CEN12FA139

NTSB accident investigation · Robinson R44 II · Centerville, LA · January 19, 2012

Accident · FatalField investigationFinal report
Date
January 19, 2012, 09:01 local (15:01 UTC)
Place
Centerville, LA
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N369TLRobinson R44 II
Defining event
Maneuvering-low-alt flying: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report August 15, 2012
Report
Approved by Office Director
NTSB office
Central Region
Parties
Robinson Helicopters, FAA Flight Standards District Office, Lycoming Engines
FAA report
20120119001929A
Case key
82704

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot allowed the helicopter to settle with power while maneuvering at low altitude.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: prop/rotor parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedRobinson Helicopter R44 II: 17 casesAll aircraft: 182 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Witnesses saw the helicopter circling at a low altitude and saw the pilot wave at them. None of the witnesses saw the impact, but they heard the impact and saw smoke. They responded to the site and used portable fire extinguishers to extinguish the fire. Examination of the accident site revealed that the helicopter struck several trees and fell straight to the ground in a nose-low attitude, coming to rest on its right side. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Impact signatures were consistent with the engine developing power at impact, and it is likely that, at the time of impact, the helicopter was in a steep descent consistent with settling with power.

Factual narrative

HISTORY OF FLIGHT On January 19, 2012, at 0901 central standard time, a Robinson R44 II, N369TL, collided with trees while maneuvering at low altitude and impacted the Belle Isle salt dome, about 12 miles south of Centerville, Louisiana. There was a fire after impact. The pilot and the pilot-rated passenger were fatally injured. The helicopter was substantially damaged. The helicopter was registered to and operated by CENAC Marine Services, LLC, Houma, Louisiana, under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Visual meteorological conditions (VMC) prevailed at the time of the accident, and no flight plan had been filed. The local flight originated from Houma (KHUM), Louisiana, at 0827. Several witnesses told St. Mary’s Parish sheriff’s deputies that they saw the helicopter circling at a low altitude. They said the left seat pilot waved at them. None of the witnesses saw the impact, but heard the impact and saw smoke. They responded to the site and used portable fire extinguishers to extinguish the fire. PERSONNEL (CREW) INFORMATION According to the helicopter owner/operator the pilot-in-command, age 40, was seated in the left seat. He held an airline transport pilot certificate with airplane multiengine land rating, commercial pilot privileges with airplane single-engine land and rotorcraft-helicopter ratings, and a flight instructor certificate with airplane single/multiengine and instrument ratings. He was type rated in the Beech 300/350 King Air, Hawker Beechjet 400, Cessna 500 Citation, and the Mitsubishi MU-300 Diamond. He held a first class airman medical certificated, dated June 24, 2011, with no restrictions or limitations. According to his employer, the pilot had logged 8,700 total flight hours and 260 hours in the Robinson R44, of which 215 hours were as pilot-in-command. His list flight review was accomplished in the Beech 350 King Air on December 6, 2011. The second pilot, age 43, was seated in the right seat. He held a private pilot certificate with a rotorcraft-helicopter rating. He also held a third class airman medical certificate, dated April 15, 2010, with the restriction that he wear corrective lenses while exercising the privileges of his airman certificate. According to his employer, the pilot had logged 450 total flight hours, the majority of which was in the Bell 47 helicopter. He had logged 18.9 hours in the Robinson R44, his last flight being on May 5, 2011. He had also flown the Brantley helicopter. AIRCRAFT INFORMATION N369TL (serial number 11055), a model R44 II, was manufactured by the Robinson Helicopter Company on January 16, 2006. It was powered by a Lycoming IO-540-AE1A5 engine (serial number L-30804-48A), rated at 300 horsepower. According the helicopter maintenance records, the last 100-hour/annual inspection was performed on March 31, 2011, at a total time of 461.5 hours. METEOROLOGICAL INFORMATION The following METARs (Aviation Routine Weather Report) were recordedat Houma (KHUM) and Patterson (KPTN), Louisiana: KHUM 0850: Wind, 020 degrees at 3 knots; visibility, 6 miles, mist; ceiling, 1,800 feet broken; temperature, 12 degrees Celsius (C.); dew point, 11 degrees C.; altimeter, 30.15 inches of Mercury. KPTN 0855: Wind, 070 degrees at 3 knots; visibility, 10 miles; ceiling, 2,400 feet overcast; temperature, 12 degrees C.; dew point, 11 degrees C.; altimeter, 30.14 inches of Mercury. WRECKAGE AND IMPACT INFORMATION The accident site was situated at an elevation of 6 feet msl (above mean sea level), encompassing a perimeter of about 500 feet. The on-scene investigation revealed the helicopter struck several trees and fell straight to the ground in a nose-low attitude, coming to rest on its right side. A post-impact fire ensued. The tail boom and tail rotor blades remained attached to the helicopter, and 3-foot stubs of the main rotor blades remained attached. The tail rotor drive shaft was intact and, when turned by hand, continuity was observed. Nearby was a 2-foot gash deep in the ground, about the length of a main rotor blade. The helicopter sustained extensive thermal damage from the tail boom forward. All control rods and linkages remained attached to the rotor hub. All breaks were consistent with overload fractures. The instrument panel was destroyed, but the vertical speed indicator registered 2,600 feet per minute descent, and the attitude indicator revealed a 35-degree left turn and nose-down attitude. Impact signatures were consistent with the helicopter in a steep descent and the engine operating at the time of impact. MEDICAL AND PATHOLOGICAL INFORMATION Autopsies were performed on both pilots by the Louisiana Forensic Center. According to their reports, both pilots succumbed to blunt force injuries. Toxicology protocols were conducted by FAA’s Civil Aeromedical Institute (CAMI). According to their reports, none of the pilot’s specimens were suitable for analysis due to putrefaction. The pilot-rated passenger had no carbon monoxide, cyanide or ethanol in the blood (cavity)`, but amlodipine, pravastatin, and valsartan were detected in the liver and blood (cavity). According to FAA’s Forensic Toxicology Drug Information website, amlodipine (Norvasc®) is a prescription calcium channel blocker medication used to treat high blood pressure and angina, pravastatin (Pravachol®) is a prescription HMG-CoA reductase inhibitor to reduce cholesterol biosynthesis and treat elevated blood lipids, and valsartan (Diovan®) is a prescription angiotensin II receptor blocker (ARB) that acts on the AT1 receptor subtype and is used to control high blood pressure. TESTS AND RESEARCH The engine was examined at Air Salvage of Dallas in Lancaster, Texas, under the auspices of the National Transportation Safety Board. Examination revealed that the intake and exhaust valves were seized due to thermal damage to the engine. There were no pre-impact anomalies with the engine which would have precluded normal operation. Thethree servos were examined at the Robinson Helicopter Company under the auspices of the National Transportation Safety Board. Thermal damaged had compromised most of the servo seals. No foreign debris, scoring, or witness marks were observed on either spool or metering edges of the sleeve. ADDITIONAL INFORMATION The Federal Aviation Administration (FAA) inspector who participated in the investigation, a former U.S. Army helicopter pilot and an FAA helicopter pilot examiner, submitted a written statement in which he noted what appeared to be a high velocity impact, large grooves in the ground indicating engine power at impact, and a near vertical descent consistent with “settling with power.” The following is based on FAA’s “Helicopter Flying Handbook,” (FAA-H-8083-21, Chapter 11, p. 11-13): “Vortex ring state” is an aerodynamic condition in which a helicopter may be in a vertical descent with 20 percent up to maximum power applied, and little or no climb performance. “Settling with power” occurs when the helicopter keeps settling even though full engine power is applied. Main rotor tip vortices generate drag and degrade airfoil efficiency. As long as the tip vortices are small, their only effect is a small loss in main rotor efficiency. However, when the helicopter begins to descend vertically, it settles into its own downwash, which greatly enlarges the tip vortices. In this vortex ring state, most of the power developed by the engine is wasted in circulating the air in a doughnut pattern around the rotor. A vortex ring state may be entered during any maneuver that places the main rotor in a condition of descending in a column of disturbed air and low forward airspeed. Airspeeds that are below translational lift airspeeds are within this region of susceptibility to settling with power aerodynamics. This condition is sometimes seen during quick-stop type maneuvers or during recovery from autorotation. Some of the situations that are conducive to a settling with power condition are hovering above ground effect altitude, specifically attempting to hover out of ground effect (OGE) at altitudes above the hovering ceiling of the helicopter, attempting to hover OGE without maintaining precise altitude control, pinnacle or rooftop helipads when the wind is not aligned with the landing direction, and downwind and steep power approaches in which airspeed is permitted to drop below 10 knots, depending on the type of helicopter.

Aircraft

Registration
N369TL
Reported as
Robinson R44 II
Category
Helicopter
Serial number
11055
Airframe hours
462
Engine
Lycoming IO-540-AE1A5, 300 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Operator
CENAC Marine Services, LLC
Registered owner
CENAC Marine Services, LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · March 31, 2011
Departed
KHUM · Houma, LA
Destination
KHUM · Houma, LA

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
40
Injuries
Fatal
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
December 6, 2011
Seat
Left
Toxicology
Performed
Flight hours
8,700 total · 260 in this make and model · 4,384 as pilot in command · 85 in the last 90 days
Role
Pilot
Age
43
Injuries
Fatal
Certificate
Private
Medical
Class 3, With waivers/limitations
Seat
Right
Toxicology
Performed
Flight hours
450 total · 450 in this make and model · 25 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
70° at 3 knots
Visibility
10 statute miles
Lowest ceiling
2,400 ft overcast
Temperature
54 °F, dew point 52 °F
Altimeter
30.13 inHg
Observed at
KPTN, 15 nm away

Docket · 23

The files NTSB released with the investigation on June 28, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 29.8 MB in all.

NTSB Form 6120, Pilot-Operator Aircraft Accident ReportItem 1 · .PDF · 1.1 MBExcerpts from Witness Statements and InterviewsItem 2 · .PDF · 73 KBRobinson R44 Seatbelt DiagramsItem 3 · .PDF · 85 KBExemplar photograph of R44 seats, seatbelts, and shoulder harnessesItem 4 · .PDF · 80 KBFAA Inspector StatementsItem 5 · .PDF · 299 KBLycoming Engines ReportItem 6 · .PDF · 4 photos · 194 KBServo Examination ReportItem 7 · .PDF · 41 KBWeather Reports and RecordsItem 8 · .PDF · 94 KBToxicology Report, Jason M. McKeanItem 9 · .PDF · 54 KBToxicology Report, Lanny D. LedetItem 10 · .PDF · 47 KBCertification of Party Representative, Robinson HelicoptersItem 11 · .PDF · 294 KBCertification of Party Representative, Lycoming EnginesItem 12 · .PDF · 1.1 MBPhoto 1 - Trees that were struck.Item 13 · .PDF · 3.2 MBPhoto 2 - Overall view of accident site.Item 14 · .PDF · 3.0 MBPhoto 3 - Hilltop overview of accident site.Item 15 · .PDF · 3.0 MBPhoto 4 - Cabin area, tail boom, and main rotor blade stubs.Item 16 · .PDF · 2.8 MBPhoto 5 - Rotor mast, rotor hub, pitch links.Item 17 · .PDF · 1.8 MBPhoto 6 - Main rotor mast, hub, blade stub, and linkages.Item 18 · .PDF · 1.6 MBPhoto 7 - Vertical, horizontal stabilizers and tail rotor assembly being held upright.Item 19 · .PDF · 2.0 MBPhoto 8 - Main rotor blade tip.Item 20 · .PDF · 3.4 MBPhoto 9 - Splintered tree and skid.Item 21 · .PDF · 3.0 MBPhoto 10 - Downed trees, helicopter skids, and cross tube.Item 22 · .PDF · 2.3 MBNTSB Form 6120.15, Release of Aircraft WreckageItem 23 · .PDF · 351 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.