protected]]

As Attitude and Power equals airspeed or altitude/height.....and the Auto-Pilot is maintaining height (thinking of the bottom of the approach)....what is counter-intuitive about having to lower collective (reduce power) to slow down?

If you do not adjust power as the aircraft levels due to the auto-pilot attempting to maintain a height....the aircraft will pitch upwards and slow down.....fail to add some power and you might well get too slow, lose auto-pilot authority and see a downward trend on height.

If the basic laws of flight escape you....perhaps you might just be in the wrong profession.

A few minutes of practice now and then is a simple way to stay in touch with those basic relationships.

Sasless - while you are busy teaching us to suck eggs, just remember that A. you are not the only helicopter pilot in the world who can fly an ILS (or even go backwards up it - and old trick from Shawbury to confuse trainee ATCers) and B. that lowering the lever on a coupled ILS in a 3 axis AP will cause the IAS to reduce - I am not talking about the auto level portion well after DA/DH - which is how the Sumburgh aircraft ended up in VRS and the sea - using power to control IAS in this way is counter intuitive. Whilst I agree that practice helps, so does a 4-axis AP that flys height/RoD using collective and IAS using cyclic which is how most of us are taught to fly a manual ILS

[flyingnomad]

Just throwing out a random thought with zero evidence, as are the rest of everyone as well.

I think he successfully accomplished the approach but failed to go visual, at night, with wx likely below appch mins, and this is a simple loss of control. It’s not unlikely he had minimal aircraft lighting turned on with the fog conditions, and may have not had a lit up appch lighting system or may not have keyed airport lights during his high workload, and simply failed to transition to visual flight.

[gulliBell]

The Airport director was quoted in the media as saying the weather at the time of the accident was foggy but above minima. For what that's worth.

[SASless]

Interesting graphic that depicts the visibility being reported at the time of the accident.

No idea how accurate it is but it is in the public media.

https://www.kare11.com/article/news/local/north-memorial-helicopter-crashes-near-brainerd-2-dead/89-eb83ed75-170a-4139-bc48-9e114faa9d08

[gulliBell]

Missed the runway by quite a bit. They also had a total hull loss prang in 2016 which was blamed on pilot error. I wonder if their pilots attend simulator training?


https://cimg8.ibsrv.net/gimg/pprune.org-vbulletin/1318x736/screen_shot_2019_07_01_at_11_23_22_b2cced728b491fc66a05ee4dc de027f60197ff4c.png

[ShyTorque]

SAS, Thanks, but you perhaps forget others here also have considerable experience of helicopter instrument approaches in all sorts of circumstances - there are even some of us with relevant type ratings and a lot of hours on the type...in my case as many as you previously said you flew on the Chinook. I had already worked out that one needs to fly with consideration of the prevailing conditions, but thanks for the reminder. :hmm:

I have no reason to ask JD to corroborate your story about the speed at which you flew that ILS at WPB; I believe you, it's not unique (I have been in a situation in an A109S where, having been directed by ATC at a major airport to "make best speed" on the ILS to fit in with the busy airliner traffic I was shortly afterwards asked to slow down again because I was catching up the B767 established ahead of me).

Are you saying that you usually changed the IAS on a S-76 on a coupled ILS by manually lowering the lever, or did you use the "Beep" trim with IAS mode selected, as per normal teaching and allow the AP to reduce the power accordingly? I did the latter, as I was taught to do and expected to do for the nine year period I flew them (A, A++, B, C and C+).

Did you keep your feet on the side rests on the yaw pedals and away from the yaw micro-switches so the AP could make it's own yaw inputs? I certainly did.

Unfortunately, you don't have that luxury of doing either in the A109S - the aircraft has no IAS mode when coupled on the ILS and the AP requires the pilot to make all yaw pedal inputs himself and to re-trim them, the trim release button on the cyclic has to be used. In effect, the A109S cannot be flown "fully coupled" on an ILS, unlike more sophisticated aircraft.

When it comes to a speed reduction near the ground, the normal teaching (at least the teaching I am familiar with) is to initiate the manoeuvre by using the cyclic to raise the nose to a decelerative attitude then to maintain the required flight path by lowering the collective. In the A109S, if still coupled at the bottom of an ILS and the system has levelled the aircraft at 50 feet (as advertised), to reduce speed the pilot has to first lower the collective and trust that the AP will prevent a descent by raising the nose. If you try to move the cyclic first you will find yourself working against the trim - not something you should be doing near the ground in poor visibility. The more sophisticated types such as the S-76 (and. I believe, the A109SP) will slow down all by itself in the same circumstances because the collective is also coupled).

It's unlikely we will ever know what this unfortunate pilot did because there is no FDR on the type. I would be interested to find out what his previous experience was.

[gulliBell]

We might know. There is a survivor. Well, I think there is (there has been no mention of his condition since the accident). In which case he might be able to provide useful information to the investigation.

Given the reported weather, the final disposition of the aircraft, and what ShyTorque has described of the A109S autopilot system, this is strongly leaning towards pilot loss of control close to the ground at night in non-visual conditions.

[ShyTorque]

gulliBell, Let's hope so but when it comes to individual control inputs, I doubt a passenger would know the precise sequence of events.

There are far, far too many aircraft involved in "low vis" accidents of this nature.

[golfbananajam]

Appears to have impacted just short of the ILS antenna...altimeter problem?


Aren't they PAPIS rather than ILS antennas?

[gulliBell]

...I would be interested to find out what his previous experience was.

His bio says 14 years experience flying helicopters, 700 hours NVG.

[Devil 49]

Perhaps as simple as autopilot failure, pilot misusing controls:

NTSB Identification: NYC06MA005

HISTORY OF FLIGHT

On October 7, 2005, at 2342 eastern daylight time, an Agusta 109E, N7YL, operated by CJ Systems Aviation Group Inc., was destroyed when it impacted trees and terrain in Smethport, Pennsylvania, while performing an instrument approach to Bradford Regional Airport (BFD), Bradford, Pennsylvania. The certificated commercial pilot was fatally injured. Night instrument meteorological conditions (IMC) prevailed, and an instrument flight rules (IFR) flight plan was filed for the flight that originated from Kane Community Hospital (PA91), Kane, Pennsylvania, at 2324. The positioning flight was conducted under 14 CFR Part 91.

In an interview, a mission flight nurse stated that he and another nurse were onboard the helicopter during a positioning flight from their base in Harborcreek, Pennsylvania, to Kane Community Hospital. Upon arrival at the hospital, he and the other nurse deplaned to prepare a patient for transport to Pittsburgh, Pennsylvania, while the helicopter departed for Bradford Airport to refuel.

Examination of radar and voice communication data provided by the Federal Aviation Administration (FAA) revealed that the helicopter departed Kane Hospital helipad and tracked the Copter GPS 246 Departure procedure course. The pilot contacted air traffic control (ATC), at 2324:47, stated that he had departed the hospital, and was "VFR to uh Bradford three thousand two hundred climbing to five."

Over the next 4 minutes, the pilot requested the instrument landing system (ILS) runway 32 approach to Bradford Regional Airport, and he and the controller discussed whether the helicopter would be vectored to the final approach course or if the full approach procedure would be flown.

The controller stated, "say your heading I've got you heading the wrong way for Bradford." The pilot replied that he was heading 246 degrees, which was prescribed in the procedure, but the controller questioned the response. The pilot reaffirmed his intention to fly to Bradford, and the controller assigned a 040-degree heading.

The pilot acknowledged the instructions; the helicopter then reversed direction, and assumed a northeasterly track. About 3 minutes later, the controller stated, "fly heading of zero eight five radar vectors runway three two I-L-S."

The pilot acknowledged the radio call, and the helicopter assumed an easterly track.

At 2339:01, the controller stated, "seven yankee lima fly heading of three four zero join the localizer report established please." At that time, the helicopter was at 5,000 feet, on an easterly track, about 1 mile west of the runway extended centerline, about 150 knots groundspeed. The pilot acknowledged the instructions.

The radar track depicted the helicopter on an easterly heading as it flew through the 322-degree final approach course, about 4 miles outside of the outer marker.

At 2340:03, the controller advised the pilot that the helicopter was "on the right side of the I-L-S," and the pilot acknowledged the call. At 2341:09, the controller asked if the pilot was established on the ILS. The pilot responded that he was "recapturing." The controller then asked if the pilot had said "affirmative," and the pilot replied "affirmative." At 0341:19, the controller transmitted, "Lifeguard seven yankee lima roger cleared I-L-S three two uh runway at Bradford uh maintain four thousand feet and uh report cancellation on this frequency..." The pilot read back the clearance at 0341:33. There were no further transmissions from the helicopter.

When the pilot replied "recapturing" the controller insisted the pilot respond "affirmative," which the pilot subsequently did.

At the time the controller advised that the helicopter was right of the localizer course, the radar track depicted the helicopter about midway through a left turn to about a 310-degree heading, at 5,000 feet, and about 1 mile east of the runway centerline.

The helicopter's track approached the localizer course centerline, and then turned sharply away from, and to the right of the inbound course. The radar target showed an approximate track of 100 degrees, when the target disappeared. During the 1 minute and 10 seconds following the pilot's acknowledgement of the 4,000-foot altitude assignment, the helicopter descended only 300 feet, slowed to approximately 65 knots groundspeed, and turned 140 degrees right of course.

The final three plots of the radar track showed a sharp left turn back towards the localizer course, and an approximate ground speed of 55 knots. The last radar plot was approximately over the crash site at 4,300 feet, about 1 mile east of the extended runway centerline, and 4 miles from the airport.

In an interview, a witness that lived approximately 1 mile from the crash site said that he did not see the helicopter, but heard it pass overhead. He said he was familiar with the sound, as he had lived close to the final approach course for runway 32 for many years.

The witness said the sound was louder than usual, and he felt the helicopter was closer to his home and lower than usual. The witness described the sound as smooth and continuous, with no change in aircraft noise. After the helicopter over flew his position, he heard the sound of an explosion.

On October 8, 2005, the FAA generated an alert notice at 0101, and a ground search for the helicopter began in the early morning hours of October 8, 2005. A search by air was not conducted due to weather. The helicopter wreckage was found on October 9, 2005, and was examined at the site on October 10, 2005.

The accident occurred during the hours of darkness approximately 40 degrees, 53 minutes north latitude, and 78 degrees, 06 minutes west longitude.

PERSONNEL INFORMATION

The pilot held a commercial pilot certificate with ratings for rotorcraft helicopter and instrument helicopter. The commercial certificate was issued February 10, 1979, and the instrument rating was added June 18, 1997. His most recent FAA second-class medical certificate was issued on October 19, 2004, and he reported 9,616 total hours of flight experience on that date.

The pilot's logbook was not recovered; however, some flight times were extracted from company records. In the 90 days prior to the accident, the pilot logged 56 hours, all of which was in the Augusta 109E. In this time period, he logged 25 hours of flight experience at night, 3 hours of simulated instrument experience, and 3 hours of actual instrument flight experience.

The company reported that the pilot had 110 total hours of instrument flight experience, and estimated that of this 70 hours were simulated instrument flight experience, and 40 hours were actual instrument flight experience. Later, the company reported that the pilot had accrued 100 hours of instrument flying experience, 10 hours of which was simulated.

AIRCRAFT INFORMATION

The helicopter was manufactured in 2001, and had accrued 1,905 total airframe hours. It was maintained under an Approved Aircraft Inspection Program (AAIP), and its most recent inspection was completed August 5, 2005.

The helicopter was equipped with an Integrated Flight Control System (IFCS). The system provided attitude automatic stabilization and automatic path control. Both stabilization and automatic path computation were actuated through the helipilot (autopilot) system and the flight director system.

A review of maintenance records revealed numerous entries related to autopilot malfunctions and failures. The malfunctions included erratic command bars on pilot and copilot displays, and uncommanded pitch and roll oscillations that occurred during preflight checks and also in flight. Over a 2-year span, 10 autopilot computers were changed on the accident helicopter due to their exposure to "high vibration levels."

A service bulletin (109EP-51) was released February 9, 2005, to address the vibration issues with the installation of shock-isolating mounts on the mounting trays for the autopilot computers. According to the site mechanic where the helicopter was based, he didn't recall having to change any computers once the service bulletin was applied.

METEOROLOGICAL INFORMATION

At 2337, the weather reported at Bradford Regional Airport included an overcast ceiling at 600 feet, with 2 1/2 miles of visibility in mist. The temperature was 50 degrees Fahrenheit, and the dew point was 48 degrees Fahrenheit.

WRECKAGE AND IMPACT INFORMATION

The helicopter impacted heavily wooded terrain about 2,000 feet elevation and all major components were accounted for at the scene. The initial impact point was in a treetop about 50 feet above the ground on level terrain. The wreckage path was about 180 feet long, and oriented about 100 degrees. The helicopter was fragmented, burned, and melted along the entire path. There were several pieces of angularly cut wood along the wreckage path, and several trees with fire damage and long angular slices along their trunks.

The wreckage path was documented at 1-foot increments called wreckage points (WP). At WP 33, a large tree, about 15 inches in diameter, was broken off about 25 feet above the ground. Sheets of composite material were embedded vertically into the trunk fracture.

The vertical fin was at WP 41. The tailboom was abeam the vertical fin, about 30 feet right of the wreckage path centerline. Structure that contained the number 1 hanger bearing was also at WP 41, 25 feet left of centerline. Both the left and the right antenna from the accident helicopter were destroyed by impact and postcrash fire.

The main wreckage, which consisted mostly of the main transmission with the mast and rotor head attached, was entangled at the base of three trees at WP 66. The cockpit and cabin area were consumed by fire, and all the flight and system instruments had been destroyed.

Because of impact and fire damage, control continuity could not be established. All flight controls, tubes, and bellcranks that were examined displayed impact damage and failures consistent with overload.

All four rotor blades were located at the site. They were extensively damaged by impact and fire. The red, white, and yellow blade grips were still attached to the rotor head. The blue blade grip, with damper attached, was located about 12 feet to the right of the transmission and rotor head.

All four main rotor blade spars were exposed, with the associated composite and honeycomb material scattered along the wreckage path.

Examination of the rotor head revealed that the red and white pitch change links were still attached to their hubs and the swashplate. The pitch change link for the yellow blade was broken at the swashplate, and the blue pitch change link was broken at the blade grip. All fractures were consistent with overload.

The red, white, and yellow dampers were still attached to the rotor head, but separated from their respective blade grips. The blue main rotor blade damper was separated from the rotor head, but still attached to its blade grip.

The engines were entangled in aircraft structure at WP 75, and both were extensively damaged by fire. The number one engine was largely intact. The number two engine was broken open, with internal components scattered on the ground.

Continuity of the powertrain could not be established. The combining gearbox was fractured into several pieces, and the oil cooler impeller was exposed. All drive couplings and driveshafts showed fracture surfaces that were consistent with impact and torsional overload.

A section of tree trunk, about 6 feet long and consistent with the fractured tree at WP 33, was found 180 feet beyond the initial point of impact. The trunk section was about 15 inches in diameter. The bark and wood along one side was shaved clean and displayed angular slices. There was aircraft structural sheet metal and associated hardware embedded in the wood.

TESTS AND RESEARCH

The engines were reexamined at Turbomeca, USA, Grand Prairie, Texas, on January 19, 2006, under the supervision of the FAA.

Examination of the number one engine revealed rotational tearing of the coupling at the accessory drive gearbox. The single-stage high-pressure turbine showed signs of rub on nozzle segments at the 1:00 o'clock position. The power turbine shaft had a torsional tear consistent with rotation and impact.

Examination of the number two engine revealed that the inlet axial compressor blades displayed impact damage and rotational tearing. The power turbine shaft was sheared and worn smooth from rotation at the accessory drive gearbox and the gas generator connection.

COMMUNICATION

A Safety Board air traffic control specialist convened an air traffic control group at Cleveland Air Route Traffic Control Center (ZOB), Oberlin, Ohio, on October 18, 2005. The group reviewed radar and voice communication recordings, collected documentation, conducted interviews, and the Safety Board specialist completed a factual report.

When questioned about the ILS runway 32 approach, the controller was unable to estimate the glideslope altitude at the point that the helicopter crossed the ILS localizer. Given an approach chart, he was able to identify the glideslope altitude at the outer marker as 3,333 feet. When he issued the approach clearance, the controller stated, "…cleared ILS three two uh runway at Bradford uh maintain four thousand feet." The controller was unable to explain what he intended by appending the 4,000 foot restriction to the approach clearance. He also stated that when he issued the approach clearance he had no feel for the relationship between the helicopter's altitude and the glideslope altitude at the helicopter's location.

According to FAAO 7110.65, the controller shall, "Assign headings that will permit final approach course interception on a track that does not exceed the interception angles specified in the TBL 5-9-1." The appropriate intercept angle values were 30 degrees for fixed-wing aircraft and 45 degrees for helicopters.

According to FAAO 7110.65, paragraph 5-9-1(b), controllers should position aircraft as follows: "For a precision approach, at an altitude not above the glideslope/glidepath or below the minimum glideslope intercept altitude specified on the approach procedure chart."

The FAA conducted a postaccident flight inspection of the ILS runway 32 approach at Bradford Regional Airport, and the results were "Satisfactory," with no deficiencies noted.

MEDICAL AND PATHOLOGICAL INFORMATION

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed the toxicological testing of the pilot. Chlorpheniramine, an antihistamine, was detected in the heart and liver.

The antihistamine chlorpheniramine was available over-the-counter under the commercial name Chlor-trimeton. According to the manufacturer, the side effects associated with chlorpheniramine included headache, fatigue, and dizziness. Among the warnings listed for consumers was, "Use caution when driving a motor vehicle or operating machinery."

According to his supervisor, the pilot was very physically fit, but "had a sinus condition on occasion." The flight nurse also stated the pilot "always seemed to have sinus problems."

The Mount Nittany Medical Center, State College, Pennsylvania, performed an autopsy on the pilot.

ADDITIONAL INFORMATION

According to the operator's director of training, as well as pilots employed by the airframe manufacturer, after the helicopter flew through the final approach course, and turned to the west, the autopilot could still capture the localizer course. However, once the helicopter was in the vicinity of the localizer course, and above the glideslope, the autopilot would be unable to capture the glideslope.

If altitude hold remained engaged at that point of the flight, and the pilot reduced collective to capture the glideslope, the autopilot would adjust pitch in an effort to maintain the selected altitude.

The Flight Safety Foundation publication Helicopter Safety, May-June 1997, Helicopter Autopilots Demand Careful Management, discussed some scenarios of "autopilot mismanagement."

One scenario described was in a flight simulator, where the crew reached a selected altitude, but no corresponding collective/power adjustment was made. Therefore, "As the aircraft approached the target altitude, the altitude preselect feature enunciated a "capture." Illumination of the altitude-hold button on the flight director followed. A few seconds later, the gear-up warning horn began to sound, triggered by airspeed below [60 knots].

"Surprised, the pilots scanned the instruments and saw that the airspeed was rapidly decreasing, the aircraft pitch attitude was very nose-high and the aircraft was in a descent…Therefore, the autopilot attempted to maintain altitude by increasing pitch attitude, thus decreasing the airspeed. At the selected power setting, the descent could not be prevented by the autopilot and airspeed decreased until the gear-up warning horn alerted the pilots."

Another scenario took place on an actual flight. In this scenario "The [pilot] was surprised to see that the attitude directional indicator (ADI) was indicating extreme nose-up pitch. A quick scan of other instruments showed that the airspeed was rapidly decreasing, and the vertical speed indicator was showing a descent. The pilot quickly took manual control of the aircraft; increasing the collective pitch and lowering the aircraft nose to recover from the unusual attitude. He succeeded, but afterwards was shaken by the event."

On April 17, 2007, flight simulations were conducted in a Level D full-motion simulator at the Augusta-Westland Training Academy, Sesto, Italy, utilizing the radar data from the accident flight. While the instrument displays in the simulator differed from the accident helicopter, the stabilization and autopilot systems were identical.

Four simulations were conducted, initiated from the same point at 145 knots at 5,000 feet, but each with different selection times for the autopilot modes (Heading, Altitude, Approach). A fifth simulation was conducted at a lower speed of 110 knots and with Approach (ILS) mode selected prior to reaching the localizer course.

During the first simulation, approach mode was selected as the helicopter passed through the localizer centerline. The autopilot captured the localizer, but the turn resulted in a wide overshoot. Later in the approach, the autopilot captured the glideslope, but the helicopter pitched 10 degrees nose-down, descended at 3,000 feet per minute, and reached the simulator's maximum airspeed of 183 knots. The simulation was stopped 950 feet above ground level.

During the fifth simulation, the approach mode was selected prior to localizer intercept. The autopilot captured and tracked both the localizer and glide slope, and automatically disengaged the heading and altitude modes.

During simulations 2, 3, and 4, the turns to intercept the localizer course were completed in heading mode, and approach mode was selected after completion of the turn. The autopilot captured the localizer, but not the glideslope. All three approaches resulted in a "slight" reduction in altitude, pitch up attitude of 10 to 30 degrees, slowing to below 30 knots, and finally a vertical descent.

The flight profile and vertical fall of the last phase of simulations 2, 3, and 4 were consistent with the accident flight and ultimate position of the wreckage, and coincided closely with the last radar sweep. At the end of simulation 3, the pilot recovered the helicopter and resumed controlled flight.

[gulliBell]

Ten AP computer changes in two years. That is eye-wateringly expensive.

[SASless]

Single Pilot IFR in a helicopter at night in bad weather is a tough chore.

Anything that goes wrong....no matter how slight....tremendously increases the difficulty.

Be it caused by the Aircraft, its systems, external causes, or self induced....it can lead to real problems.


Question: Why not route east out of Kane and get radar vectors to a straight in for the ILS 32 approach at Bradford?

We are not talking about a very long distance between the two places.

That would have made the process much simpler and provide a bit of time to get it all sorted out.

Knowing the crossing height at the LOM or OM combined with DME data and other information would have facilitated a better approach.

The GPS could be used to assist in Situational Awareness as well.

https://flightaware.com/resources/airport/BFD/IAP/ILS+OR+LOC+RWY+32/pdf

[212man]

Aren't they PAPIS rather than ILS antennas?

The ILS antennas are to the right of the first photo attached to the mast by the white hut. Yes, the other equipment looks like PAPIs

[[email protected]]

Devil49 - that crash report highlights exactly what I was trying to explain to Sasless - a 3-axis AP needs very good awareness and knowledge of how the system works if it is to be safely used in a high pressure SP IFR situation. It is too easy to presume that the 'automatic' capture for LOC and GS will work without intervention or monitoring.

[SASless]

Crab,

No explaining needed for me to understand....as I flew two types of aircraft with a three axis auto-pilot and if you remember my posts.

Also...recall I did not disagree with what you had to say....but did say it requires a pilot to fully understand how his particular aircraft responds to control inputs....either human or by avionic system.

That takes education, training, and practice.

As a Sim Instructor on the 212/412 and 76....I have observed many (far too many actually) well experienced working Pilots, single and two pilot crewing, fail to raise the Collective when performing a Missed Approach.

The usual warning clue was when there was no briefing or the Missed Approach part of the brief was omitted.

In my Sim....that guaranteed there would be a need to perform the Missed because I would disappear the airfield completely.

Sometimes in real life even....you have to declare a missed approach and go around....it helps to be prepared.

I somehow wonder if this might have been the cause of this latest 109 crash.

The symptoms are at DH (and if you are sneaking a bit) well below DH, the pilot decides to go around....either hits the GA Button and the aircraft pitches up, and without a proper Collective/Power addition or manually adjusts the pitch attitude and does not add power or enough power....the aircraft slows, the autopilot loses ability to control the machine and the Pilot is confronted with an unusual attitude, low and decreasing airspeed, and low power setting....and in this case in the dark and in cloud/fog perhaps. Usually it has a very bad outcome.

I taught an assertive response for a missed approach....as once taught back in the dark ages where we hand flew machines with basic instruments.....that being adding power first and to a predetermined power setting....adjusting the pitch attitude to a predetermined position and establishing Vbroc and climb rate. I also advocated flying the machine to 500 feet AGL before getting involved in collateral tasks.

[[email protected]]

I agree SAS - it's down to education, training and practice but since civil type rating is a very quick process compared to converting to a new type in the military and there often aren't the non-revenue hours to give the practice, is it any wonder that pilots don't really know their AP systems?

Having taught on the 365N3 (3-axis) and as a recent convert to the 412 (again 3-axis) I am very comfortable with using the AP but that is after 500 hours of instructing it on the N3.

Although helping the cyclic channel capture the GS by lowering the lever and assisting the go-around by raising it are what would be considered 'normal' helicopter control inputs (ie what tyou would do if you were flying it manually), it is the conflicting element of controlling IAS with collective on approach that I believe causes problems.

It is the 'half' level of automation that is dangerous - it lulls you into a false sense of security because the AP is doing the hard work for you (where you would otherwise be working quite hard, especially in difficult conditions) and there is the problem of under-arousal at a critical stage of flight ie not visual at DA/DH.

Add in fatigue and body clock issues and its just a question of when not if.

[ShyTorque]

Crab, I concur.

As I always say, VFR helicopter flying is relatively straightforward. IFR helicopter flying slightly less so. Changing from VFR to IFR or from IFR to VFR is the tricky bit and it still tends to catch some pilots out.

[212man]

Sometimes in real life even....you have to declare a missed approach and go around....it helps to be prepared.

Ideally, as airlines do, you fly the approach with a 'missed approach mentality' and seeing the lights is a bonus - that way you are not taken by surprise by not following the '6 Ps'.

Worse than flying a 3-axis AP, where ideally you should be familiar with its logic, is flying a 4-axis AP in 3-axis and jumping between the two. CHC showed us that in Sumburgh 6 years ago.

[Jack Carson]

I received a SPIFR qualifications in the B-230UT, A-109E and the EC-135P2/T2. All aircraft were equipped with 3 axis autopilots. Coupled ILS approaches were straight forward. As the glide slope was captured collective/power was set to achieve the desired approach speed. The specific autopilot installed by A109E (Duke Lifeflight) autopilot was an adaptation of a fixed wing unit. The A109E autopilot had a placarded limitation on the use of the take off/go around mode. Specifically, a placard limited the use to airspeeds greater than 120 KIAS. Attempted use at 70KIAS resulted in some very extreme attitude excursions. Has anyone one else experienced this?

[noooby]

I received a SPIFR qualifications in the B-230UT, A-109E and the EC-135P2/T2. All aircraft were equipped with 3 axis autopilots. Coupled ILS approaches were straight forward. As the glide slope was captured collective/power was set to achieve the desired approach speed. The specific autopilot installed by A109E (Duke Lifeflight) autopilot was an adaptation of a fixed wing unit. The A109E autopilot had a placarded limitation on the use of the take off/go around mode. Specifically, a placard limited the use to airspeeds greater than 120 KIAS. Attempted use at 70KIAS resulted in some very extreme attitude excursions. Has anyone one else experienced this?

As per the 109E RFM, they recommend you don't engage GA mode at less than 100 knots.

There are two different wiring versions and they do different things when GA is pushed. Only the later version has the above note. Not sure about the 109S but the E and S are nearly identical electrically.

[gulliBell]

My experience teaching in the simulator is very similar to SASless. Trainees just don't understand the flight director and autopilot systems sufficiently well to be competent at using it. A lot of trainees need to be talked through the instrument approach by the instructor, step-by-step. "Now push this button", "now watch for the...", "now is a good time to do the before landing checks" etc etc. If you don't tell them what to do and when, they simply get overwhelmed. Another common error is flying level at 200' DH waiting to get visual. They slow down. And slow down some more. The nose pitches up slowly at first, and then all of a sudden, big nose pitch up and crash. And these are not initial issue IR applicants, they are annual recurrent, command qualified. The average competency is very low.

[JimEli]

IMHO, the EMS SPIFR community is an accident waiting to happen. It’s hard to believe, in such a high workload environment with very little room for error, operators and the FAA do not demand overwhelming procedural standardization. Airlines have operated this way for years.

For example, an approach checklist from an EMS operator is approach-type generic, completely ignores use of automation, and lacks any specificity to actual installed avionics.

https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/282x172/approach_9573cb7decf128d995e1fb71f9ac7063c6f9567a.jpg

[gulliBell]

...and lacks any specificity to actual installed avionics.

I'm guessing many EMS operators simply don't have a standard common avionics fit in their fleet. They buy used aircraft that have whatever installed, and no two ships in the fleet are the same.

[rotorspeed]

Surely the fact that one needs to pull substantial power to go around at the bottom of an aborted ILS should be pretty obvious? Quite frankly if it’s not, a pilot should lose his IR until convincingly retrained. A 3 axis autopilot as on a 109 is not exactly basic hand flying on raw data.

I suggest IR proficiency checks should include the ability to uncouple and hand fly away if not visual at the bottom of an ILS. At least that would reinforce understanding of the basics. Surely many must agree?

[gulliBell]

Yes. A manually flown approach must also be demonstrated. Sometimes a manually flown approach is more successful than a coupled approach because there is less reliance on knowing what FD buttons to push, and when. Especially with a single engine missed approach, some trainees don't realize that the AP doesn't know whether one or two engines are working, leading to some interesting outcomes when the GA button is pushed.

[air pig]

I work on fixed wing air ambulance in the UK and look in sadness and horror at the number of crashes or major incidients in the rotary wing EMS community particulary in the US. Reading both professional journals and other sources, the number of people killed over recent years in these incidents I'm afraid and I maybe flamed here that sometimes that some companies financial imperative may outweigh good judgemnt and lead to inadvertant pressuring the flightcrews to make decisions that on other days in other places that they would not make. There is debate in the USA in some states at the moment about costs to patients for such flights either borne by the patients or their insurers.

https://abcnews.go.com/Health/doctor-56000-bill-air-ambulance-ride-accident-atv/story?id=58125900

https://www.latimes.com/business/la-fi-air-ambulance-cost-20180611-story.html

The statistics from what I can find are between 2010 to 16 there were 46 accidents/incidents in which 20 had fatalities involved and in that a total of 50 crew and patients died.

[JimEli]

I work on fixed wing air ambulance in the UK and look in sadness and horror at the number of crashes or major incidients in the rotary wing EMS community particulary in the US. Reading both professional journals and other sources, the number of people killed over recent years in these incidents I'm afraid and I maybe flamed here that sometimes that some companies financial imperative may outweigh good judgemnt and lead to inadvertant pressuring the flightcrews to make decisions that on other days in other places that they would not make.
...
The statistics from what I can find are between 2010 to 16 there were 46 accidents/incidents in which 20 had fatalities involved and in that a total of 50 crew and patients died.


I just completed a very quick review of all NTSB database EMS helicopter accidents for the period you stated. I found 2 accidents attributed to IIMC while either on the outbound leg for patient pickup, or with a patient onboard. The remaining IIMC accidents occurred returning to base. I believe the “management pressure into accepting flight” is ignorantly applied as the scapegoat blame.

[SASless]

The most intense pressure is self inflicted....based upon my experience flying EMS.

The Med Crews are generally Type A Personality kinds of folks....and far too many buy into the "We are Lifesavers who steal victims from the Grim Reaper...mentality." and even if unkowningly create an environment that can facilitate a Pilot making a bad call on weather.

Good weather....and plainly below minimums weather are easy calls.

It is the marginal weather that gets you in trouble.

Add in the fact that these spur of the moment SPIFR flights in the middle of the night do not allow for much time to prepare yourself.....as the "need" for a timely response is measured in mere minutes.

[gulliBell]

In this instance wasn't the aircraft returning to its home operating base? The environment and procedures should be 100% familiar to a home base crew, or maybe, familiarity caused a reduction in vigilance?

[SASless]

I cannot find any information about the flight details in any news article.

There is a graphic that shows the area of fog in the area that night.....with some clear areas surrounding the crash site but with dense fog at the crash site.

If they were operating in the clear areas and then returning to where the fog existed...that could have a bearing on the accident.

The Pilot for former US Army and at some point in his Army flying was assigned to flight duty on Sikorsky Blackhawks.

[Max Power 3503e]

Looks like no or limited power to the rotor system.

[helonorth]

https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20190628X64455&AKey=1&RType=Prelim&IType=FA