# NTSB ANC17LA040: Robinson Helicopter R44, N4138M, Solomon, AK, August 3, 2017

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Class 3 · Limited · Final report
- Date: August 3, 2017, 10:32 local (18:32 UTC)
- Place: Solomon, AK
- Coordinates: 64.566108, -164.29638 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=64.5661&lon=-164.2964&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Defining event: [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Alaska Regional Office
- Parties: FAA Anchorage FSDO, Robinson Helicopter Company
- NTSB case key (mKey): 95762
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC17LA040
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95762/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95762
- Page: https://openairdocs.org/ntsb/ANC17LA040

## Probable cause

The pilot's failure to maintain adequate altitude above water, and his loss of situational awareness, which resulted in an inadvertent descent and collision with water.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Robinson Helicopter R44 II, 99 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7640122), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Robinson Helicopter R44 II, 29 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=7640122), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md)
- [Perception/orientation/illusion: situational awareness](https://openairdocs.org/ntsb-findings/02022035): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Robinson Helicopter R44 II, 2 cases](https://openairdocs.org/ntsb-findings/02022035/cases.md?model=7640122), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02022035/cases.md)
- [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Robinson Helicopter R44 II, 39 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=7640122), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Maneuvering-low-alt flying: Loss of visual reference](https://openairdocs.org/ntsb-events/402); cases with it: [Robinson Helicopter R44 II, 11 cases](https://openairdocs.org/ntsb-events/402/sequence.md?model=7640122), [All aircraft, 242 cases](https://openairdocs.org/ntsb-events/402/sequence.md)
- [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) (defining event); cases with it: [Robinson Helicopter R44 II, 45 cases](https://openairdocs.org/ntsb-events/220/sequence.md?model=7640122), [All aircraft, 780 cases](https://openairdocs.org/ntsb-events/220/sequence.md)
- [Maneuvering-low-alt flying: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Robinson Helicopter R44 II, 95 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7640122), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

The pilot was conducting a commercial charter flight for the passenger to place mineral claim markers. He stated that, while flying over a lagoon at an altitude lower than he "should have been," while making inputs to the GPS unit, he likely inadvertently applied forward cyclic and allowed the helicopter to descend into the water below. The pilot reported that there were no mechanical malfunctions or anomalies with the helicopter that would have precluded normal operation. Although helicopters operated under 14 CFR Part 135 are required to be equipped with radar altimeters, the accident helicopter was not, as the operator had been authorized by the Federal Aviation Administration (FAA) to operate the helicopter without one. It is likely that if a radar altimeter was installed in the helicopter at the time of the accident, was functioning properly, and was set to provide an aural warning at a predetermined altitude, the pilot may have had adequate time to recognize and stop the inadvertent descent before impact with water.

## Factual narrative

On August 3, 2017, about 1032 Alaska daylight time, a Robinson Helicopter Company R-44 helicopter, N4138M, was substantially damaged when it was involved in an accident near Solomon, Alaska. The commercial pilot and passenger were not injured. The helicopter was operated as a Title 14 Code of Federal Regulations (CFR) Part 135 on-demand charter flight. The pilot reported that the purpose of the flight was to place mineral claim markers, which involved maneuvering the helicopter over a designated GPS location, after which the passenger would drop the marker from the rear left seat of the helicopter. Some of the mineral claim corners were in water, and the placement of those markers had to be offset to the nearest land mass. The pilot departed Nome Airport (OME), Nome, Alaska, and flew to the passenger's residence about 4 miles east, where the passenger boarded the helicopter and they departed on the accident flight. After reaching the destination and while placing the markers, helicopter was operating about 10 to 15 ft above the water over a lagoon between the mainland and a sand barrier. The pilot reported that he was "lower than he should have been" and lost situational awareness while programming the GPS. He inadvertently allowed the helicopter to descend into the water "in a more level or slight nose-low attitude." He further reported that he must have pushed forward on the cyclic as he leaned forward to manipulate the GPS. Upon impact, the helicopter rolled and came to rest on its right side in about 4 ft of water. After egressing, the pilot and passenger waded about 200 ft to the shore with the helicopter occupant survival bag and a satellite telephone. The pilot contacted the operator with the satellite telephone and a second company helicopter was dispatched to pick up the pilot and passenger about 1200. The pilot reported that there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation and stated that the accident could have been prevented by maintaining a higher altitude and not fixating on the GPS unit. The helicopter sustained substantial damage to the main rotor system, the fuselage, the tail boom, and the tail rotor system.

## Aircraft

- Registration: [N4138M](https://openairdocs.org/deregistered/N4138M-2023-02-04), registration cancelled 2023-02-04, S/N 12159, built 2008 (OpenAirDocs)
- Reported make and model: ROBINSON HELICOPTER COMPANY R44 (II)
- Registry model: [Robinson Helicopter R44 II](https://openairdocs.org/model/robinson-helicopter-r44-ii) (registry code 7640122) (OpenAirDocs)
- Registry engine: [Lycoming IO-540-AE1A5](https://openairdocs.org/engine/lycoming-io-540-ae1a5) (registry code 41899, reciprocating) (OpenAirDocs)
- Category: Helicopter
- Serial number: 12159
- Year built: 2008
- Airframe hours: 2053.8
- Engines: Lycoming IO-540 Series 205 horsepower reciprocating
- Damage: Substantial damage
- Flight: Part 135
- Operator: Bering Air, Inc., doing business as Bering Air, Inc.
- Registered owner: Bering Air, Inc.
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, July 8, 2017
- Departed: OME, NOME, AK
- Destination: OME, NOME, AK
- Flight plan: Company VFR
- Equipment: Satellite tracking device, Handheld GPS

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 48; injuries: none; commercial, flight instructor; instrument ratings: helicopter; medical: class 1, with waivers/limitations; last flight review May 9, 2017; seat: right; restraint: 4-point; flight hours: 3,818 total, 266 in this make and model, 742 as pilot in command, 184 in the last 90 days, 90 in the last 30 days, 3 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 310° at 4 knots
- Visibility: 10 statute miles
- Lowest ceiling: 5,000 ft overcast
- Temperature: 57 °F, dew point 54 °F
- Altimeter: 29.84 inHg
- Observed at: PAOM, 30 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20170803017929A](https://openairdocs.org/incident/20170803017929A), Aug 3, 2017: Robinson Helicopter Company R44 II, Solomon, AK, Substantial damage. Pilot stated he was lower than he should have been and lost situational awareness when working with the GPS. He might have pushed forward on the Cyclic as he…

## Docket (10 files)

The files NTSB released with the investigation on January 5, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95762. 7.3 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 729 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8588046&FileExtension=pdf&FileName=NTSB%20Form%206120_1%20Redacted-Rel.pdf
- Pilot record of conversation (item 2, PDF, 1 page, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8587920&FileExtension=pdf&FileName=Pilot%20Record%20of%20Conversation-Rel.pdf
- FAA bering air operations specifications A160 (item 3, PDF, 2 pages, 864 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8588421&FileExtension=pdf&FileName=FAA%20Bering%20Air%20Operations%20Specifications%20A160-Rel.pdf
- FAA n 8900.405 (item 4, PDF, 4 pages, 174 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8586610&FileExtension=pdf&FileName=FAA%20N_8900.405%20Redacted-Rel.pdf
- FAA documents (item 5, PDF, 7 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8588055&FileExtension=pdf&FileName=FAA%20Documents%20Redacted-Rel.pdf
- FAA bering air poi interview transcript (item 6, PDF, 18 pages, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8588306&FileExtension=pdf&FileName=FAA%20Bering%20Air%20POI%20Interview%20Transcript%20Redacted-Rel.pdf
- NTSB rhc R-44 radar altimeter installation email (item 7, PDF, 3 pages, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8587241&FileExtension=pdf&FileName=NTSB%20RHC%20R-44%20Radar%20Altimeter%20Installation%20Email%20Redacted-Rel.pdf
- Rhc R-44 series ipc excerpts (item 8, PDF, 8 pages, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8586803&FileExtension=pdf&FileName=RHC%20R-44%20Series%20IPC%20Excerpts-Rel.pdf
- Statement of party representatives to NTSB investigation (item 9, PDF, 1 page, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8586019&FileExtension=pdf&FileName=NTSB%20Party%20Member%20Form%20RHC%20Redacted-Rel.pdf
- Accident photographs (item 10, PDF, 2 pages, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8587410&FileExtension=pdf&FileName=Accident%20Photographs-Rel.pdf

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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