witness who’d heard the crash the night before also resumed searching and found the wreckage lying inverted in 16 ft. of water just 1.2 nm from the departure heli- pad. The retractable landing gear was still extended. Divers recovered the bodies of all seven occupants. Bahamian authorities delegated the
investigation to the NTSB. Having found no evidence of equipment failure, the board determined the probable cause of the acci- dent to be “the pilots’ decision to take off over water in dark-night conditions with no external visual reference, which resulted in spatial disorientation and subsequent colli- sion with the water. Also causal was the pilots’ failure to adequately monitor their instruments and respond to multiple EGPWS warnings to arrest the helicopter’s descent.”
External pressure to complete the flight,
lack of night flying experience from the island, and inadequate crew resource man- agement were all cited as contributory.
Unanswered Questions Several aspects of the accident sequence remain difficult to explain. Especially puz- zling is why the pilot who was both less experienced and, by his own admission, uncomfortable flying at night took the con- trols to lift off into utter blackness, with no ground lights or visible horizon. It’s possible the PIC’s uneventful departure from Palm Beach, where the lights of the airport envi- ronment and the Florida coastline provided visual references for their climb to the 2,500-ft. cruising altitude logged in the flight data recorder, led him to underesti- mate the challenge posed by this departure. Before that, it’s not clear why two pilots consistently described as careful, compe- tent, and safety-conscious didn’t perform any kind of departure briefing or formally assign responsibilities as pilot flying versus pilot monitoring. Perhaps concern for the ailing passengers led them to hurry their preparations, or perhaps their long-standing comfort flying together made a briefing seem redundant. Family members and
colleagues interviewed by investigators agreed that they probably weren’t seriously fatigued.
Most baffling, though, is why the SIC
didn’t take the controls once he realized his partner was struggling, especially after his comment about the nearly identical British accident (which also involved an AW139). At that point, the helicopter was less than 200 ft. above the ocean, descending at a rate accelerating through 1,000 fpm. Disaster might still have been averted in the nine seconds that remained. Given their prior relationship as instructor and stu- dent, a sharp callout of “My controls!” would almost surely have triggered an immediate transfer of command.
The Takeaway Many accidents begin with flights that seem routine until they’re not, but some flight operations aren’t routine at any point and can’t be treated that way. A medical
evacuation requiring a black-night departure over the ocean is among the situations that combine an extremely narrow margin for error with the most severe consequences should anything go wrong. Regardless of weather, this is a pure
instrument flight and must be handled as such. With no established departure proce- dure from an off-airport site, the takeoff and climb to cruising altitude require detailed and specific planning. A hard check on the pilot’s current level of skill is also in order. Instrument flight requires regular recurrent training to main- tain proficiency. Year after year, about one- third of all pilots killed attempting VFR flight in low-visibility conditions already held instrument ratings. The two ailing passengers mightn’t have
been better off had they waited until morn- ing, but they certainly wouldn’t have fared any worse. Transporting patients to safety rests on safely transporting the patients.
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