CEN21LA109

NTSB accident investigation · Robinson Helicopter R44 II · Albany, TX · January 9, 2021

Accident · No injuriesClass 3 · LimitedFinal report
Date
January 9, 2021, 10:00 local (16:00 UTC)
Place
Albany, TX · NW of T23
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N322SHRobinson Helicopter R44 II
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Robinson Helicopter Company, Lycoming Engines, FAA FSDO
FAA report
20210109004419A
Case key
102510

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 inadequate pretakeoff checks which resulted in the magneto switch (key) remaining in the OFF position during the takeoff sequence and initial climb and the right magneto grounding intermittently.

Findings · 3

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 pilot reported that it was the second flight of the day. After an uneventful first flight, the helicopter returned to the airport to refuel and pick up new passengers. The purpose of the flight was to hunt game. As the passengers were getting into the helicopter, a rifle was dropped on the dash of the helicopter which turned the alt switch, master switch, and clutch switch to off. The pilot immediately turned the switches back on and conducted a hover power and final systems check. The helicopter then took off uneventfully. About 120 ft above the ground, the engine sputtered once then lost complete power. The pilot performed a left turning autorotation to a field. During the descent, the pilot increased the throttle, but the engine did not respond. The helicopter impacted trees before it landed hard on a small mound of dirt and came to rest nose low. During the impact sequence, the main rotor blade contacted and severed the tail boom. The pilot never reported that he conducted the ‘starting engine and run up’ checklist before taking off. This was confirmed by an onboard video. The video also showed the ignition switch in OFF throughout the flight, the impact, and following the accident sequence. During a postaccident engine run, the engine started uneventfully, and a magneto check was completed. When the ignition switch was in the right magneto position the engine rpm stayed the same instead of decreasing, indicating the magneto was not properly grounding. In addition, the engine continued to run despite the ignition switch being in the off position, indicating the engine was operating on one magneto. The ignition switch key was jiggled, manipulated, and even removed from the ignition switch, but the engine continued to run. The engine was shut down and electrical continuity was established from the ignition switch to the magnetos. The magneto grounding wires were examined and appeared to be properly secured. The wiring was tested with a volt/ohm meter and functioned normally. The grounding wires were reinstalled, and the engine was restarted. It operated normally and several magneto checks were normal. The magnetos were removed for a functional bench test and disassembly; no anomalies were noted with either magneto. The ignition switch was also removed, disassembled, and examined. No anomalies were found. Even though functional and disassembly tests did not indicate a problem with the magnetos themselves, the right magneto did not ground appropriately during the initial engine run. The anomaly was unable to be recreated after the magneto grounding wires were removed and reinstalled. Because the pilot did not perform all the required pretakeoff checks to ensure all the switches were in the correct positions prior to takeoff, the helicopter took off with the ignition switch in the OFF position. An undefined issue with the grounding wire caused the right magneto to not ground and allowed the helicopter to operate with the ignition in the “off”position. The magneto likely grounded during the initial climb, and since the ignition switch was in the OFF position, the engine shut down.

Factual narrative

On January 9, 2021, about 1000 central standard time, a Robinson R44II helicopter, N322SH, was substantially damaged when it was involved in an accident near Albany, Texas. The pilot and two passengers were not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 hog hunting flight. The pilot reported that it was the second flight of the day. After an uneventful first flight, the helicopter returned to the airport to refuel and pick up new passengers. As the passengers were getting into the helicopter, a rifle was dropped on the dash of the helicopter. “The alt switch, master switch, and clutch [were] switch off” After turning the switches back on, the pilot conducted a “hover power and final systems check.” The helicopter then took off uneventfully. The pilot reported that when 120 ft above the ground, the engine sputtered once then lost complete power. The pilot performed a left turning autorotation to a field. During the descent, the pilot increased the throttle, but the engine did not respond. The helicopter impacted trees before it landed hard on a small mound of dirt and came to rest nose low. The main rotor blade contacted, and severed, the tail boom. Video of the accident flight begins with the helicopter on the ramp with the engine running with the magneto key in what appears to be the OFF position. In addition, as the pilot shuts down the helicopter after impact, the position of the key did not appear to move despite his fingers touching the key. During a postaccident examination of the airframe and engine, the helicopter was prepped for an engine run. It started normally and idled for a short time, then a magneto check was conducted. The engine rpm decreased when the key was turned to the left magneto position; however, the rpm remained the same when the right magneto was selected. The key was then moved to the OFF position, and the engine continued to run. The key was jiggled, manipulated, and even removed from the ignition switch, but the engine continued to run. The engine was shut down, and electrical continuity was established from the ignition switch to the magnetos. The grounding wires on the magnetos were examined and appeared to be properly secured. The wires were disconnected; they were pulled and manipulated with no anomalies noted. The magneto grounding wires were tested with a volt/ohm meter and functioned normally. The grounding wires were reinstalled for each magneto and the engine was restarted. It operated normally with several normal magneto checks. The magnetos were removed from the engine and the caps were removed; there were no obvious anomalies noted with the internal components. The ignition switch was also removed and disassembled, with no anomalies noted. The magnetos were removed for a functional bench test and disassembly. During the bench test, their temperature was increased to 190° F and the magnetos performed normally. Disassembly of the magnetos did not reveal anyanomalies with the E-gap, contact settings, condensers, coils, and distributor gear timing that would have precluded normal operations. In the Robinson R-44II Pilot operating handbook the “STARTING ENGINE AND RUN-UP” checklist includes: “Ignition switch…Prime, then Both,” and “Mag drop at 75% RPM….7% max in 2 seconds.” Both checklist items involve manipulating the key prior to takeoff.

Aircraft

Registration
N322SH
Reported as
Robinson Helicopter R44 II
Category
Helicopter
Serial number
13391
Built
2012
Airframe hours
255
Engine
Lycoming IO-540-AE1A5, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Other work use · Part 91
Operator
S2 Helicopter Services LLC
Registered owner
S2 Helicopter Services LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 22, 2020
Airport
T23 · Albany Municipal Airport
Equipment
ADS-B, 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
31
Injuries
None
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
March 15, 2020
Seat
Right
Flight hours
4,954 total · 3,000 in this make and model · 4,500 as pilot in command · 100 in the last 90 days · 25 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 3 knots
Visibility
7 statute miles
Lowest ceiling
None
Temperature
36 °F, dew point 36 °F
Altimeter
30.34 inHg
Observed at
GZN, 25 nm away
METAR
KBKD 091615Z AUTO 00000KT 1SM BR OVC001 01/01 A3038 RMK AO2 T00060006

Docket · 7

The files NTSB released with the investigation on August 8, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.7 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.