Agusta A109 N11NM

Summary

On 28 June 2019 at about 05:40 local time, a Agusta A109 registered N11NM, operated by North Memorial Healthcare, was involved in an accident near Brainerd, Minnesota, United States. 3 people were on board and 2 died, one was seriously injured. The aircraft was substantially damaged. The NTSB has published a probable cause for this accident; it is quoted in full below.

Date

28 June 2019 at 05:40

Classification

Accident

Location

Brainerd, Minnesota, United States

Nearest airport

Brainerd Lakes Rgnl (BRD)

Coordinates

46.4033, -94.1283

Aircraft

Agusta A109

Registration

N11NM

Category

Helicopter

Year built

2008

Engines

2

Operator

North Memorial Healthcare

Operating rule

Part 135: Air Taxi & Commuter

Phase of flight

Not recorded

Route

Robbinsdale → Brainerd

Aircraft damage

Substantial

Weather

IMC

Light

Night/Dark

NTSB number

CEN19FA185

2 people died.

The pilot's spatial disorientation during an instrument approach in dark night instrument meteorological conditions, which resulted in a loss of control and subsequent impact with terrain.

Quoted verbatim from the NTSB record. This site does not paraphrase or interpret it.

Read the full NTSB narrative

The crew of the helicopter air ambulance flight was approaching the airport for landing in dark night instrument meteorological conditions (IMC) after delivering a patient to the hospital. The reported weather conditions about the time the pilot initiated the instrument landing system (ILS) approach included 1/2-mile visibility with haze, which then deteriorated to 1/4 mile, which was within the operator's approved visibility approach minimums. The paramedic onboard reported that he saw the runway environment through a thin layer of fog as the helicopter descended toward the decision height (DH) of 200 ft above ground level during the approach. After descending below the DH, with a power setting below 30% torque, the helicopter's pitch attitude increased from -3° (nose-down) to +20° (nose-up), its airspeed decreased from 100 to 50 knots, and the pilot declared a missed approach, likely due to a loss of visual contact with the runway environment. The pilot's increased collective input and the helicopter's decreasing airspeed resulted in an increase in torque, and the helicopter entered a right rotational yaw that accelerated into a spin. The helicopter subsequently impacted terrain near the runway. The dark night conditions at the rural airport resulted in little to no visual references during the pilot's transition to landing and the attempted missed approach. It is likely that the pilot became spatially disoriented, which led to the excessive pitch attitude, slow airspeed, his failure to recognize and arrest the right yaw, and the subsequent loss of control.

Quoted verbatim from the NTSB record.