# NTSB CEN11LA648: Robinson Helicopter R44, N828PM, Ocate, NM, September 15, 2011

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: September 15, 2011, 16:50 local (22:50 UTC)
- Place: Ocate, NM
- Coordinates: 36.255554, -105.056114 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=36.2556&lon=-105.0561&mi=10
- Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping)
- Defining event: [Landing: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: Serious injuries
- Injuries: 1 serious, 1 minor
- Status: Completed, report February 27, 2013
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: Lycoming Engines, FAA Albuquerque FSDO, Robinson Helicopter Company
- NTSB case key (mKey): 81813
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11LA648
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/81813/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=81813
- Page: https://openairdocs.org/ntsb/CEN11LA648

## Probable cause

The pilot’s failure to apply carburetor heat, which resulted in the formation of carburetor ice and a partial loss of engine power.

## Findings

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

- [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Not used/operated (probable cause); cases with it: [Robinson Helicopter R44, 1 case](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=7640120), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md)
- [Action: incomplete action](https://openairdocs.org/ntsb-findings/02041040): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Robinson Helicopter R44, 2 cases](https://openairdocs.org/ntsb-findings/02041040/cases.md?model=7640120), [All aircraft, 105 cases](https://openairdocs.org/ntsb-findings/02041040/cases.md)
- [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Effect on equipment; cases with it: [Robinson Helicopter R44, 2 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=7640120), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md)

## Sequence of events

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

- [Landing: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Robinson Helicopter R44, 10 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7640120), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md)
- [Landing: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Robinson Helicopter R44, 43 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7640120), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Robinson Helicopter R44, 56 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7640120), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

The helicopter was about 80 to 150 feet above ground level with the airspeed about 10 to 15 knots, when the pilot got a low rotor rpm warning, and the engine lost power. The pilot lowered the collective pitch lever, put in right pedal, and kept “full throttle.” The helicopter made two to three complete 360 degree turns before it impacted terrain. According to a carburetor icing probability chart, an engine operating in the ambient conditions at the time of the accident could expect a serious risk of carburetor icing while at cruise power. The pilot reported that he had possibly failed to use enough carburetor heat and he thought that was the reason for the loss of engine power. An examination of the helicopter showed no preimpact mechanical failures or anomalies that would have precluded normal operation.

## Factual narrative

On August 15, 2011, at 1650 mountain daylight time, a Robinson R44 helicopter, N828PM, was substantially damaged when it impacted terrain during landing at a remote hunting lodge near Ocate, New Mexico. The helicopter was owned and operated by a private individual. The pilot was seriously injured and the passenger sustained minor injuries. Visual meteorological conditions prevailed and a flight plan had been not filed for the 14 Code of Federal Regulations Part 91 personal flight. At the time of the accident the helicopter was returning from a local flight. The pilot reported that he was about 40 feet above power lines with the helicopter flying about 80 to 150 feet above ground level with the airspeed at about 10 to 15 knots. At that point a gust of wind caused the nose of the helicopter to begin an uncommanded turn to the left and the pilot got a low rotor warning and a loss of engine power. The pilot lowered the collective pitch lever, put in right pedal, and kept “full throttle”. The pilot reported that the helicopter continued to spin and made two to three complete 360 degree turns before it impacted terrain. During impact the skid landing gear collapsed and the lower fuselage and tail boom were substantially damaged. The helicopter came to rest mostly upright. There was adequate fuel on-board, but there was no fuel spill and no postimpact fire. According to a carburetor icing probability chart, an engine operating in the ambient conditions at the time of the accident could expect a serious risk of carburetor icing while at cruise power. The pilot reported that he had possibly failed to use enough carburetor heat on this flight and he thought that was the reason for the loss of engine power. An examination of the helicopter showed no preimpact mechanical failures or anomalies that would have prevented operations.

## Aircraft

- Registration: [N828PM](https://openairdocs.org/deregistered/N828PM-2013-07-03), registration cancelled 2013-07-03, S/N 1493, built 2005 (OpenAirDocs)
- Reported make and model: ROBINSON HELICOPTER R44
- Registry model: [Robinson Helicopter R44](https://openairdocs.org/model/robinson-helicopter-r44) (registry code 7640120) (OpenAirDocs)
- Registry engine: [Lycoming 0-540F1 SERIE](https://openairdocs.org/engine/lycoming-0-540f1-serie) (registry code 41531, reciprocating) (OpenAirDocs)
- Category: Helicopter
- Serial number: 1493
- Airframe hours: 1381
- Engines: LYCOMING O-540F1 SERIE 260 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, January 14, 2011, 64 hours before
- Departed: Ocate, NM
- Destination: Ocate, NM

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 39; injuries: serious; private; medical: class 3, without waivers/limitations; last flight review July 16, 2010; seat: right; flight hours: 500 total, 144 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: 260° at 6 knots
- Visibility: 10 statute miles
- Lowest ceiling: 6,000 ft broken
- Temperature: 54 °F, dew point 41 °F
- Altimeter: 30.22 inHg
- Observed at: KAXX, 14 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 20110915021219A](https://openairdocs.org/incident/20110915021219A), Sep 15, 2011: Robinson Helicopter R44, Ocate, NM, Substantial damage. Pilot stated he felt vibration during flight and attempted a precautionary landing near previous landing site. During approach, aircraft began uncontrollable…

## Docket (13 files)

The files NTSB released with the investigation on January 30, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=81813. 5.0 MB in all.

- Summary of Findings by IIC (item 1, .PDF, 290 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385863&FileExtension=.PDF&FileName=Summary%20of%20Findings%20by%20IIC-Master.PDF
- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 636 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361104&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Additional Statement From The Pilot (item 3, .PDF, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361105&FileExtension=.PDF&FileName=Additional%20Statement%20From%20The%20Pilot-Redacted.PDF
- Record of Conversation With The Pilot (item 4, .PDF, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361106&FileExtension=.PDF&FileName=Record%20of%20Conversation%20With%20The%20Pilot-Master.PDF
- GPS 17 - Specialist's Factual Report (item 5, .PDF, 933 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40364887&FileExtension=.PDF&FileName=GPS%2017%20-%20Specialist%27s%20Factual%20Report-Master.PDF
- GPS 17 - Attachment 1 - Tabular data (item 6, .CSV, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40364888&FileExtension=.csv&FileName=GPS%2017%20-%20Attachment%201%20-%20Tabular%20data-Master.csv
- Maps (item 7, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361107&FileExtension=.PDF&FileName=Maps-Master.PDF
- Weather Summary (item 8, .PDF, 596 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361108&FileExtension=.PDF&FileName=Weather%20Summary-Master.PDF
- Photo 1 - View from the front of the wreckage - viewer looking northeast (FAA Photo) (item 9, .PDF, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383405&FileExtension=.PDF&FileName=Photo%201%20-%20View%20from%20the%20front%20of%20the%20wreckage%20-%20viewer%20looking%20northeast%20%20(FAA%20Photo)-Master.PDF
- Photo 2 - Wreckage as seen from the right rear (FAA Photo) (item 10, .PDF, 204 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383406&FileExtension=.PDF&FileName=Photo%202%20-%20Wreckage%20as%20seen%20from%20the%20right%20rear%20%20(FAA%20Photo)-Master.PDF
- R44 - Height Velocity Diagram (item 11, .PDF, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385862&FileExtension=.PDF&FileName=R44%20-%20Height%20Velocity%20Diagram-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 301 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383399&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361109&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.

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