North Memorial Healthcare Agusta A109 S accident
Agusta A109 S · Accident: loss of control in flight on approach
From North Memorial Heliport (MY77) to Brainerd Lakes Regional Airport (BRD)
Event
- NTSB case
- CEN19FA185
- Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
- Accident
- InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
- Completed
- API-reported fatalities
- 2 · all aircraft and ground
- Ground fatalities
- Unknown
- OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
- Charter & commuter
- WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
- Instrument Meteorological Cond
Agusta A109 S
- Aircraft type
- Agusta A109
- Category
- Helicopter
- RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
- N11NM
- Operator
- North Memorial Healthcare
- Onboard fatalities
- Unknown
- Route
- From North Memorial Heliport (MY77), Robbinsdale, MNTo Brainerd Lakes Regional Airport (BRD), Brainerd, MN
- Aircraft age
- About 11 years (built 2008)
- Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
- Part 135: Air Taxi & Commuter
- Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
- Approach · IFR missed approach
- Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
- Loss of control in flight
- DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
- Substantial
Cause areas
- Aircraft › Aircraft oper/perf/capability
- Personnel issues › Task performance
Approximate · Coordinates from the NTSB case API, not marked as estimated; no uncertainty radius is established.
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.
Probable cause
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.
Verbatim NTSB analysis and probable cause from the NTSB dataset
Sources
NTSB record CEN19FA185
- Event ID
- 20190628X64455
- Case number
- CEN19FA185
- Dataset
- full-current
- Source SHA-256
- 5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
- Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
- Filled from the NTSB case API where the bulk record had no value: investigation status, coordinates. Values present in the bulk record are kept.
- The date is the local date, which is the same as the UTC date the NTSB stores.
- API snapshot SHA-256: b7027d11c9396e067f214b23bf2e268353df5282d5d1715361b2ec7ddfe1fadc; retrieved 2026-09-15T07:00:41.460Z.