Accident Cosby TN December 2021 NTSB Final Report
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Accident Cosby TN December 2021 NTSB Final Report
I’m sure there might be a previous thread regarding this accident(Mods please move this if an alternative thread exists)
Came across this today, the pilot seems to have made a complete mess of this entire episode (that resulted in a fatality) from start to finish.
buff.ly/3QP47OM
Location:
Cosby, Tennessee
Accident Number:
ERA22FA096
Date & Time:
December 29, 2021, 14:25 Local
Registration:
N544SC
Aircraft: ROBINSON HELICOPTER COMPANY R44 II
Aircraft Damage: Substantial
Defining Event: VFR encounter with IMC Injuries: 1 Fatal, 1 Serious
Flight Conducted Under: Part 91: General aviation - Personal
Analysis
The pilot was preparing for a cross-country flight in the newly-leased, non-instrument flight rules (IFR) equipped helicopter. Per the lease agreement, he flew in the local traffic pattern to assess the helicopter without incident. The weather reportedly deteriorated during the day, changing from marginal visual flight rules (VFR) conditions to IFR conditions. Local personnel warned him of the hazards of flying through the Smoky Mountains in such conditions; however, the pilot responded, “those are hills” and he had 14 years of mountain flying experience. The pilot subsequently took off with his passenger toward mountainous terrain.
On-board video captured most of the flight and all of the accident sequence, revealing that the pilot proceeded to the east, flying along valleys and roads, as the mountains ahead were obscured in low ceilings. The flight continued as the visibility eventually deteriorated to “zero” and the helicopter entered instrument meteorological conditions. The were no attempts to reverse course to get to better weather. The pilot eventually lost control of the helicopter and crashed into a tree line in a steep descent. The helicopter was substantially damaged, the pilot was seriously injured, and his passenger was fatally injured. The pilot would later report to law enforcement personnel that he remembered losing engine oil pressure and the main rotor began to make a loud noise, so he performed an autorotation; however, with the cloud cover, he could not see.
Postaccident examination of the airframe and engine revealed no evidence of a malfunction or anomaly that would have precluded normal operation. There was no evidence of a loss of engine oil or oil pressure. The on-board video did not support the pilot’s claims of an inflight loss of oil pressure or a main rotor malfunction, nor did it indicate that an autorotation was performed.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be: The pilot’s intentional, continued flight into instrument meteorological conditions in a helicopter that was not certified for instrument conditions, which resulted in a loss of helicopter control and a collision with trees and terrain.
Findings
Aircraft - Pitch control - Not attained/maintained
Aircraft Personnel issues - Lateral/bank control - Not attained/maintained Decision making/judgment - Pilot
Environmental issues - Obscuration - Contributed to outcome
Factual InformationHistory of Flight
Enroute - VFR encounter with IMC (Defining event)
Enroute - Loss of control in flight
Uncontrolled descent - Collision with terr/obj (non-CFIT)
On December 29, 2021, at 1425 eastern standard time, a Robinson Helicopter Company R-44 II, N544SC, was substantially damaged when it was involved in an accident near Cosby, Tennessee. The commercial pilot received serious injuries and the passenger was fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.
According to personnel at Gatlinburg-Pigeon Forge Airport (GKT), Sevierville, Tennessee, the pilot and passenger traveled from Utah to pick up the helicopter after leasing it from the owner. They arrived at the service center where the helicopter had been stored about 0830 on the day of the accident. The pilot reviewed the lease agreement and conducted a local flight around the GKT airport traffic pattern to assess the helicopter per the lease agreement.
According to personnel at the service center, “the weather throughout the day was changing from marginal VFR conditions to IFR conditions.” The pilot had conversations with the service center employees about leaving the area but was cautioned by all of them he spoke with about the dangers of flying in the Smoky Mountains in marginal weather. One person showed him a book in their training room filled with controlled flight into terrain (CFIT) accidents that occurred in the area. The pilot’s response was “those are hills,” and informed him he had 14 years of experience of mountain flying. Additionally, a local helicopter air ambulance pilot who worked on the airport met the pilot and asked about his intentions. The pilot stated he planned on departing towards Asheville and was going to follow Interstate 40 (I-40) through the gorge to Raleigh, North Carolina, where he would visit relatives before heading back west. The other helicopter pilot told him that the mountains east of GKT were 6,000 ft and “there was no way he would make it there.” He also stated there were powerlines above the I-40 gorge.
About 1413, the pilot and passenger departed GKT eastbound. Federal Aviation Administration radar data showed the helicopter flying through the valleys in an easterly/southeasterly direction at altitudes between 1,200 ft and 1,750 ft. The data was not continuous along the route.
A GoPro video camera was mounted inside the cockpit and was recording during the flight. The camera and its memory card were forwarded to the National Transportation Safety Board Vehicle Recorders Laboratory for examination and analysis.
Automatic dependent surveillance-broadcast (ADS-B) data for the flight began about ˝ nm east of the departure end of runway 10, at 1413:20. The video began at 1414:54, when the helicopter was already in flight. When the video began, there was rising terrain ahead of the helicopter, portions of which contained mountain top obscuration. The cloud layer appeared broken at the helicopter’s current position, with thickening ahead of the helicopter and up along the horizon.
As the helicopter approached an area of low visibility and rising terrain, the helicopter continued in a gradual ascent. At 1424:34, the visibility started to greatly decrease. The helicopter’s groundspeed (and indicated airspeed) at first showed a decreasing trend. By 1424:48, the manifold pressure was reduced and the groundspeed and indicated airspeed decreased and reached a minimum of less than 20 knots.
As the indicated airspeed reached a minimum, manifold pressure increased, the helicopter pitched forward, and airspeed increased slightly. Visible landmarks under the helicopter suggested it again had a forward component of speed. As the helicopter continued to fly forward, visibility decreased even further, eventually to “zero” at 1425:07. About the time this occurred, the manifold pressure went through the red arc range to a maximum of about 27 inHg (beyond the red arc range). The helicopter then pitched forward and airspeed rapidly increased to about 85 knots. During this time, the manifold pressure indicated steadily above the red arc (above 27 inHg). The helicopter then appeared to yaw rapidly to the right, the airspeed suddenly displayed “zero” knots, and the altitude decreased. The low rotor rpm warning light and aural warning alerted.
The helicopter emerged from the cloud layer, first in a right roll and right yaw condition that quickly reversed to a left roll and left yaw condition. The helicopter then descended rapidly into a tree line, impacting the tops of the trees in a left yaw and level roll condition. As the helicopter descended into the tree line, the main rotor blades struck tree branches and tree trunks. Reflections in the windshield suggested the low rotor rpm light (yellow), and the low engine oil pressure light (red) illuminated during impact. The helicopter came to rest amongst the trees at ground level.
There was no evidence in the recording that suggested that there were preimpact mechanical malfunctions or failures that would have precluded normal operation prior to the helicopter entering an extremely low visibility condition.
Local law enforcement personnel interviewed the pilot after the accident. He stated that he did recall the accident. He further stated that he remembered losing oil pressure and the main rotor began to make a loud noise, so he performed an autorotation; however, with the cloud cover, he could not see.
Came across this today, the pilot seems to have made a complete mess of this entire episode (that resulted in a fatality) from start to finish.
buff.ly/3QP47OM
Cosby, Tennessee
Accident Number:
ERA22FA096
Date & Time:
December 29, 2021, 14:25 Local
Registration:
N544SC
Aircraft: ROBINSON HELICOPTER COMPANY R44 II
Aircraft Damage: Substantial
Defining Event: VFR encounter with IMC Injuries: 1 Fatal, 1 Serious
Flight Conducted Under: Part 91: General aviation - Personal
Analysis
The pilot was preparing for a cross-country flight in the newly-leased, non-instrument flight rules (IFR) equipped helicopter. Per the lease agreement, he flew in the local traffic pattern to assess the helicopter without incident. The weather reportedly deteriorated during the day, changing from marginal visual flight rules (VFR) conditions to IFR conditions. Local personnel warned him of the hazards of flying through the Smoky Mountains in such conditions; however, the pilot responded, “those are hills” and he had 14 years of mountain flying experience. The pilot subsequently took off with his passenger toward mountainous terrain.
On-board video captured most of the flight and all of the accident sequence, revealing that the pilot proceeded to the east, flying along valleys and roads, as the mountains ahead were obscured in low ceilings. The flight continued as the visibility eventually deteriorated to “zero” and the helicopter entered instrument meteorological conditions. The were no attempts to reverse course to get to better weather. The pilot eventually lost control of the helicopter and crashed into a tree line in a steep descent. The helicopter was substantially damaged, the pilot was seriously injured, and his passenger was fatally injured. The pilot would later report to law enforcement personnel that he remembered losing engine oil pressure and the main rotor began to make a loud noise, so he performed an autorotation; however, with the cloud cover, he could not see.
Postaccident examination of the airframe and engine revealed no evidence of a malfunction or anomaly that would have precluded normal operation. There was no evidence of a loss of engine oil or oil pressure. The on-board video did not support the pilot’s claims of an inflight loss of oil pressure or a main rotor malfunction, nor did it indicate that an autorotation was performed.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be: The pilot’s intentional, continued flight into instrument meteorological conditions in a helicopter that was not certified for instrument conditions, which resulted in a loss of helicopter control and a collision with trees and terrain.
Findings
Aircraft - Pitch control - Not attained/maintained
Aircraft Personnel issues - Lateral/bank control - Not attained/maintained Decision making/judgment - Pilot
Environmental issues - Obscuration - Contributed to outcome
Factual InformationHistory of Flight
Enroute - VFR encounter with IMC (Defining event)
Enroute - Loss of control in flight
Uncontrolled descent - Collision with terr/obj (non-CFIT)
On December 29, 2021, at 1425 eastern standard time, a Robinson Helicopter Company R-44 II, N544SC, was substantially damaged when it was involved in an accident near Cosby, Tennessee. The commercial pilot received serious injuries and the passenger was fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.
According to personnel at Gatlinburg-Pigeon Forge Airport (GKT), Sevierville, Tennessee, the pilot and passenger traveled from Utah to pick up the helicopter after leasing it from the owner. They arrived at the service center where the helicopter had been stored about 0830 on the day of the accident. The pilot reviewed the lease agreement and conducted a local flight around the GKT airport traffic pattern to assess the helicopter per the lease agreement.
According to personnel at the service center, “the weather throughout the day was changing from marginal VFR conditions to IFR conditions.” The pilot had conversations with the service center employees about leaving the area but was cautioned by all of them he spoke with about the dangers of flying in the Smoky Mountains in marginal weather. One person showed him a book in their training room filled with controlled flight into terrain (CFIT) accidents that occurred in the area. The pilot’s response was “those are hills,” and informed him he had 14 years of experience of mountain flying. Additionally, a local helicopter air ambulance pilot who worked on the airport met the pilot and asked about his intentions. The pilot stated he planned on departing towards Asheville and was going to follow Interstate 40 (I-40) through the gorge to Raleigh, North Carolina, where he would visit relatives before heading back west. The other helicopter pilot told him that the mountains east of GKT were 6,000 ft and “there was no way he would make it there.” He also stated there were powerlines above the I-40 gorge.
About 1413, the pilot and passenger departed GKT eastbound. Federal Aviation Administration radar data showed the helicopter flying through the valleys in an easterly/southeasterly direction at altitudes between 1,200 ft and 1,750 ft. The data was not continuous along the route.
A GoPro video camera was mounted inside the cockpit and was recording during the flight. The camera and its memory card were forwarded to the National Transportation Safety Board Vehicle Recorders Laboratory for examination and analysis.
Automatic dependent surveillance-broadcast (ADS-B) data for the flight began about ˝ nm east of the departure end of runway 10, at 1413:20. The video began at 1414:54, when the helicopter was already in flight. When the video began, there was rising terrain ahead of the helicopter, portions of which contained mountain top obscuration. The cloud layer appeared broken at the helicopter’s current position, with thickening ahead of the helicopter and up along the horizon.
As the helicopter approached an area of low visibility and rising terrain, the helicopter continued in a gradual ascent. At 1424:34, the visibility started to greatly decrease. The helicopter’s groundspeed (and indicated airspeed) at first showed a decreasing trend. By 1424:48, the manifold pressure was reduced and the groundspeed and indicated airspeed decreased and reached a minimum of less than 20 knots.
As the indicated airspeed reached a minimum, manifold pressure increased, the helicopter pitched forward, and airspeed increased slightly. Visible landmarks under the helicopter suggested it again had a forward component of speed. As the helicopter continued to fly forward, visibility decreased even further, eventually to “zero” at 1425:07. About the time this occurred, the manifold pressure went through the red arc range to a maximum of about 27 inHg (beyond the red arc range). The helicopter then pitched forward and airspeed rapidly increased to about 85 knots. During this time, the manifold pressure indicated steadily above the red arc (above 27 inHg). The helicopter then appeared to yaw rapidly to the right, the airspeed suddenly displayed “zero” knots, and the altitude decreased. The low rotor rpm warning light and aural warning alerted.
The helicopter emerged from the cloud layer, first in a right roll and right yaw condition that quickly reversed to a left roll and left yaw condition. The helicopter then descended rapidly into a tree line, impacting the tops of the trees in a left yaw and level roll condition. As the helicopter descended into the tree line, the main rotor blades struck tree branches and tree trunks. Reflections in the windshield suggested the low rotor rpm light (yellow), and the low engine oil pressure light (red) illuminated during impact. The helicopter came to rest amongst the trees at ground level.
There was no evidence in the recording that suggested that there were preimpact mechanical malfunctions or failures that would have precluded normal operation prior to the helicopter entering an extremely low visibility condition.
Local law enforcement personnel interviewed the pilot after the accident. He stated that he did recall the accident. He further stated that he remembered losing oil pressure and the main rotor began to make a loud noise, so he performed an autorotation; however, with the cloud cover, he could not see.
He was right....those were hills.....but as he picked up Interstate 40 heading east there be mountains there.....one of them known as Grandfather Mountain is the tallest on the east coast and is above 6,000 feet elevation.
The I-40 highway winds itself through what is known as "The Gorge"....really narrow, twisty, and flanked by mountains...not hills. It is treacherous to drive through by ;automobile due to the many curves and frequent rock slides that sometimes close the roadway for weeks.
It is about 25-30 miles of curves, wires, and challenging flying in decent weather if you are down low.
How many people with lots of experience and plenty of local knowledge tried to convince the fellow not to try it. The hard head has to live with knowing he killed his companion that day out of pure stupidity.
The I-40 highway winds itself through what is known as "The Gorge"....really narrow, twisty, and flanked by mountains...not hills. It is treacherous to drive through by ;automobile due to the many curves and frequent rock slides that sometimes close the roadway for weeks.
It is about 25-30 miles of curves, wires, and challenging flying in decent weather if you are down low.
How many people with lots of experience and plenty of local knowledge tried to convince the fellow not to try it. The hard head has to live with knowing he killed his companion that day out of pure stupidity.
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But he had 14 years of mountain experience!
With that much 'experience' he should have known there is more to mountain flying than the size of the hills and he really should have known to listen to the locals.
With that much 'experience' he should have known there is more to mountain flying than the size of the hills and he really should have known to listen to the locals.
