Loss of Control in Flight: AgustaWestland AW139, N32CC; fatal accident occurred July 04, 2019 in Big Grand Cay, Bahamas

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities: 
Federal Aviation Administration Office of Accident Investigation; Washington, District of Columbia
Leonardo Helicopters; Cascina Costa
Pratt & Whitney Canada; Longueuil, Quebec 
Air Accident Investigation Department; Nassau New Providence
Transportation Safety Board of Canada; Ontario 
European Aviation Safety Agency; Cologne 
Agenzia Nazionale per la Sicurezza del Volo

Investigation Docket - National Transportation Safety Board:

https://dms.ntsb.gov/Docket

https://registry.faa.gov/N32CC

Location: Big Grand Cay 

Accident Number: ERA19FA210

Date and Time: July 4, 2019, 01:53 Local 

Registration: N32CC

Aircraft: Agusta AW139 

Aircraft Damage: Substantial

Defining Event: Loss of control in flight

Injuries: 7 Fatal

Flight Conducted Under: Part 91: General aviation - Personal

Analysis

The pilot-in-command (PIC) and second-in-command (SIC) were conducting a personal flight from the Bahamas to Fort Lauderdale, Florida, with five passengers onboard. The night flight was conducted under visual flight rules. About 2324 the day before the accident, the helicopter and company owner contacted the PIC, who was his friend and confidante, and told him that he needed him to conduct the

flight to transport his daughter and her friend from Big Grand Cay, Abaco, Bahamas, to the United States for medical treatment. About 20 minutes later, the PIC contacted the SIC telling him he needed him to conduct the flight with him.

The flight from Florida landed in Big Grand Cay at 0142. At 0145, the PIC filed an instrument flight rules flight plan, but it was not activated. While the flight crew was on the ground, the cockpit voice recorder (CVR) did not record them conducting a formal preflight instrument flight briefing. The flight crew’s pretakeoff conversation was limited to discussing flight plan information, including altitude, heading, and navigation; programming the flight computer; and the number of passengers expected on board. They did not discuss how to take off in night, visual meteorological conditions over water or their roles and responsibilities. The flight crew had a short discussion about the use of the flight controls and their automated functions during takeoff. Thus, their limited planning and communication for the takeoff from Big Grand Cay was indicative of inadequate crew resource management (CRM).

According to flight data recorder data, the helicopter departed about 0152. The helipad from which they departed was brightly lit with floodlights, but then the helicopter proceeded over water in dark night conditions with no visible moon, likely zero ambient illumination, and no visible horizon, which would necessitate the pilots’ reliance on the instruments in order to fly because of the very limited outside cues. After takeoff, the PIC, who was the pilot flying, manipulated the cyclic and antitorque control pedals, engaged the collective pitch trim, and began the helicopter’s first climb to about 190 ft. The cyclic force trim release (FTR) switch was engaged and remained engaged for the entire flight, indicating that the pilot was controlling the cyclic motion. Subsequently, the helicopter began to descend and the airspeed increased, all while the cyclic’s position continued to move forward to a more nose-down attitude. The first of numerous enhanced ground proximity warning system (EGPWS) warnings began and continued during the descent. About 0152:50, while at an altitude of about 110 ft descending about 1,380 ft per minute (fpm), one of the pilots engaged the autopilot in the altitude acquire (ALTA) mode with indicated airspeed hold, which set a vertical speed reference target of +1,000 fpm and an airspeed reference target of about 110 knots. Nearly simultaneous to the ALTA mode activation, the collective FTR switch was momentarily activated. Because the helicopter was descending at that time and the target altitude for ALTA was above the helicopter’s current altitude, the ALTA rate of climb was reset to +100 fpm (per system design), where it remained for the rest of the flight. Despite the repeated EGPWS warnings, the PIC continued commanding forward cyclic and the helicopter continued to descend.

About 0152:51, with the helicopter about 52 ft above the water, the PIC pulled the cyclic back and initiated a second climb. He then asked the SIC for the altitude, and, not receiving a response, stated that the helicopter was at 300 ft, and the SIC advised him that the helicopter was not at 300 ft and that it was "diving." It is likely that the PIC confused the vertical speed indication with the altitude indication, as the helicopter was at 116 ft radio altitude but was climbing about 300 fpm at the time. Subsequently, multiple EGPWS warnings annunciated until the helicopter climbed above 150 ft and the warnings stopped. Although the PIC and SIC each made comments during the remainder of the flight, there did was no apparent coordination or troubleshooting between them, further indicative of a lack of CRM.

When near the top of the climb, the collective pitch trim increased about 5% per second, with a corresponding increase in engine torque and power index (PI) values. After activation of ALTA mode, the PI levels began to increase to a point where the PI limiting function, as part of the flight director, began restricting collective movement, which prevented the ALTA mode from maintaining a positive vertical speed and climb to the set altitude. Because the PIC was manually controlling the cyclic, the flight director was unable to compensate for the high PI levels, such as reducing airspeed; thus, the flight director had to reduce collective to prevent a PI level exceedance. Given the lack of discussion about the negative vertical speed or any attempts by the PIC to manually manipulate the collective, it is likely neither pilot was adequately monitoring the vertical speed and altitude trends, which led to a loss of altitude.

About 0153:13, as the helicopter began to descend from 212 ft because the cyclic was moved forward again to command a nose-down attitude and the EGPWS warnings began to annunciate again, the SIC stated that “this is exactly what happened” in a fatal accident in the United Kingdom in which the accident was caused by somatogravic illusion and subsequent spatial disorientation. The PIC did not respond to the SIC, likely due to his continued confusion about the helicopter’s position in space and his misunderstanding of the information on the helicopter’s flight instruments. The helicopter then entered a left descending turn in a nose-down attitude with airspeed and engine torque increasing, significant forward cyclic being applied, the descent rate increasing, and EGPWS warnings continuing. The PIC repeatedly asked for a heading and once for altitude, but the SIC did not respond. As the helicopter continued descending toward the water, the flight crew did not communicate the helicopter’s attitude, energy state, and steps needed to recover from the descent. Given that postaccident examination indicated the helicopter’s flight instruments were operational (and they were operational for the flight to the Bahamas), they had information available to them to understand the helicopter’s flightpath. However, about 0153:22, the helicopter impacted water at high speed while in a nose-down, left-bank attitude.

As the pilot transitioned the helicopter to forward flight by commanding forward cyclic, the flight crew appeared initially unaware of the helicopter’s first descent until multiple EGPWS warnings annunciated. The PIC likely perceived that the accelerations associated with the helicopter’s increasing forward airspeed was the helicopter pitching up and he provided control inputs that caused the helicopter to descend. These improper control inputs during the second descent were consistent with the onset of a type of spatial disorientation known as somatogravic illusion, and the PIC likely did not effectively use his instrumentation during the departure to recognize the helicopter’s flightpath and orientation. The CVR indicated that the SIC recognized and announced the helicopter’s first descent to the PIC. In response, the PIC likely selected ALTA, which contributed to the recovery of the altitude lost from the first descent. However, the PIC continued to command forward cyclic (using the FTR switch), leading to the helicopter’s second descent. Again, numerous EGPWS warnings annunciated, but the PIC continued decreasing the helicopter’s pitch attitude while the airspeed and descent rate increased; these inputs were also consistent with spatial disorientation and a failure to rely on the helicopter’s instruments.

Based on the sequence of events and the flight crew’s actions and comments, they lost awareness of the helicopter's flightpath after takeoff over water during dark night conditions, which likely led to spatial disorientation and the subsequent collision with water.

The PIC’s night flight experience and instrument currency could not be determined. The SIC was reportedly night current but it could not be determined if he was night current in the helicopter make and model. Further, the PIC and the SIC had never flown to Big Grand Cay at night. Given both pilots’ many hours of flight experience, it is likely the PIC recognized the risk associated with the intended flight and contacted the SIC to make the flight with him. The PIC’s comfort flying with the SIC likely contributed to his decision to take the flight. Further, the urgency of the mission and the direct communication from the helicopter owner likely created external pressure on the flight crew, which can affect decision-making and create a sense of pressure to complete a flight. However, no records were found that the flight crew evaluated or planned for the impact of external pressure on their flights to and from Big Grand Cay in dark night conditions to transport ill passengers to a hospital. It is likely that they allowed the external pressure to affect their decision to conduct the flight even though neither of them had ever flown to Big Grand Cay at night.

Examination of the helicopter’s flight control system including autopilot system, structures, main and tail rotor system, and engines revealed no evidence of any preimpact mechanical failures or malfunctions that precluded normal operation. Although one of the four separated sections of tail rotor blades was not recovered, analysis of the recorded flight data as well as the CVR showed no evidence of anomalous operation of the tail rotor prior to impact. All observed damage was consistent with the helicopter’s impact with the water.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilots’ decision to takeoff over water in dark night conditions with no external visual reference, which resulted in spatial disorientation and subsequent collision 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. Contributing to the pilots’ decision was external pressure to complete the flight. Contributing to the accident was the pilots’ lack of night flying experience from the island and their inadequate crew resource management.

Findings

Personnel issues Decision making/judgment - Flight crew

Personnel issues Spatial disorientation - Flight crew

Personnel issues Monitoring equip/instruments - Flight crew

Aircraft (general) - Incorrect use/operation

Environmental issues (general) - Contributed to outcome

Personnel issues CRM/MRM techniques - Flight crew

Personnel issues (general) - Flight crew

Environmental issues Dark - Effect on operation

Factual Information

History of Flight

Initial climb Loss of control in flight (Defining event)

Other Miscellaneous/other

Uncontrolled descent Collision with terr/obj (non-CFIT)

On July 4, 2019, about 0154 eastern daylight time, an Agusta AW139, N32CC, owned and operated by Challenger Management LLC, was substantially damaged when it impacted the Atlantic Ocean near Big Grand Cay, Abaco, Bahamas. The commercial pilot, airline transport pilot rated copilot, and five passengers were fatally injured. The helicopter was being operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Night visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed for a flight from Walker's Cay Airport (MYAW), Walker's Cay, Bahamas, to Fort Lauderdale/Hollywood International Airport (FLL), Fort Lauderdale, Florida. The flight departed from a concrete pad at Big Grand Cay, which was located about 5 nautical miles (nm) southeast from MYAW, about 1 minute prior to the accident.

The purpose of the accident flight was to transport two of the passengers to FLL for medical treatment.

The helicopter departed from Palm Beach International Airport (PBI), West Palm Beach, Florida, about 0057, and a witness reported that it landed on the concrete pad at Big Grand Cay between 0130 and 0145. After landing, the helicopter remained on the ground with the engines operating, while the passengers boarded. During the subsequent takeoff to the east, the witness reported that the helicopter climbed to about 30 to 40 ft and accelerated while in a nose-down attitude. He did not notice anything unusual while he observed the helicopter depart.

Another witness, who was located about 1.6 nm southwest of the accident site reported seeing the helicopter lift off and climb to between 40 and 50 ft above ground level; then shortly thereafter, he noted blue and white lights spinning to the left at a rate of about 1 to 2 seconds between rotations while descending. He estimated that the helicopter rotated to the left three to four times. He then heard a "whoosh whoosh whoosh" sound, and lost sight of the helicopter, which was followed by the sound of an impact. The witness reported what he had heard to the "caregiver" of Big Grand Cay. The witness went out on his boat about 0205 and used spotlights to search the area where he thought the helicopter had crashed but was unable to locate it.

The Federal Aviation Administration issued an alert notice for the overdue flight about 1521. The helicopter was subsequently located by local residents sometime between 1600 and 1700, in about 16 ft of water about 1.2 nm north-northeast of the departure point.

The helicopter was found inverted and the tailboom was separated from the aft fuselage and was recovered in multiple pieces. All five main rotor blades were separated but recovered. The tail rotor assembly, which was also separated was subsequently recovered. All four tail rotor blades were separated, and one tail rotor blade was not recovered. The recovered wreckage was retained for further examination, to include examination of the airframe, engines, flight controls, seats and restraints.

The helicopter was equipped with a multi-purpose flight recorder, an enhanced ground proximity warning system and several additional components capable of storing non-volatile memory, which were retained for evaluation and data download.

The accident investigation was initially under the jurisdiction of the Air Accident Investigation Department (AAID) of the Bahamas. On July 6, 2019, in accordance with Annex 13 to the Convention on International Civil Aviation, the AAID requested delegation of the accident investigation to the NTSB, which the NTSB accepted on July 8, 2019. 

Aircraft and Owner/Operator Information

Aircraft Make: Agusta
Registration: N32CC
Model/Series: AW139 No Series
Aircraft Category: Helicopter
Amateur Built: No
Operator: Challenger Management LLC
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night/Dark
Observation Facility, Elevation: MYGF, 8 ft msl
Observation Time: 2000 EDT
Distance from Accident Site: 46 Nautical Miles
Temperature/Dew Point: 29°C / 25°C
Lowest Cloud Condition: Few / 2500 ft agl
Wind Speed/Gusts, Direction: 4 knots / , 160°
Lowest Ceiling: Broken / 25000 ft agl
Visibility:  10 Miles
Altimeter Setting: 29.95 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Big Grand Cay, FN

Destination: Fort Lauderdale, FL (FLL) 

Wreckage and Impact Information

Crew Injuries: 2 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 5 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 7 Fatal
Latitude, Longitude: 27.238056, -78.304444

Employees oversee the arrival of the bodies of four women and three men at the airport in Nassau, Bahamas.

David Jude

Geoffrey Painter

Killed in the July 4, 2019, crash off of Big Grand Cay in the Bahamas were Christopher Cline; his daughter, Kameron, 22; Brittney Searson, 21; Delaney Wykle, 23; Jillian Clark, 22; and pilots David Jude and Geoffrey Painter.

As two pilots prepared to land in the Bahamas in July 2019 on an emergency run to fly two sick newly graduated college students, two of their friends and the pilots’ billionaire boss to Fort Lauderdale, one remarked to the other: “I haven’t flown this thing in over a month until today.”

The co-pilot retorted “Bloody #,” a recently released National Transportation Safety Board transcript from the cockpit reveals. The transcript uses ”#” to replace expletives.

When the pilot, Jupiter resident David Jude, responds that the helicopter has been in “the # shop,” co-pilot Geoffrey Painter replies: “Has it? What’s been wrong with it?”

Jude’s answer would in retrospect prove unnerving: “Every # thing,” he said.

The pilots landed in the pre-dawn hours of July 4 on coal magnate Christopher Cline’s private Big Grand Cay in the Bahamas and soon set off on their medical run with five more passengers.

Within minutes, the 15-passenger Agusta SpA AW139 crashed, killing all seven onboard.

More than a year after the July 4, 2019, crash new details of the tragedy have emerged in National Transportation Safety Board reports released on Aug. 17.

Cline, 60, the self-made West Virginia coal billionaire whose homes included a mansion in northern Palm Beach County, had gathered with family members and their friends for a celebration of his July 5th birthday on his island in Abaco.

The chopper, piloted by Jude, 57, with co-pilot Painter, 52, went down in the ocean about one minute after taking off, records show. Their last utterance came at 1:53 a.m., nine seconds before the transcript stopped.

Besides Cline and the two pilots, on board were Cline’s daughter Kameron, 22; Brittney Searson, 21, her best friend and classmate at The Benjamin School in Palm Beach Gardens and at Louisiana State University, where they had graduated just two months earlier; Delaney Wykle, 23, a childhood friend of Kameron’s; and Jillian Clark, 22, another recent LSU graduate and fellow sorority member of Kameron’s.

About 15 to 20 family members and friends had been arriving on the island by helicopter, fishing yacht and seaplane, according to a witness statement given to investigators by Robert Hogan, Cline’s property manager on Big Grand Cay and his friend for 38 years.

People were playing chess, riding Sea-doos and playing music. They had dinner, and Hogan said he was present with everyone until 11 p.m.

Shortly after, Hogan said he was informed by a host that Kameron Cline and a friend had become ill. Hogan described the young women as “groggy and unresponsive,” and told investigators he was not sure of the cause.

Hogan said he also learned that Jude, one of Cline’s regular corporate pilots, was flying to the island to transport the two ill women, along with Cline and the other two passengers, to the United States for emergency medical attention.

The flight plan shows the helicopter having arrived from Walter’s Cay Airport in the Bahamas, and bound for Fort Lauderdale/Hollywood International Airport, where U.S. Customs was still open at that hour.

It landed on a helipad on Big Grand Cay between 1:30 a.m. and 1:45 a.m. and remained on the ground with the engines running, Hogan said. The passengers boarded and the two sick young women had to be helped onto the plane and strapped in.

Cline even brought a puppy dog with them.

‘Warning terrain. Warning terrain’

The chopper lifted off, turned right, climbed three to four stories high, and accelerated with its nose down over the west end of the island for the 30-40 minute flight to Fort Lauderdale, where authorities were alerted to have two ambulances waiting for Kameron and her friend.

According to Hogan and another witness, George Russell, who was on a dock with six other people, the takeoff appeared normal. But he told investigators that he then saw the chopper’s “lights moving funny, the lights went out, and he heard an impact.”

The cockpit voice recorder shows the pilot and co-pilot in discussion over routine pre-flight steps until Painter says at 1:52:30 a.m. “Alright airspeed coming up. No, it’s not coming up. So push that nose forward. Get some airspeed.

Within seconds the sounds of an electronic voice and a warning tone filled the cockpit.

Jude asks at 1:52:56, “How high are you and three seconds later answers his own question, “Three-hundred feet.”

Painter says, “We’re not” and Jude replies “That’s what it says over here.”

An electronic voice repeats “Warning terrain. Warning terrain.”

“Yeah, we were diving,” Painter says at 1:53:05.

Eight seconds later, he adds: “There was a fatal accident in the UK and this is exactly what happened there.”

Jude asks “Give us a heading” three times.

And then the human voices stop. The electronic voice keeps repeating “Warning terrain. Warning terrain.”

At 1:53:22, there’s the sound of an impulsive noise.

The electronic voice says “Bank angle. Bank angle.” And finally “Rotor low,” before recording stops at 1:53:28.

Something was amiss

Hogan said he went to bed that night, and arose at 6 the next morning and began his day as usual.

He said he began to realize something was amiss when he learned that the helicopter never made it back to the hangar where it was stationed at Palm Beach International Airport. Jude was supposed to fly Cline’s other son, Logan, to the island that day.

Hogan began calling the U.S. Coast Guard, hospitals and anyone else he could think of to see if anyone had heard from Cline. No one had. He asked the Coast Guard to begin a search.

Later that day, he learned that people on the island had heard a strange sound, like a thud, around the time the helicopter took off.

By early afternoon, a search team, including Cline’s chef and party planner, boarded a fishing boat and headed into the ocean where witnesses said they heard the strange sound.

They spotted the wreckage, the chopper’s wheels still extended, in an oily spot in the water. A diver spotted the bodies, still strapped to their seats.

They were removed from the wreckage and brought to shore where Hogan said he identified them.