CEN17FA209

NTSB accident investigation · Robinson Helicopter R44 II · Dimmitt, TX · June 3, 2017

Accident · FatalField investigationFinal report
Date
June 3, 2017, 14:37 local (19:37 UTC)
Place
Dimmitt, TX
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N7091FRobinson Helicopter R44 II
Defining event
Maneuvering-low-alt flying: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report March 18, 2019
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, Robinson Helicopter Company
FAA report
20170603005379A
Case key
95289

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

On this page

Probable cause

The pilot's incapacitation due to scarring from previous heart attacks and severe hypertrophy of the left ventricular wall which resulted in arrhythmia and a loss of control while maneuvering at low altitude.

Findings · 4

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.

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

The private pilot, who did not hold a rotorcraft rating, departed in the helicopter on a routine flight to check and observe crop fields, business facilities, and other business-related assets. A search was initiated when the pilot did not return from the flight, and the accident site was located in a field the following morning. There were no witnesses to the accident. Data obtained from an onboard GPS showed the helicopter making a series of turns at a low altitude above the field in which the wreckage was located. Examination of the helicopter did not reveal any preimpact mechanical malfunctions and there was no damage to nearby obstructions to suggest an in-flight collision. The pilot's autopsy revealed scarring in heart muscle from previous heart attacks and severe left ventricular hypertrophy. Each of these findings significantly increased his risk for a sudden arrhythmia. Such an arrhythmia would likely cause sudden symptoms such as palpitations or altered/decreased consciousness as a result of diminished blood pressure. It is likely that scarring from previous heart attacks and severe hypertrophy of the left ventricular wall caused arrhythmia which resulted in incapacitation and a loss of control at low altitude. Although the pilot did not hold a rating for rotorcraft, his recent flight experience in the accident helicopter performing similar flight profiles make it unlikely that he simply lost helicopter control.

Factual narrative

The accident helicopter, serial number 13910, was a Robinson R44 II, four-place, two-bladed, single main rotor, single-engine helicopter, with skid-type landing gear. The primary structure was welded steel tubing and riveted aluminum. The tailboom was a semi-monocoque structure consisting of an aluminum skin. Each seat was equipped with a combined seat belt and inertia reel shoulder strap. The helicopter was equipped with a Lycoming IO-540- AE1A5 engine, serial number L-36203-48E, rated at 260 horsepower; however, according to the helicopter's type certificate, the engine had a 5-minute takeoff rating of 245 horsepower and a maximum continuous rating of 205 horsepower. The helicopter was registered to the owner on December 1, 2015. On June 3, 2017, about 1437 central daylight time, a Robinson R44 II helicopter, N7091F, impacted terrain while maneuvering at near Dimmitt, Texas. The private pilot sustained fatal injuries, and the helicopter sustained substantial damage. The helicopter was registered to Don Oppliger Trucking, Inc, Clovis, New Mexico, and privately operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed for the local business flight, which departed a private helipad near Farwell, Texas, about 1302. According to the pilot's business manager, the pilot departed on a routine flight to check and observe crop fields, business facilities, and other business-related assets. When the pilot did not return from the flight, a search was initiated. The helicopter wreckage was located in a field about 0800 the following morning. There were no witnesses to the accident. Flight data downloaded from a Garmin GPSmap 496 handheld GPS unit located at the accident site included the accident flight. Data extracted from the unit included 13 flight track logs from April 22, 2017, to June 3, 2017. The accident flight was recorded starting at 1302:31 and ended at 1437:28, and included 730 discrete points. The flight track was consistent with the pilot overflying fields, facilities, and other business assets. The end of the data showed the helicopter making a series of turns at a low altitude above the field where the wreckage was located. An autopsy was performed by South Plains Forensic Pathology, P.A., Lubbock, Texas. The cause of death was blood loss due to visceral injuries due to blunt force injuries, and the manner of death was an accident. The autopsy also described significant heart disease. The heart weighed 610 gm and both the ventricles were dilated; the left ventricle was described as having severe hypertrophy, but no measurements were given. There was very severe coronary artery disease in the native arteries, but the grafts were all described as patent. A stent was identified, but not further described. Sections of the myocardium revealed scarring from old heart attacks in the left ventricle. Microscopy of the heartshowed myocyte hypertrophy with interstitial and perivascular fibrosis. There were areas where adipose and fibrotic tissue replaced normal cells. Toxicology testing performed by the Federal Aviation Administration's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, identified no ethanol in the vitreous. In addition, salicylate (a metabolite of aspirin) was found in urine, losartan was found in cavity blood and liver, and clopidogrel was identified in liver tissue. As stated above, none of these are considered impairing. The pilot held a Federal Aviation Administration (FAA) private pilot certificate with airplane single and multi-engine land and instrument airplane ratings. The pilot did not hold a rotorcraft rating; however, according to his business manager, he had flown helicopters for several years for business purposes. Based on the 177 total hours on the accident helicopter, the pilot's estimated rotorcraft flight experience was at least 177 hours. The pilot reported a total flight experience of 4,225 hours on his 2016 FAA medical certificate application. According to the FAA medical files, the 68 year-old pilot reported having had a 4 vessel coronary artery bypass graft procedure in 2008, followed by a stent in his right coronary artery in 2009. After reviewing the data related to these events, the FAA granted the pilot special issuance medical certificates beginning in 2010. At the time of his last aviation medical examination on March 29, 2017, he reported using aspirin and clopidogrel as blood thinners, losartan for blood pressure control, and a combination of ezetimibe and simvastatin to control his cholesterol. None of these were considered impairing. A stress echo cardiogram, dated January 6, 2017, demonstrated that the pilot reached 16 mets, more than 150% of the target heart rate, and had no ischemic findings on his electrocardiogram or echocardiogram. The aviation medical examiner found no abnormalities and the pilot received a special issuance third class medical certificate limited by a requirement for corrective lenses and marked, "Not valid for any class after March 31, 2018." Examination of the accident site revealed that the helicopter came to rest on its right side in a wheat field (the wheat crop was about 3 inches tall) owned by the pilot's business. Three ground scars, consistent with main rotor blade strikes, were observed adjacent to the main wreckage. Fragmented plexiglass was scattered between the ground scars and main wreckage. Separated sections of the main rotor blades were located within a 75-ft diameter of the main wreckage; the main rotor blades were fragmented, bent, deformed, and their root sections remained attached to the rotor hub. No evidence of contact with any adjacent structures or power lines was observed. The lower forward fuselage was crushed aft and upward. The tailboom was intact, and the horizontal stabilizer was bent. No damage was noted to the tail skid. The forwardlanding gear skid tubes were fractured, and the left forward skid tube was separated and located in the debris field. The left forward door was separated, the right forward door and rear cabin doors were damaged and partially fragmented. The forward seat belts and shoulder harnesses were unlatched. The helicopter was not equipped with an emergency locator transmitter. Flight control continuity was established from the cockpit flight controls to the swashplate and tail rotor system. Drivetrain continuity was established from the engine to the main transmission and tail rotor systems. The engine remained attached to the engine mount and secured in the airframe. Thumb compression was noted on all cylinders, and mechanical continuity throughout the engine was established. The magnetos and ignition leads produced spark when engine crankshaft was rotated.

Aircraft

Registration
N7091F
Reported as
Robinson Helicopter R44 II (II)
Category
Helicopter
Serial number
13910
Built
2015
Airframe hours
177
Engine
Lycoming IO-540-AE1A5, 245 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 20, 2017 · 27 hours before
Departed
PVT · Farwell, TX
Destination
PVT · Farwell, TX
Equipment
Handheld GPS

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
68
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Right
Restraint
None
Toxicology
Performed
Flight hours
4,225 total · 177 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
70° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 57 °F
Altimeter
30.05 inHg
Observed at
HRX, 28 nm away

Docket · 10

The files NTSB released with the investigation on November 15, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.8 MB in all.

FAA reports on this event · 1

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