A109S Medevac Crash Brainerd Minnesota
 

Apparently N11NM.

Quote:

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Pilot, nurse killed in helicopter crash at Brainerd airport

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https://kstp.com/news/fatal-helicopter-crash-brainerd-airport/5406014/


https://cimg5.ibsrv.net/gimg/pprune....bbc106f31c.jpg

A weather observation from another media outlet.

Quote:

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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.

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https://www.kare11.com/article/news/...8-9e114faa9d08

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.

METAR KBRD
 

[code=left]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[/code]=left
[code=left]KBRD 281144Z AUTO 04005KT 2SM HZ OVC002 18/16 A3011 RMK AO2 T01830156[/code]=left
[code=left]KBRD 281120Z AUTO 05005KT 1SM HZ OVC002 18/16 A3010 RMK AO2 T01830156[/code]=left
[code=left]KBRD 281053Z AUTO 05006KT 3/4SM HZ OVC002 18/16 A3009 RMK AO2 SLP187 T01830156[/code]=left
[code=left]KBRD 281029Z AUTO 04005KT 1/4SM HZ VV002 18/16 A3008 RMK AO2 T01830156[/code]=left
[code=left]KBRD 281014Z AUTO 06005KT 1/2SM HZ VV002 18/16 A3008 RMK AO2 T01830156[/code]=left
[code=left]KBRD 281004Z AUTO 05005KT 1/4SM HZ VV002 19/16 A3008 RMK AO2 T01890156[/code]=left
[code=left]KBRD 280953Z AUTO 06004KT 1/2SM HZ OVC002 19/16 A3008 RMK AO2 SLP182 T01890156[/code]=left
[code=left]KBRD 280933Z AUTO 09003KT 1SM HZ OVC002 18/16 A3008 RMK AO2 T01830156[/code]=left
[code=left]KBRD 280925Z AUTO 00000KT 1 3/4SM HZ OVC003 19/16 A3008 RMK AO2 T01890161[/code]=left
[code=left]KBRD 280853Z AUTO 00000KT 8SM OVC003 19/16 A3009 RMK AO2 SLP184 T01890161 51004[/code]=left
[code=left]KBRD 280824Z AUTO 08005KT 3SM HZ OVC002 19/17 A3008 RMK AO2 T01940167[/code]=left
[code=left]KBRD 280815Z AUTO 09004KT 1 3/4SM HZ OVC002 19/17 A3008 RMK AO2 T01940167[/code]=left
[code=left]KBRD 280753Z AUTO 06004KT 2SM HZ OVC002 19/17 A3008 RMK AO2 SLP181 T01940167[/code]=left
[code=left]KBRD 280746Z AUTO 07004KT 2SM HZ OVC002 19/17 A3008 RMK AO2 T01940167[/code]=left
[code=left]KBRD 280738Z AUTO 06006KT 1 1/2SM HZ OVC002 19/17 A3009 RMK AO2 T01940167[/code]=left
[code=left]KBRD 280653Z AUTO VRB04KT 1/2SM HZ VV002 20/17 A3009 RMK AO2 SLP184 T02000172[/code]=left
[code=left]KBRD 280642Z AUTO 05005KT 1/2SM HZ VV002 20/17 A3008 RMK AO2 T02000172[/code]=left

Code:

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KBRD 280553Z AUTO 04003KT 1/4SM HZ VV002 19/17 A3007 RMK AO2 SLP181 60000 T01940167 10233 20178 402440178 50000

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=left
[code=left]KBRD 280518Z AUTO 05004KT 1/4SM HZ BKN002 19/16 A3008 RMK AO2 T01890161[/code]=left
[code=left]KBRD 280513Z AUTO 04003KT 1SM HZ BKN002 19/16 A3008 RMK AO2 VIS 1/4V5 T01890161[/code]=left
[code=left]KBRD 280510Z AUTO 03003KT 2SM HZ BKN002 19/16 A3008 RMK AO2 VIS 1V5 T01890161[/code]=left
[code=left]KBRD 280500Z AUTO 03003KT 1SM HZ VV002 19/17 A3008 RMK AO2 T01940167[/code]=left
[code=left]KBRD 280458Z AUTO 03003KT 1 3/4SM HZ FEW002 19/17 A3008 RMK AO2 T01940167[/code]=left
[code=left]KBRD 280453Z AUTO 03003KT 1 1/2SM HZ CLR 19/17 A3008 RMK AO2 SLP183 T01940167[/code]=left
[code=left]KBRD 280430Z AUTO 05004KT 1SM HZ CLR 19/16 A3008 RMK AO2 T01940161[/code]=left
[code=left]KBRD 280423Z AUTO 04004KT 1 1/2SM HZ FEW003 19/17 A3008 RMK AO2 T01940167[/code]=left
[code=left]KBRD 280416Z AUTO 03003KT 1SM HZ VV003 20/17 A3008 RMK AO2 T02000172[/code]=left
[code=left]KBRD 280413Z AUTO 00000KT 1 1/2SM HZ FEW003 20/17 A3008 RMK AO2 T02000172[/code]=left
[code=left]KBRD 280401Z AUTO 03003KT 1 3/4SM HZ CLR 19/16 A3008 RMK AO2 T01940161[/code]=left
[code=left]KBRD 280353Z AUTO 02003KT 9SM CLR 19/16 A3008 RMK AO2 RAE0254 SLP182 P0000 T01940161[/code]=left
[code=left]KBRD 280253Z AUTO 04004KT 10SM -RA FEW095 21/17 A3007 RMK AO2 RAB34 SLP180 P0000 60000 T02060172 53006[/code]=left
[code=left]KBRD 280153Z AUTO 08003KT 10SM SCT100 23/18 A3006 RMK AO2 RAB0057E12 SLP175 P0000 T02280178[/code]=left
[code=left]KBRD 280053Z AUTO 08004KT 10SM BKN110 23/18 A3005 RMK AO2 SLP171 T02280178[/code]=left
[code=left]KBRD 272353Z AUTO 07005KT 10SM SCT110 23/17 A3005 RMK AO2 RAE09 SLP173 P0000 6//// T02330172 10244 20222 56005[/code]=left
[code=left]KBRD 272253Z AUTO 05007KT 10SM -RA OVC110 23/18 A3006 RMK AO2 RAB00 SLP175 P0000 T02330183[/code]=left
[code=left]KBRD 272153Z AUTO 06006KT 10SM FEW044 SCT110 23/18 A3006 RMK AO2 SLP174 T02330178[/code]=left
[code=left]KBRD 272053Z AUTO 03004KT 10SM OVC041 24/17 A3007 RMK AO2 SLP178 6//// T02390172 51037[/code]

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.

Killer Fog!!!!?????

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

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.

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/...NVIS_final.pdf

The operator's website is interesting:

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

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.

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.

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


https://cimg3.ibsrv.net/gimg/pprune....7262fdc30d.jpg
https://cimg5.ibsrv.net/gimg/pprune....cb0f3b704d.jpg

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.

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

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

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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/publ...section_1.html

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:

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.

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.

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

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?

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

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.

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/...8-9e114faa9d08

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....f60197ff4c.png

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.

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.