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NTSB Preliminary Report: Brainerd, MN

 

Location:

Brainerd, MN

Accident Number:

CEN19FA185

Date & Time:

06/28/20190041 CDT

Registration:

N11NM

Aircraft:

AGUSTA A109

Injuries:

2 Fatal, 1 Serious

Flight Conducted Under:

Part 135: Air Taxi & Commuter - Non-scheduled - Air Medical (Discretionary)

On June 28, 2019, about 0041 central daylight time, an Agusta Spa A109S helicopter, N11NM, impacted terrain while landing at Brainerd Lakes Regional Airport (BRD), Brainerd Lakes, Minnesota. The pilot and flight nurse were fatally injured, the flight paramedic was seriously injured, and the helicopter sustained substantial damage. The helicopter was registered to and operated by North Memorial Healthcare under the provisions of Title 14 Code of Federal Regulations Part 135. Instrument meteorological conditions prevailed at BRD for the instrument flight rules (IFR) flight, which departed from North Memorial Heliport (MY77), Robbinsdale, Minnesota, about 2348.

The helicopter was returning to BRD after delivering a patient to MY77. Following descent from a cruise altitude of 6,000 ft mean sea level, the pilot flew the ILS Runway 23 approach at BRD. According to the flight paramedic, who was seated in the left forward seat, the runway surface and lights were visible below a thin fog layer during the approach to landing. He noticed a few clouds to the side of the helicopter and recalled the pilot remarking that the weather conditions were foggy, and they would need to go-around. He subsequently noticed the helicopter spin to the right and impact the ground.

The helicopter impacted a grassy area to the left of Runway 23 and came to rest on a heading of 074 degrees. The main fuselage and tail boom exhibited crushing consistent with a high velocity vertical descent. The helicopter was upright and nearly intact, with no movement from the initial impact point. There was no evidence of a postcrash fire.

A portion of the ground was soaked of fuel and the smell of fuel was present at the accident site. The transmission deck exhibited a downward deformation leading to fracturing of drive train connections between the engines to the main transmission and from the combining gearbox's tail rotor output drive to the tail rotor drive train.

All four main rotor blades were attached to the main rotor head. One main rotor blade exhibited separation of its tip and portions of its afterbody. The remaining three main rotor blades exhibited cracks on their skins but were otherwise whole. An arc-shaped ground scar, consistent with a main rotor blade strike, was found to the left of the fuselage. One of the two tail rotor blades remained attached to the tail rotor hub. The inboard section of the second tail rotor blade remained attached to the hub, and the remaining outboard section was found about 211 feet to the southwest of the helicopter. A 7-inch deep ground scar was located underneath the tail rotor and exhibited evidence of multiple tail rotor blade strikes.

The first stage compressor blades for both engines did not exhibit evidence of foreign object debris ingestion. Both first stage compressors were able to be rotated freely by hand. All power turbine blades for both engines were present. Both power turbines were able to be rotated freely by hand, resulting in rotation each of the engines output diaphragm coupling.

An Appareo Vision 1000 cockpit image recording device, engine data collection units, data acquisition unit, Outerlink satellite communications unit, and HeliTAWS unit were recovered from the wreckage and transported to the NTSB in Washington, DC for examination and download. The wreckage was recovered for postaccident examination.

Aircraft and Owner/Operator Information

Aircraft Make:

AGUSTA

Registration:

N11NM

Model/Series:

A109 S

Aircraft Category:

Helicopter

Amateur Built:

No

 

 

Operator:

North Memorial Healthcare

Operating Certificate(s) Held:

On-demand Air Taxi (135)

Operator Does Business As:

 

Operator Designator Code:

S6GA

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Instrument Conditions

Condition of Light:

Night

Observation Facility, Elevation:

KBRD, 1221 ft msl

Observation Time:

0018 CDT

Distance from Accident Site:

0 Nautical Miles

Temperature/Dew Point:

19°C / 16°C

Lowest Cloud Condition:

 

Wind Speed/Gusts, Direction:

4 knots / 50°

Lowest Ceiling:

Broken / 200 ft agl

Visibility

0.25 Miles

Altimeter Setting:

30.08 inches Hg

Type of Flight Plan Filed:

IFR

Departure Point:

Robbinsdale, MN (MY77)

Destination:

Brainerd, MN (BRD)

 

Wreckage and Impact Information

Crew Injuries:

2 Fatal, 1 Serious

Aircraft Damage:

Substantial

Passenger Injuries:

N/A

Aircraft Fire:

None

Ground Injuries:

N/A

Aircraft Explosion:

None

Total Injuries:

2 Fatal, 1 Serious

Latitude, Longitude:

46.403333, -94.128333

 

Administrative Information

Investigator In Charge (IIC):

Michael J Folkerts

Additional Participating Persons:

Edward Martin; Flight Standards District Office; Minneapolis, MN

Scott Tyrrell; FAA Rotorcraft Directorate; Fort Worth, TX

Joshua Jones; North Memorial Health; Crystal, MN

Marc Hamilton; Transportation Safety Board of Canada; Ottawa, ON

Mikael Amura; Italian Civil Aviation Authority; San Marino, FN

Note:

The NTSB traveled to the scene of this accident.






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