NTSB Illuminates Pilot Performance in AW139 Fatal

 - August 25, 2020, 11:16 AM
The NTSB has reported on a July 4, 2019 fatal accident involving a private medical evacuation flight from the Bahamas to Fort Lauderdale in Florida.

The NTSB's recently released accident docket of the July 4, 2019, Leonardo AW139 crash in the Bahamas points to pilot performance and lack of situational awareness. However, the NTSB has yet to issue a final report or conclude a probable cause of the accident.  

According to the NTSB, the AW139 crashed shortly after lifting off from a private helipad in the Bahamas shortly before 2 a.m. on a private medical evacuation flight to Fort Lauderdale, killing the pilots and five passengers. The NTSB’s performance study indicates that one minute and two seconds into the flight, the helicopter hit the water at a speed of 141 knots.

The study concludes: “While longitudinal input was not initially different from the prior 10 flights, the combination of high collective input and increasingly forward longitudinal cyclic inputs lead to significant nose-down attitudes during the flight that led to losses of altitude. A calculation of apparent pitch showed that it was possible for the pilots to have misinterpreted the helicopter’s nose-down attitude to be nose up for the entirety of the flight.” 

Other documents contained in the docket, including the transcript from the cockpit voice recorder (CVR) and human factors report, fashion a mosaic of two pilots with marginal training performance, still unfamiliar with key systems of their aircraft, and a lack of crew resource management. The accident PIC was faulted for a basic lack of skills and knowledge during initial and recurrent training in 2017 and 2018. During 2018 recurrent training, “progressive training/checking was halted and changed to traditional 61.58 training due to the applicant not reaching the required proficiency and failed more items than required.”

Meanwhile, during the SIC’s initial training, instructors noted that he struggled with the FMS and had crew resource management “issues;” could be “overwhelmed” with weather, ATC, and flying; and did not always use a checklist, which led to “momentary loss of situational awareness during the flight.” Similar to the PIC’s 2018 recurrent training, the SIC’s training reverted to 61.58 due to failures. He also scored below average for Category A takeoffs and use of the flight director. His instructor noted, “The SIC was not trained or he received substandard initial training for all the maneuvers he failed.” Additional training led to a proficiency check pass. 

Before the accident, the PIC and the SIC had flown together 14 times between November 2017 and February 2019. Ten of those flights were daylight, the other four could not be determined. On all flights, the PIC was always the pilot flying. 

Twenty-three seconds before impact, the PIC appears to recognize and momentarily recover from pitch down attitude, acknowledging, "Yeah, we were diving," before reinitiating it. Fifteen seconds before impact, against the background of multiple electronic voice terrain warning alerts, the SIC remarked, “There was a fatal accident in the UK and this is exactly what happened there.”