Dark Night Flight Into Terrain, Part 2

Altimeter from the UH-1H crash. Photo credit: NTSB

In Part 1, we discussed the circumstances surrounding the crash of a Bell UH-1H in New Mexico.

The 57-year-old pilot was employed by Sapphire Aviation in September 2017, just four months before the accident. He had been a law enforcement pilot for the California Highway Patrol for 20 years, then a helicopter maintenance test pilot and a utility pilot until he was hired at Sapphire. He graduated from U.S. Army Warrant Officer Helicopter Flight School in 1984 and had served in the U.S. Army Reserve flying the UH-1.

The pilot had a commercial helicopter certificate with an instrument rating and a night vision goggle (NVG) endorsement. His last flight check was an FAR Part 135.293 and Part 135.299 annual check flown in a Bell 206 and MD 500 in September 2016. On his Sapphire employment application, he had meticulously listed his flight time on nine different helicopter types, including 2,065 hr. in the UH-1. He showed a total of 8,613 flight hours in turbine rotary-wing aircraft.

The pilot had logged 56 hr. in the last 12 months, and 3 hr. in the last 90 days, all in the UH-1. His most-recent FAA medical exam, a Class II, was accomplished just a month before the accident. He needed to use corrective lenses while flying.

He reported having had one accident, in 2007--a crosswind tailwheel airplane landing gone wrong. However, the rest of his record was spotless. According to an obituary in the Auburn (California) Journal, the pilot had been a chief warrant officer 4 who flew missions in Central and South America, and he flew many rescue missions in extreme conditions. He was the 2005 winner of the Jeep Hero Award and donated his prize to a homeless organization. He was also in the Hall of Fame at the New Mexico Military institute.

A post-accident toxicology test showed that the pilot had a relatively low, but therapeutic, level of Benadryl (diphenhydramine) in his blood. Benadryl is one of the over-the-counter drugs the FAA restricts because it induces drowsiness.

Seated in the left seat of the helicopter was a pilot-rated passenger, the head of Sapphire. He was 67 years old and also had been through army warrant officer flight school. He flew Cobra gunships in Vietnam, then spent 33 years with the Pasadena, Texas, police department, rising to the rank of chief of police. After retiring from his police job, he spent 13 years as a system and operations manager at a Texas university.

Sapphire hired the pilot-passenger in January 2017 and he listed experience in 10 different helicopter types on his employment application. He had a commercial rotorcraft certificate and a Class II medical certificate specifying he must wear corrective lenses. His total flight time was 3,140 hr. He had only flown 20 hr. in the 12 months before he began work at Sapphire. His flight time in the year prior to the accident was unknown.

Apparently the two pilots performed a variety of tasks for Sapphire’s owner. Both were listed as working at a shooting center in the Houston area, but the accident pilot lived in Trinidad, Colorado, and performed maintenance duties. He serviced the helicopter, but he also serviced and repaired vehicles. A charge card invoice showed he installed a GPS and cellphone booster on a Hummer vehicle.

The Passengers

Besides the pilots in the two front seats, there were four passengers aboard the flight. One couple were long-time residents of Zimbabwe, where the man had been a prominent political opponent of the Mugabe regime. The other two passengers were the owner of the ranch and his girlfriend, who was also the daughter of the pilot-passenger.

The owner of the ranch was Charles Ryland Burnett III. He was also the owner of Sapphire Aviation, the operator of both the Hawker 800 and the UH-1. He had owned the jet since 2013, but purchased the ranch and helicopter in February 2017.

According to the Daily Mail, Burnett was heir to the family interest in British retailers Selfridges, Fortnum & Mason, and Primark. He owned a Georgian mansion in England that had a private airstrip with separate hangars for cars, boats and airplanes. He was gregarious and formed friendships with people all over the world, and he made large donations to many charities.

Thinking About Possible Causal Factors

I see two areas of analysis to this case, one objective and the other interpersonal.

The pilot was highly experienced flying Hueys and other helicopters in all kinds of hazardous conditions, but he was new to the operation. He had taken Benadryl, a common sedating sleep aid, sometime in the two days before the accident, and the level in his bloodstream was enough to affect his alertness. He was familiar with the general area, but not the terrain from Raton to the ranch.

Flying toward an upslope creates the illusion of being on a steeper than actual flight path. The “black hole” effect removes visual cues. Experienced pilots fly lower than inexperienced pilots in night visual conditions, according to a 2008 study. All of these factors could have contributed to the accident.

The fact that the two altimeters found in the wreckage differed in their altimeter setting and differed from the Raton-reported setting indicates the two pilots did not communicate systematically. The pilot-passenger had just arrived from Houston and was probably not involved in preflight planning. They probably did not run a before-takeoff checklist.

The fact that the pilot headed southeast and climbed only a few hundred feet after takeoff indicated he had not carefully examined a sectional or terrain chart and that he intended to navigate by reference to the ground and avoid obstacles by visual means.

The pilot was trained to use night vision goggles but did not use them on the flight.

The helicopter was equipped with expensive, late-model avionics that would have supported clear graphic terrain representations and terrain warnings, but the pilots apparently paid them no heed. In the 56 hr. the pilot had flown the Huey since it was purchased, he may not have become very familiar with the avionics. His last flight check was in 2016. There was no record of him receiving formal training in the use of the avionics. This is another indication that he reverted to his customary method of night flying--visual contact.

All of these objective factors point to poor planning and overconfidence on the pilot’s part.

The interpersonal factors are harder to establish. Investigators provided a hint when they classified the flight as a “personal” Part 91 flight. Normally, a professionally flown flight is classified as an executive/business flight.

The ranch owner was described by people who knew him as both determined to get his way and as sweet and kind, and never having overridden any expert advice in 30 years. The pilots and passengers were friendly and looking forward to celebrating a birthday.

The owner had acquired the helicopter and the ranch and employed the pilot at about the same time. His goal of using them all was obvious.

When the pilot took off into dark night conditions under visual flight rules, he must have known this was a hazardous course of action. He likely did not want to disappoint the passengers. Even if the owner did not express any direct desire to fly that flight, there was an unspoken commitment to go.

The interpersonal factors suggest the pilot was reluctant to cancel the flight when his judgment probably told him he should.

As new private fliers move into aircraft charter and ownership, they should be aware of the influence they have on their crews. Crews take cues from the client. Former police and military pilots are especially mission oriented. Establishing some firm ground rules about no-go conditions is important. It’s wise to get some expert outside help doing that and to put it in writing. Then meeting with the crew(s) and putting the rules into effect makes them clear.

Roger Cox

A former military, corporate and airline pilot, Roger Cox was also a senior investigator at the NTSB. He writes about aviation safety issues.