# NTSB CEN10FA139: Robinson Helicopter R22 Beta II, N922SH, Cotulla, TX, March 6, 2010 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 6, 2010, 11:20 local (17:20 UTC) - Place: Cotulla, TX - Coordinates: 28.6025, -99.338058 - Nearby events: https://openairdocs.org/map.md?lat=28.6025&lon=-99.3381&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 19, 2011 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Lycoming Engines, Robinson Helicopter Company, Federal Aviation Administration - NTSB case key (mKey): 75449 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN10FA139 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75449/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75449 - Page: https://openairdocs.org/ntsb/CEN10FA139 ## Probable cause A loss of engine power due to fuel exhaustion as a result of the pilot's inadequate fuel planning. Contributing to the accident was the low-altitude operating environment that would not allow for a successful autorotation after the loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Robinson Helicopter R22 BETA, 1 case](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=7640110), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Robinson Helicopter R22 BETA, 2 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7640110), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Environmental issues](https://openairdocs.org/ntsb-findings/03010000): Environmental issues › Operating environment · Contributed to outcome (probable cause); cases with it: [Robinson Helicopter R22 BETA, 1 case](https://openairdocs.org/ntsb-findings/03010000/cases.md?model=7640110), [All aircraft, 14 cases](https://openairdocs.org/ntsb-findings/03010000/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: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Robinson Helicopter R22 BETA, 1 case](https://openairdocs.org/ntsb-events/192/sequence.md?model=7640110), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Maneuvering-low-alt flying: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Robinson Helicopter R22 BETA, 18 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7640110), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Autorotation: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Robinson Helicopter R22 BETA, 85 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7640110), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis During a safety briefing prior to the flight, the pilot mentioned that he would be operating with a limited amount of fuel so that the two-seat helicopter would be more maneuverable. Witnesses reported observing the pilot add fuel while the helicopter was running between several flights; however, no one recalled the pilot adding fuel before the last flight. The truck-mounted fuel tank that the pilot used to fuel the helicopter did not have a gauge or means to determine how much fuel was being pumped into the helicopter. The pilot was on his sixth flight of the day when the accident occurred. Approximately 10 minutes after the flight departed, several waiting passengers heard what they described as a sound that resembled a lawn mower bogging down in tall grass. The helicopter wreckage was located a short time later. A postaccident investigation showed only residual fuel in each of the helicopter’s two fuel tanks. Neither tank exhibited hydraulic deformation and no significant fuel blight was observed on the surrounding vegetation. The helicopter was being operating at a low altitude that would not allow for a successful autorotation in the event of a loss of engine power. No evidence of mechanical failure of the helicopter structure, flight controls, systems, or engine was found. ## Factual narrative HISTORY OF FLIGHT On March 6, 2010, about 1120 central standard time, a Robinson R22 Beta II, N922SH, was substantially damaged during impact with terrain while maneuvering at low altitude at the Agave Ranch near Cotulla, Texas. The commercial pilot and passenger were fatally injured. The helicopter was registered to and operated by a private individual. Visual meteorological conditions prevailed and no flight plan was filed for the 14 Code of Federal Regulations Part 91 local flight. The aerial hog hunting flight was the sixth flight of the morning and had departed around 1110. According to individuals at the Agave Ranch, they were contacted about providing an Axis deer hunt for the accident weekend. During the initial arrangements, the hunters were offered an aerial hog hunt in addition to the deer hunt, to which they agreed. To facilitate the aerial hog hunt, the ranch manager contacted the helicopter owner and arranged for the owner to furnish the helicopter, pilot, shotgun, and ammunition. Following the hunt the helicopter owner would provide an invoice for payment. On the morning of the accident, the pilot arrived at the ranch around 0900 towing the two-seat helicopter on a trailer. The pilot provided a safety briefing to the four hunters to include proper use of the shotgun. The pilot also mentioned that each flight would be approximately 20 minutes in length, and that he would be operating the helicopter "light" on fuel so the helicopter would be more maneuverable. An initial flight of 5 to 10 minutes was conducted with the ranch manager so he could point out the ranch perimeters to the pilot. The pilot then proceeded to fly the next three hunters, one at a time, for approximately 20 minutes each. The forth hunter requested the pilot return and land after approximate 10 minutes in order to give the first hunter more time to hunt. Approximately 10 minutes after the last flight departed, several of the waiting hunters heard what they described as a "whoosh whoosh whoosh," or a sound that resembled "a lawn mower bogging down in tall grass.” The helicopter wreckage was located a short time later. According to the hunters, during each flight the pilot would fly about the height of a telephone pole and in a speed range of 0 to 25 mph. The pilot would notify the hunter when it was safe to shoot. While offloading and boarding the next hunter, the pilot would exit the running helicopter and add fuel from a tank located in the back of his truck. Those interviewed were unsure how many times the pilot added fuel to the helicopter. Two of the hunters reported that it was at least twice and the ranch manager recalled the pilot refueling between each hunter; however, he did not recall if the pilot had refueled before the last flight. An examination of the truck-mounted fuel tank revealed that there was no gauge or means to determine how much fuel was being pumped into the helicopter. PERSONNEL INFORMATION The pilot, age 40, held a commercial pilotcertificate for rotorcraft helicopter and a rating for instrument helicopter. His last Federal Aviation Administration (FAA) second-class medical was issued on June 24, 2008, with no limitations. A partial record of the pilot's flight time was submitted to the National Transportation Safety Board (NTSB) investigator-in-charge (IIC). As of the last entry dated July 26, 2008, the pilot had accumulated a total flight time of 498 hours; of which 303.3 hours were in this make and model of helicopter. No flight records for the time between July 26, 2008 and the date of the accident were submitted to the IIC. The pilot’s last noted flight review was completed July 2, 2009. The owner of the helicopter estimated the pilot’s total flight time, at the time of the accident, to be approximately 1,000 hours, with 700 hours in make and model. AIRCRAFT INFORMATION The two-seat helicopter, serial number 3863 was manufactured in 2005. It was powered by a Lycoming O-360-J2A, 145-hp engine. Review of maintenance records revealed the last annual inspection was completed April 16, 2008, at an airframe and engine total time of 1273.3 hours. The helicopter had accumulated a total airframe and engine time of 1,935 hours at the time of the accident and 27.2 hours since the last 100-hour inspection. METEOROLOGICAL INFORMATION At 1053, the automated weather observing system at the Cotulla Airport (COT), Cotulla, Texas, located 12 nautical miles southeast from the site of the accident, reported wind from 130 degrees at 13 knots, 10 miles visibility, clear of clouds, broken ceiling at 1,700 feet, temperature 64 degrees Fahrenheit (F), dew point 57 degrees F, and a barometric pressure setting of 30.18 inches of Mercury. WRECKAGE AND IMPACT INFORMATION On site documentation of the wreckage was conducted by investigators from the NTSB, FAA, and Robinson Helicopter Company. The helicopter impacted in an open field on a heading of 190 degrees and came to rest on a heading of 335 degrees. Control continuity was established to all flight controls and all major components were accounted for at the site. The fuselage came to rest in an upright position and exhibited downward crushing. The tail boom was bent downward and the aft end had been separated in a manner consistent with a main rotor blade strike. The aft section of the tail boom, with the attached tail rotor gearbox, was located 127 feet from the main wreckage. Both main rotor blades remained attached to the rotor head. One blade exhibited a gradual curve upward along its entire length. The other blade contained less upward curvature then the first blade and exhibited several areas of buckling. Main rotor driveshaft continuity was established from the upper drive sheave through the main rotor head. The sprag clutch operated normally when manually rotated. Impact signatures on the swash plate were consistent with the collective being in the full up position during impact. The automatic carburetor heat control was found lockedin the cold position. Both fuel tanks contained residual fuel and did not exhibited hydraulic deformation. The engine’s valve covers and lower spark plugs were removed. Investigators manually rotated the engine and valve train continuity was established to each cylinder and to the accessory gears. Thumb compression was developed in each cylinder. Both magnetos were removed and produced a blue spark at each terminal when rotated by hand. The oil filter was removed and cut open. An examination of the oil filter element revealed no visible abnormal contaminants. The carburetor exhibited impact damaged and the bowl was found separated from the engine. The carburetor fuel inlet screen was removed and found to be clean and unobstructed. The fuel gascolator bowl was found separated from the gascolator upper housing and mount. The grass directly underneath the helicopter, with the attached upper fuel gascolator housing, contained a discolored area, approximately 5 inches in diameter, which was consistent with fuel blight. The IIC removed the topsoil and found a live earthworm approximately one half inch below the discolored grass. No other blight was observed on the surrounding vegetation. MEDICAL AND PATHOLOGICAL INFORMATION The Webb County Medical examiner’s office, Laredo, Texas, performed an autopsy on the pilot on March 7, 2010. The cause of death was reported as "multiple blunt force injuries.” The FAA Civil Aerospace Medical Institute (CAMI), Oklahoma City, Oklahoma, performed forensic toxicology on specimens from the pilot. The toxicology report stated no carbon monoxide or cyanide was detected in the blood, and no ethanol was detected in the vitreous. Chlorpheniramine and Ibuprofen were detected in the urine. ADDITIONAL INFORMATION According to the FAA’s Rotorcraft Flying Handbook, chapter 11, page 4, “A height/velocity (H/V) diagram, published by the manufacturer for each model of helicopter, depicts the critical combinations of airspeed and altitude should an engine failure occur. Operating at the altitudes and airspeeds shown within the crosshatched or shaded areas of the H/V diagram may not allow enough time for the critical transition from powered flight to autorotation.” A Robinson R22 Pilot Operating Handbook was located in the wreckage. According to the H/V Diagram, chapter 5, page 11, the helicopter was being operated in the crosshatched area. ## Aircraft - Registration: [N922SH](https://openairdocs.org/deregistered/N922SH-2011-03-24), registration cancelled 2011-03-24, S/N 3863, built 2005 (OpenAirDocs) - Reported make and model: ROBINSON HELICOPTER R22 BETA II - Registry model: [Robinson Helicopter R22 BETA](https://openairdocs.org/model/robinson-helicopter-r22-beta) (registry code 7640110) (OpenAirDocs) - Registry engine: [Lycoming O-360 series](https://openairdocs.org/engine/lycoming-o-360-series) (registry code 41575, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 3863 - Airframe hours: 1935 - Engines: Lycoming O-360-J2A 145 hp reciprocating - Damage: Substantial damage - Flight: Aerial observation, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, February 18, 2010, 27 hours before - Departed: Cotulla, TX - Destination: Cotulla, TX - Flight plan: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: fatal; commercial; instrument ratings: helicopter; medical: class 2, without waivers/limitations; last flight review July 2, 2009; seat: right; toxicology performed; flight hours: 1,000 total, 700 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 130° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: 1,700 ft broken - Temperature: 64 °F, dew point 57 °F - Altimeter: 30.18 inHg - Observed at: COT, 12 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 20100306028509A](https://openairdocs.org/incident/20100306028509A), Mar 6, 2010: Robinson He R22 BETA, Cotulla, TX, Destroyed, 2 fatal. On mar. 6, 2010, a helicopter, N922SH Robinson R-22, was engaged in a predator control flight, on a private ranch northwest of Cotulla, Texas. These hunts are… ## Docket (19 files) The files NTSB released with the investigation on November 9, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75449. 6.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356713&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - RECORD OF CONVERSATION (Armbrecht) (item 2, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356515&FileExtension=.PDF&FileName=RECORD%20OF%20CONVERSATION%20(Armbrecht)-Master.PDF - RECORD OF CONVERSATION (Hall) (item 3, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356516&FileExtension=.PDF&FileName=RECORD%20OF%20CONVERSATION%20(Hall)-Master.PDF - RECORD OF CONVERSATION (Knust) (item 4, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356517&FileExtension=.PDF&FileName=RECORD%20OF%20CONVERSATION%20(Knust)-Master.PDF - RECORD OF CONVERSATION (Menconi) (item 5, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356518&FileExtension=.PDF&FileName=RECORD%20OF%20CONVERSATION%20(Menconi)-Master.PDF - RECORD OF CONVERSATION (Rutherford) (item 6, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356519&FileExtension=.PDF&FileName=RECORD%20OF%20CONVERSATION%20(Rutherford)-Master.PDF - Photo 1, Front View (item 7, .PDF, 350 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356549&FileExtension=.PDF&FileName=Photo%201,%20Front%20View-Master.PDF - Photo 2, Left Front Quarter View (item 8, .PDF, 263 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356550&FileExtension=.PDF&FileName=Photo%202,%20Left%20Front%20Quarter%20View-Master.PDF - Photo 3, Left Side View (item 9, .PDF, 252 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356551&FileExtension=.PDF&FileName=Photo%203,%20Left%20Side%20View-Master.PDF - Photo 4, Left Rear Quarter View (item 10, .PDF, 369 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356552&FileExtension=.PDF&FileName=Photo%204,%20Left%20Rear%20Quarter%20View-Master.PDF - Photo 5, Rear View (item 11, .PDF, 384 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356556&FileExtension=.PDF&FileName=Photo%205,%20Rear%20View-Master.PDF - Photo 6, Right Rear Quarter View (item 12, .PDF, 370 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356558&FileExtension=.PDF&FileName=Photo%206,%20Right%20Rear%20Quarter%20View-Master.PDF - Photo 7, Right Side View (item 13, .PDF, 308 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356559&FileExtension=.PDF&FileName=Photo%207,%20Right%20Side%20View-Master.PDF - Photo 8, Right Front Quarter View (item 14, .PDF, 319 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356560&FileExtension=.PDF&FileName=Photo%208,%20Right%20Front%20Quarter%20View-Master.PDF - Photo 9, Main Impact Crater (item 15, .PDF, 470 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356561&FileExtension=.PDF&FileName=Photo%209,%20Main%20Impact%20Crater-Master.PDF - Photo 10, Grass With Fuel Blight (item 16, .PDF, 444 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356563&FileExtension=.PDF&FileName=Photo%2010,%20Grass%20With%20Fuel%20Blight-Master.PDF - Toxicological Report (item 17, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356735&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 18, .PDF, 672 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356539&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 19, .PDF, 416 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356543&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.