# NTSB CEN17FA209: Robinson Helicopter R44 II, N7091F, Dimmitt, TX, June 3, 2017 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 3, 2017, 14:37 local (19:37 UTC) - Place: Dimmitt, TX - Coordinates: 34.420555, -102.512222 - Nearby events: https://openairdocs.org/map.md?lat=34.4206&lon=-102.5122&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 18, 2019 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration, Robinson Helicopter Company - NTSB case key (mKey): 95289 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN17FA209 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95289/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95289 - Page: https://openairdocs.org/ntsb/CEN17FA209 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Robinson Helicopter R44 II, 25 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=7640122), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Impairment/incapacitation: cardiovascular](https://openairdocs.org/ntsb-findings/02012050): Personnel issues › Physical · Pilot (probable cause); cases with it: [Robinson Helicopter R44 II, 2 cases](https://openairdocs.org/ntsb-findings/02012050/cases.md?model=7640122), [All aircraft, 69 cases](https://openairdocs.org/ntsb-findings/02012050/cases.md) - [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) - [Experience/qualifications: qualification/certification](https://openairdocs.org/ntsb-findings/02031010): Personnel issues › Experience/knowledge · Pilot; cases with it: [Robinson Helicopter R44 II, 5 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md?model=7640122), [All aircraft, 280 cases](https://openairdocs.org/ntsb-findings/02031010/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: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Robinson Helicopter R44 II, 74 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7640122), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Maneuvering-low-alt flying: 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 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](https://openairdocs.org/deregistered/N7091F-2019-02-06), registration cancelled 2019-02-06, S/N 13910, built 2015 (OpenAirDocs) - Reported make and model: ROBINSON HELICOPTER COMPANY R44 II (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: 13910 - Year built: 2015 - Airframe hours: 177 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: fatal; 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 ## 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 20170603005379A](https://openairdocs.org/incident/20170603005379A), Jun 3, 2017: Robinson Helicopter RH44 II, Dimmitt, TX, Substantial damage, 1 fatal. On June 3, 2017, at approximately 1437 CDT, N7091F, a Robinson Helicopter, R44 ii, crashed into the ground while maneuvering for aerial cattle and land… ## Docket (10 files) The files NTSB released with the investigation on November 15, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95289. 8.8 MB in all. - Weather Study (item 1, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468370&FileExtension=.PDF&FileName=Weather%20Study-Master.PDF - GPS Factual Report (item 2, .PDF, 2 photos, 601 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468371&FileExtension=.PDF&FileName=GPS%20Factual%20Report-Master.PDF - GPS Maps (Google Earth) (item 3, .PDF, 4 photos, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468372&FileExtension=.PDF&FileName=GPS%20Maps%20(Google%20Earth)-Master.PDF - NTSB GPS Data (item 4, .PDF, 906 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468373&FileExtension=.PDF&FileName=NTSB%20GPS%20Data-Master.PDF - Medical Factual Report (item 5, .PDF, 238 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468374&FileExtension=.PDF&FileName=Medical%20Factual%20Report-Master.PDF - Record of Conversation - Jackson (item 6, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468375&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Jackson-Master.PDF - Excerpts of Maintenance Records (item 7, .PDF, 349 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468376&FileExtension=.PDF&FileName=Excerpts%20of%20Maintenance%20Records-Master.PDF - Statement of Party Representatives to NTSB Investigation - Robinson Helicopter (item 8, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468377&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20Robinson%20Helicopter-Master.PDF - Toxicological Report (item 9, .PDF, 350 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468378&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photos (item 10, .PDF, 6 photos, 946 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468379&FileExtension=.PDF&FileName=Photos-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.