# NTSB CEN19FA160: Robinson R44, N41351, Cass, AR, June 3, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: June 2, 2019, 19:50 local (Jun 3, 2019, 00:50 UTC) - Place: Cass, AR - Coordinates: 35.705276, -93.794998 - Nearby events: https://openairdocs.org/map.md?lat=35.7053&lon=-93.7950&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Fatal - Injuries: 3 fatal, 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO, Lycoming Engines, Robinson Helicopters - NTSB case key (mKey): 99538 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA160 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99538/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99538 - Page: https://openairdocs.org/ntsb/CEN19FA160 ## Probable cause A loss of engine power for reasons that could not be determined based on the available information. ## 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) ## 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 engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Robinson Helicopter R44 II, 20 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7640122), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240); 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) ## Analysis The pilot and three passengers departed on a local sightseeing flight at a music festival. The helicopter impacted a densely wooded area and came to rest between trees on its right side. The surviving passenger stated to the media that the helicopter’s engine made sounds “like your car does when it runs out of fuel.” Examination of the helicopter at the accident site indicated evidence of main rotor blade rotation; however, damage to the engine drive system did not reveal evidence of engine power at the time of impact. Additionally, the oil pressure warning light bulb filament was found stretched consistent with illumination at the time of impact, which according to the helicopter’s operating handbook, may be one indication of a loss of engine power. About 5 gallons of fuel was drained from the helicopter following the accident, with no evidence of fuel contamination. Examination of the airframe, flight controls, and engine revealed no evidence of any preimpact mechanical anomalies that would have precluded normal operation. ## Factual narrative The helicopter’s most recent inspection was a combined 2,200 hour overhaul, 100-hour, and annual inspection, completed on May 6, 2019. As part of this inspection, the engine was removed, overhauled, and reinstalled on the helicopter. According to the helicopter’s type certificate data sheet, the unusable fuel quantity was 1 gallon. R44 Emergency Procedures The pilot operating handbook for the helicopter, Section 3, Emergency Procedures, Power Failure – General, stated that an engine failure may be indicated by a change in noise level, nose left yaw, an oil pressure light, or decreasing engine rpm. On June 2, 2019, about 1950 central daylight time, a Robinson R44 II helicopter, N41351, was substantially damaged when it was involved in an accident near Cass, Arkansas. The pilot and two passengers were fatally injured, and one passenger survived with serious injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 sightseeing flight. The helicopter flew passengers from a local music festival over the densely wooded area to the south of the performance arena. The helicopter was reported overdue and was located by search and rescue crews in a densely wooded area of the Ozark National Forest. There were no witnesses to the accident. A witness recalled seeing the helicopter while camping at the music festival. He saw the helicopter flying in an area different from the previous flights. He saw the helicopter’s nose pitch “dramatically” up. The helicopter climbed and then its climb stopped, sliding backwards tail first before the nose of the helicopter pitched rapidly down. The helicopter then entered a right turn and descended out of his view. He did not witness an impact and did not know about the accident until after viewing news reports. It is unknown if this was the accident sequence or if he witnessed a previous flight. The survivor of the accident was unable to provide a statement to investigators. During media interviews he stated that “the helicopter started chugging like your car does when it runs out of fuel. The engine cut and we started dropping.” A review of Automatic Dependent Surveillance – Broadcast (ADS-B) information captured numerous sporadic points of multiple flights flown on the day of the accident. The last recorded points captured the helicopter in a left turn about 200-300 ft above ground level at a groundspeed between 55 and 70 knots. The final point was about 250 yards from the accident site. An autopsy was conducted on the pilot by the Arkansas State Crime Laboratory. The cause of death was multiple injuries and the manner of death was ruled an accident. Toxicology testing was conducted by the FAA Forensic Sciences Laboratory. Testing was negative for carbon monoxide, cyanide, and ethanol. Hydroxychloroquine was detected in blood and in the liver. The pilot’s logbooks were not available for review. On his most recent application for a Federal Aviation Administration (FAA) medical certificate,dated December 19, 2018, the pilot reported 5,000 total hours of flight experience with 200 hours in the preceding 6 months. The helicopter impacted a densely wooded area of the Ozark National Forest and came to rest between trees on its right side. The tailboom was fractured and bent to the right but remained attached via the tail rotor drive shaft. Damage to the helicopter was consistent with an impact with trees in a nose-low right bank. Several large branches at the site displayed cuts and a tree trunk exhibited 45° slash marks. About 5 gallons of fuel was drained from the fuel tank. Fuel collected at the firewall gascolator appeared clean and free of contaminants. The gascolator filter was clear of debris. All main rotor blade and tail rotor linkages remained secured. Flight control continuity was confirmed from the cockpit controls to the swash plate to the blade pitch change links. Continuity of the main rotor drive system was confirmed by manually rotating the main rotor blades. The frame tubing displayed impact marks from the engine belt pulley with no directional score marks on either surface. All engine drive belts remained in place and were not damaged. The attitude indicator displayed a right bank, and the airspeed indicator displayed about 88 knots. Several of the cockpit lights were impact damaged, of the remaining lights, the oil pressure warning light’s filament was stretched. Examination of the airframe revealed no evidence of any preimpact anomalies. Examination of the engine revealed no evidence of any preimpact anomalies. The fuel servo was removed and bench tested. No malfunctions were detected with the fuel servo. ## Aircraft - Registration: [N41351](https://openairdocs.org/deregistered/N41351-2021-04-03), registration cancelled 2021-04-03, S/N 12351, built 2008 (OpenAirDocs) - Reported make and model: Robinson 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: 12351 - Year built: 2008 - Airframe hours: 2246 - Engines: Lycoming IO-540-AE1A5 245 horsepower reciprocating - Damage: Substantial damage - Flight: Other work use, Part 91 - Operator: D & C Aviation Llc - Registered owner: D & C Aviation Llc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 6, 2019, 46.08 hours before ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: fatal; commercial; instrument ratings: helicopter; medical: class 2, with waivers/limitations; seat: right; restraint: 3-point; toxicology performed; flight hours: 5,000 total ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: 10,000 ft overcast - Temperature: 70 °F, dew point 66 °F - Altimeter: 29.70 inHg - Observed at: KFSM, 36 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 20190602005609A](https://openairdocs.org/incident/20190602005609A), Jun 2, 2019: Robinson Helicopter Company R44 II, Cass, AR, Destroyed, 3 fatal. On Sunday June 2, 2019 at approximately 1930L, robison R-44 operating as a 14 CFR part 91 sightseeing aircraft, registered as N41351, crashed in the vicinity… ## Docket (12 files) The files NTSB released with the investigation on November 9, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99538. 41.1 MB in all. - Toxicological report (item 1, PDF, 1 page, 962 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12647587&FileExtension=pdf&FileName=Pilot%20tox%20cen19fa160_Redacted-Rel.pdf - Pilot information (item 2, PDF, 1 page, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12647220&FileExtension=pdf&FileName=Pilot%20Information%20CEN19FA160-Rel.pdf - Helicopter documents (item 3, PDF, 5 pages, 24.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12647127&FileExtension=pdf&FileName=Helicopter%20Documents_Redacted-Rel.pdf - Helicopter information (item 4, PDF, 1 page, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12646625&FileExtension=pdf&FileName=Helicopter%20records-Rel.pdf - All ADS b points (item 5, PDF, 1 page, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12646796&FileExtension=pdf&FileName=document1-Rel.pdf - ADS-B data (item 6, CSV, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12893958&FileExtension=csv&FileName=20190602000000_N41351_A4E266-Rel.csv - Record of conversation possible witness (item 7, PDF, 1 page, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12654140&FileExtension=pdf&FileName=ROC%20M%20Johnson_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 8, PDF, 1 page, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12653749&FileExtension=pdf&FileName=Release_Redacted-Rel.pdf - Examination notes (item 9, PDF, 2 pages, 239 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12654077&FileExtension=pdf&FileName=Examination%20Notes%203-10-2020-Rel.pdf - Photos (item 10, PDF, 8 pages, 8 photos, 8.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12702316&FileExtension=pdf&FileName=Photo%20cen19fa160-Rel.pdf - POH power failure entry (item 11, PDF, 1 page, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12894663&FileExtension=pdf&FileName=r44_poh_3%20power%20failure-Rel.pdf - Media statements (item 12, PDF, 11 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12894391&FileExtension=pdf&FileName=Media-Rel.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.