# NTSB CEN15LA375: Robinson Helicopter R44 II, N445HS, Carlos, TX, August 22, 2015 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: August 22, 2015, 17:42 local (22:42 UTC) - Place: Carlos, TX - Coordinates: 31.055255, -97.563514 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=31.0553&lon=-97.5635&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-hover: Loss of tail rotor effectiveness](https://openairdocs.org/ntsb-events/242) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report June 16, 2016 - Report: Approved by Office Director - NTSB office: Central Region - Parties: National Transportation Safety Board, Recorder Lab, Flight Standards District Office - NTSB case key (mKey): 91840 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15LA375 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91840/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91840 - Page: https://openairdocs.org/ntsb/CEN15LA375 ## Probable cause The pilot’s improper decision to turn the helicopter toward a tailwind during an out-of-ground-effect hover, which resulted in a loss of tail rotor effectiveness. Contributing to the accident was the accident and lead pilots’ inadequate preflight risk management. ## 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) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Robinson Helicopter R44 II, 40 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7640122), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Performance/control parameters: prop/rotor parameters](https://openairdocs.org/ntsb-findings/01062052): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Robinson Helicopter R44 II, 17 cases](https://openairdocs.org/ntsb-findings/01062052/cases.md?model=7640122), [All aircraft, 182 cases](https://openairdocs.org/ntsb-findings/01062052/cases.md) - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Robinson Helicopter R44 II, 13 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=7640122), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md) - [Planning/preparation](https://openairdocs.org/ntsb-findings/02061000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Robinson Helicopter R44 II, 3 cases](https://openairdocs.org/ntsb-findings/02061000/cases.md?model=7640122), [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/02061000/cases.md) - [Planning/preparation](https://openairdocs.org/ntsb-findings/02061000): Personnel issues › Task performance · Pilot of other aircraft (probable cause); cases with it: [Robinson Helicopter R44 II, 3 cases](https://openairdocs.org/ntsb-findings/02061000/cases.md?model=7640122), [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/02061000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-hover: Loss of tail rotor effectiveness](https://openairdocs.org/ntsb-events/242) (defining event); cases with it: [Robinson Helicopter R44 II, 9 cases](https://openairdocs.org/ntsb-events/242/sequence.md?model=7640122), [All aircraft, 100 cases](https://openairdocs.org/ntsb-events/242/sequence.md) - [Uncontrolled descent: 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 commercial pilot was conducting the flight behind another helicopter in order to film the passengers on board the lead helicopter hunting wild hog. At the filming location, the accident pilot initially established a hover about 400 ft above ground level (agl). After the lead pilot radioed to the accident pilot that he was flying too high, the accident pilot descended to about 200 ft agl, which was 100 ft above the lead helicopter. The accident pilot made a right pedal turn away from a headwind of 20 knots in an attempt to keep the lead helicopter in sight. The accident helicopter subsequently entered a right descending spin, which the pilot was unable to arrest. The helicopter subsequently impacted trees, which damaged the main rotor, tail rotor, and fuselage. Examination of the helicopter revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The helicopter was operating in a high-power, low-airspeed condition that required the pilot to be especially aware of wind direction to avoid tailwinds, which can result in a loss of control due to a loss of tail rotor effectiveness. The combination of an out-of-ground-effect hover and the pilot's subsequent turn away from the headwind toward a tailwind of about 20 knots resulted in the loss of tail rotor effectiveness. The flight was the accident pilot's first commercial operation and also the first flight that required him to maintain a hover while close to another helicopter. Neither the accident pilot nor the lead pilot was aware of the helicopter manufacturer's safety notice regarding photo flights, which recommended that pilots flying such operations should have a higher level of experience than the accident pilot had. The lead pilot, who was more experienced, reported that he was concerned about the accident pilot's inexperience relative to the challenging flight but chose to continue with the flight because he wanted to capture the film footage. ## Factual narrative On August 22, 2015, about 1742 central daylight time, a Robinson R44 II helicopter, N445HS, was substantially damaged after impact with terrain near Carlos, Texas. The pilot and passenger were seriously injured. The helicopter was registered to and operated by Perfect Filler LLC under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Day visual meteorological conditions prevailed for the flight, with no flight plan filed. The local flight departed from Coulter Field Airport (CFD), Bryan, Texas, about 1630. The pilot stated the purpose of the flight was to film a second (lead) helicopter while hunters onboard utilized rifles to hunt wild hogs. At the filming location, the lead pilot radioed to the accident pilot that he was flying much too high. Based on this feedback from the more experienced pilot, the accident pilot descended from about 400 feet agl to 200 feet agl, which was about 100 feet above the lead helicopter. The accident pilot stated his descent made it more challenging for him to keep the lead helicopter in sight while facing into the headwind, which was about 20 knots. The accident pilot initiated a right pedal turn to keep the lead helicopter in sight and the accident helicopter entered into a descending right spin, which the pilot was not able to arrest. The helicopter subsequently impacted trees, which damaged the main rotor, tail rotor, and fuselage. Federal Aviation Administration (FAA) personnel responded to the accident site and located the wreckage in a rural, wooded area, with no evidence of a post-crash fire. The helicopter came to rest on its right side, with both main and tail rotor blades attached. The main and tail rotor blades were observed to have damage consistent with impact. Flight control continuity was established to all flight controls and the tail rotor system was intact, with no anomalies noted. Examination of the helicopter revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. TESTS AND RESEARCH A recording was recovered from the passenger's video camera and evaluated by the NTSB Recorder Laboratory. The passenger was seated in the back right seat of the helicopter and was filming the lead helicopter as it engaged in aerial hog hunting. Because the recording did not capture any part of the accident helicopter during the accident sequence, it was difficult to judge the camera's orientation as compared to the accident helicopter's orientation. The video began with the camera view pointed downward towards the lead helicopter and captured trees being blown by the rotor wash of the lead helicopter. This rotor wash was northwest of the lead helicopter's position. The camera view was shaky and occasionally zoomed toward the lead helicopter. At 00:28 into the recording, both helicopters appeared to have lessened their groundspeed. At 00:36, the camera's view zoomed in tight to two individuals holding rifles leaning out of the leadhelicopter. Between 00:36 and 00:57, both helicopters appeared to be stationary and facing southeast. Around 00:58, the lead helicopter appeared to move away from its stationary hunting position and at 01:09, the lead helicopter moved over a clear area in the surrounding vegetation. At 01:10, the accident helicopter entered a yaw to the right, which quickly developed into a rapid spin. The camera's view began to blur within the first second of the onset of the spin. The accident helicopter completed at least seven continuous spin rotations as it descended and subsequently impacted into trees at about 01:45. ADDITIONAL INFORMATION According to the FAA Helicopter Handbook, a loss of tail rotor effectiveness (LTE) is caused by aerodynamic conditions resulting in a tail rotor control margin deficiency and is not caused by a mechanical failure in the tail rotor system. Certain factors can exacerbate LTE, such as slow forward airspeed (a higher power demand from the main and tail rotor), high gross weight, and relative winds that may result in a disruption of airflow through the tail rotor or the lateral stability of the helicopter. In a LTE situation, once an adverse yaw rate has sufficiently developed, it may be impossible to correct it with full pedal in the opposite direction. The Robinson R44 II has a main rotor system that rotates counter-clockwise (when viewed from above), which requires a tail rotor system to yaw the helicopter left in order to provide main rotor anti-torque. In a LTE situation where there is insufficient tail rotor thrust to maintain directional control, the R44 II yaws to the right. Robinson Helicopter Corporation (RHC) Safety Notice No. SN-34 titled "Aerial Survey and Photo Flights – Very High Risk", issued in March 1999 and revised in April 2009, discusses the safety risks associated with such flights performed by inexperienced pilots. The accident pilot did not meet the RHC safety notice recommendation of 500 hours of pilot in command in helicopters and 100 hours in the model flown. Additionally, the accident pilot had never conducted a commercial operation or a flight requiring him to maintain a hover while in close proximity to another helicopter. Neither the accident pilot nor the lead pilot was aware of the Robinson SN-34. The RHC safety notice also recommends that photo flights "should only be conducted by experienced pilots who are willing to say no to the photographer and only fly at speeds, altitudes, and wind angles that are safe and allow good escape routes." Prior to the flight, the lead pilot recognized and was concerned with the inexperience of the accident pilot relative to the flight profile. He stated that a conversation with the accident pilot "raised many red flags" regarding the flight's safety. He considered not using the accident pilot for the filming, but decided to proceed "because of the value of the footage." ## Aircraft - Registration: [N445HS](https://openairdocs.org/aircraft/N445HS), registered now, S/N 13312 (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: 13312 - Year built: 2012 - Airframe hours: 340 - Engines: LYCOMING IO-540-AE1A5 245 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 91 - Operator: Perfect Filler LLC - Registered owner: Perfect Filler LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, August 8, 2015, 5 hours before - Departed: CFD, BRYAN, TX - Destination: CFD, BRYAN, TX ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 36; injuries: serious; flight instructor, commercial; airplane ratings: single-engine land; instrument ratings: helicopter; medical: class 2, without waivers/limitations; last flight review October 12, 2014; seat: right; restraint: 3-point; flight hours: 399 total, 83 in this make and model, 292 as pilot in command, 32 in the last 90 days, 26 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 13 knots, gusting 17 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 97 °F, dew point 70 °F - Altimeter: 29.87 inHg - Observed at: KCLL, 15 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 20150822013239A](https://openairdocs.org/incident/20150822013239A), Aug 22, 2015: Robinson Helicopter Company R44 II, Lola, TX, Destroyed. In an interview with the crashed helicopter?s pilot he stated that he was flying at altitude of approximately 250 feet above ground level carrying a cameraman… ## Docket (8 files) The files NTSB released with the investigation on April 22, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91840. 11.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 8.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439242&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Correspondence with Accident Pilot (item 2, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439243&FileExtension=.PDF&FileName=Correspondence%20with%20Accident%20Pilot-Master.PDF - Statement of Lead Helicopter Pilot (item 3, .PDF, 753 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439244&FileExtension=.PDF&FileName=Statement%20of%20Lead%20Helicopter%20Pilot%20-Master.PDF - FAA Accident Site Report (item 4, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439245&FileExtension=.PDF&FileName=FAA%20Accident%20Site%20Report-Master.PDF - RHC Safety Notice - Aerial Survey and Photo Flights (item 5, .PDF, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439246&FileExtension=.PDF&FileName=RHC%20Safety%20Notice%20-%20Aerial%20Survey%20and%20Photo%20Flights-Master.PDF - FAA Helicopter Handbook - LTE Excerpt (item 6, .PDF, 512 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439247&FileExtension=.PDF&FileName=FAA%20Helicopter%20Handbook%20-%20LTE%20Excerpt-Master.PDF - R44 II Out of Ground Effect Performance Chart (item 7, .PDF, 134 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439248&FileExtension=.PDF&FileName=R44%20II%20Out%20of%20Ground%20Effect%20Performance%20Chart-Master.PDF - Onboard Image Recorder - Specialist's Factual Report (item 8, .PDF, 481 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439251&FileExtension=.PDF&FileName=Onboard%20Image%20Recorder%20-%20Specialist%27s%20Factual%20Report-Master.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.