CEN22FA151

NTSB accident investigation · Robinson Helicopter R44 · Rowlett, TX · March 25, 2022

Accident · FatalClass 3 · FieldFinal report
Date
March 25, 2022, 11:27 local (16:27 UTC)
Place
Rowlett, TX · Municipality of Rowlett Texas
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N514CDRobinson Helicopter R44
Defining event
Maneuvering: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Robinson Helicopters, FAA North Texas FSDO, Lycoming Engines
FAA report
20220325004299A
Case key
104828

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

A loss of helicopter control while maneuvering, which resulted in main rotor blade contact with the tailboom in flight, tail boom separation, and an uncontrolled descent.

Findings · 2

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · Instructor/check pilotRobinson Helicopter R44: 40 casesAll aircraft: 9,295 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedRobinson Helicopter R44: 6 casesAll aircraft: 1,269 casesProbable cause

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

**This report was modified on April 29, 2024. Please see the docket for the original report.** According to the operator, the lesson syllabus for the instructional helicopter flight included emergency procedures, equipment malfunctions, and vortex ring state (VRS) recognition and recovery. Flight track data, video, and a witness statement indicated that the helicopter was maneuvering at slow speeds about 2,000 ft mean sea level in the minute before the accident and shortly before a 4-ft section of the tailboom separated and the helicopter entered a spiraling descent to the ground. The witness stated that the helicopter appeared to hover when the tail boom separated. The 4-ft section of the tailboom which included the tail rotor came to rest on the roof of a commercial building about 300 ft from the main wreckage. Examination of the helicopter revealed that the main rotor elastomeric teeter stops were severely damaged, and the brackets were bent. The main rotor drive shaft displayed scuff marks where the teeter stops were damaged, consistent with extreme teetering of the main rotor. Main rotor blade contact marks and dents were consistent with the main rotor blades contacting the tailboom in flight, resulting in its separation. Examination of the helicopter and engine did not reveal any preaccident anomalies with the helicopter that would have precluded normal operation. The syllabus for the accident flight included an introduction to VRS and given the flight track information and witness statement, it is possible that the flight instructor was demonstrating, or the pilot receiving instruction was performing, a VRS entry/recovery when the accident occurred. However, since detailed information regarding the helicopter’s flight control and engine parameters was not available, the exact maneuver being conducted at the time of the tail boom separation could not be determined. The main rotor’s contact with the tailboom is consistent with improper flight control inputs or low rotor RPM. Toxicology testing of the flight instructor revealed the presence of bupropion, an antidepressant medication. Based on the available information, it could not be determined whether effects of the flight instructor’s bupropion use or an associated condition contributed to the accident. Toxicological testing of the pilot receiving instruction revealed the presence of cetirizine, an antihistamine. It is unlikely that the effects of this medication contributed to the accident.

Factual narrative

Vortex Ring State Information from Robinson Flight Training Guide, dated March 2019: The vortex ring state is most dangerous when it happens at relatively low altitudes. The most common condition is during a steep approach with a tailwind. It should be demonstrated at an altitude of at least 1000 feet AGL. To enter a maneuver, adjust the power to approximately 13–15 inches manifold pressure. Hold altitude with aft cyclic until the airspeed approaches 20 KTS. Allow the sink rate to increase to 300 FPM or more as the attitude is adjusted to obtain airspeed of less than 10 KTS. The aircraft will begin to shudder. Application of additional up collective will increase the vibration and sink rate while the cyclic and pedal effectiveness is reduced. Once the condition is well developed, rate of sink in excess of 2000 FPM can result. Recovery should be initiated at the first sign. The maneuver can also be entered from an OGE hover. There are two recovery techniques: 1. The traditional technique is to apply forward cyclic to increase airspeed and simultaneously reduce the collective. When the airspeed indicates 20- 30 KTS and the trim strings have become effective raise the collective to takeoff power and adjust the cyclic to a maximum performance climb attitude. The recovery is completed when the VSI reads 0. 2. A more efficient recovery technique is called the Vuichard Recovery. Initiate the recovery by raising the collective to takeoff power (MCP at lower gross weights), simultaneously applying left pedal to maintain heading and right cyclic (10°–20° bank) to get lateral movement. Once the right side of the rotor disc reaches the upwind part of the vortex the recovery is completed. Average loss of altitude during the recovery is 20–50 feet. In January 2024, Robinson amended paragraph 2 in its Flight Training Guide to read: To enter a maneuver, adjust the power to approximately 13-15 inches of manifold pressure. Hold altitude with aft cyclic until the airspeed approaches 20 KTS. Allow the sink rate to increase to 300 FPM or more as the attitude is adjusted to obtain airspeed of less than 10 KTS. The aircraft will begin to shudder. Application of additional up collective will increase the vibration and sink rate while the cyclic and pedal effectiveness is reduced. If this condition becomes well developed, rate of sink in excess of 2000 FPM can result. Do not allow the condition to develop beyond the initial indications and avoid large control inputs. Recovery should be initiated at the first sign. The maneuver can also be entered from an OGE hover. On March 25, 2022, about 1127 central daylight time, a Robinson R44 helicopter was destroyed when it was involved in an accident near Rowlett, Texas. The flight instructor and pilot receiving instruction sustained fatal injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the operator, the accident flight was the second flight of the dayfor the flight instructor and the pilot receiving instruction. The first flight, which was lesson 10 of the training syllabus, was completed successfully. The accident flight was lesson 11, which included pre-solo maneuvers, introduction/simulation of emergency procedures, equipment malfunctions, and vortex ring state (VRS) recognition and recovery. Video provided to the National Transportation Safety Board (NTSB) showed the helicopter and its separated tailboom and tail rotor section falling. The video did not show the actual in-flight separation of the tail section. About the last minute of the automatic dependent surveillance – broadcast (ADS-B) data for the flight showed that the helicopter was maneuvering at various slow airspeeds and altitudes. At 1126:07, the helicopter was about 1,975 ft mean sea level (msl) and flying at 7 knots ground speed. (See figure 1.) Figure 1. Final Minute of Flight Track from ADS-B Data The ADS-B data points were consistent with a witness report. The witness heard the helicopter and did not think much of it until after a minute, when he noticed that the helicopter was not moving. He then looked up and saw the helicopter hovering in one place and assumed that it was taking photos of the area. Continuing to observe the helicopter, the witness saw it move about 100 ft and hovered in one place again. After about 10 seconds, the helicopter moved about another 100 ft and hovered. The witness then observed something separate from the helicopter. He saw the helicopter start to go backwards and the tail section fell toward the west. He then saw the helicopter spiraling and falling for about 100 ft. The helicopter stopped falling and spinning for a couple of seconds. Then the helicopter started to spin again and nose-dived to the ground. There were no radio or distress calls heard from the helicopter. Autopsies on the flight instructor and pilot receiving instruction were conducted at the Southwestern Institute of Forensic Sciences at the Dallas Office of the Medical Examiner, Dallas, Texas. The cause of death for both was blunt force injuries. Toxicological testing of the flight instructor and pilot receiving instruction were performed at the Federal Aviation Administration Forensic Sciences Laboratory. Tests were also performed at the Southwestern Institute of Forensic Sciences at the Dallas Office of the Medical Examiner, Dallas, Texas. 68 ng/g of the antidepressant medication bupropion was detected in specimens from the flight instructor. 258 ng/ml, ng/g of the antihistamine medication cetirizine was detected in the specimens from the pilot receiving instruction. The pilot was receiving instruction to add a helicopter rating to his pilot certificate. Seven of his previous lessons were flown with a different instructor. According to training records provided by the operator, the accident instructor flew with the pilot for three lessons before the accident flight. The flight instructor was qualified as an instructor inthe R-22 and R-44 helicopters and had completed the Robinson Helicopter Pilot Safety Training Course on May 5, 2021. The main section of the helicopter was found in a vacant lot between a commercial strip mall and a municipal roadway. The main wreckage was mostly consumed by a post-impact fire. A 4-ft section of the tail boom, with the tail rotor assembly attached, impacted the top of a one-story commercial building about 300 ft from the main wreckage. Main rotor blade impact marks on the separated section of the tail boom were consistent with main rotor blade contact of the tail boom in flight. The elastomeric teeter stops were severely damaged, and the brackets bent. The main rotor drive shaft displayed scuff marks where the teeter stops were damaged. Although most of the helicopter was consumed by a post-impact fire, detailed examinations of the airframe, drive system, annunciator light panel, flight controls, main rotor, tail rotor, drive systems, powerplant controls, and fuel system did not reveal any preaccident mechanical failures or malfunctions with the helicopter systems that would have precluded normal operation. All fractures in the flight control tubes were consistent with overload or thermal damage. All control tube attachments were accounted for and secure. The main rotor swashplate moved freely by hand. Both main rotor blade pitch links were fractured at the upper rod end in overload. All three hydraulic servos sustained thermal damage and could not be moved by hand. The tail rotor pitch change slider moved freely by hand. A detailed examination of the engine was completed on-scene. No preaccident mechanical failures or anomalies were observed that would have precluded normal operation.

Aircraft

Registration
N514CD
Reported as
Robinson Helicopter R44
Category
Helicopter
Serial number
30007
Built
2016
Airframe hours
920
Engine
Lycoming O-540-F1B5, 185 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Sky Helicopters Inc
Registered owner
Sky Helicopters Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 14, 2022
Departed
T57 · Garland, TX
Destination
F46 · Rockwall, TX
Flight plan
Company VFR
Equipment
ADS-B, Auto-pilot, Electronic primary flight display, Satellite tracking device

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
31
Injuries
Fatal
Certificates
Commercial, Flight instructor
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
March 15, 2022
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
525 total · 330 in this make and model · 455 as pilot in command · 39 in the last 90 days · 30 in the last 30 days · 3 in the last 24 hours
Role
Student pilot
Age
42
Injuries
Fatal
Certificates
Commercial, Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Right
Restraint
3-point
Toxicology
Performed
Flight hours
486 total · 16 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 28 °F
Altimeter
30.16 inHg
Observed at
KF46, 8 nm away
METAR
KF46 251615Z AUTO 23005KT 10SM CLR 19/M02 A3016 RMK AO2 T01911019

Docket · 21

The files NTSB released with the investigation on April 18, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 31.8 MB in all.

ADS b data CEN22FA151Item 1 · CSV · 3.0 MBADS b flight track graph entire flight CEN22FA151Item 2 · PDF · 1 page · 893 KBADS b flight track graph final portion of flight CEN22FA151Item 3 · PDF · 1 page · 840 KBWiteness statement CEN22FA151Item 4 · PDF · 1 page · 4.1 MBMemorandum for the record accident site and airframe examination findings CEN22FA151Item 5 · PDF · 6 pages · 1.1 MBMemorandum for the record engine examination findings CEN22FA151Item 6 · PDF · 2 pages · 146 KBCFI records CEN22FA151Item 7 · PDF · 5 pages · 8.9 MBStudent helicopter training records CEN22FA151Item 8 · PDF · 10 pages · 1.7 MBRobinson private pilot flight training syllabus CEN22FA151Item 9 · PDF · 58 pages · 2.0 MBExcerpt from Robinson flight training guide dated January 2024Item 10 · PDF · 10 pages · 204 KBExcerpt from Robinson flight training guide dated March 2019 CEN22FA151Item 11 · PDF · 1 page · 93 KBRobinson helicopters safety notices 24 and 29 CEN22FA151Item 12 · PDF · 3 pages · 799 KBNTSB medical factual report CEN22FA151Item 13 · PDF · 5 pages · 159 KBToxicology report CFIItem 14 · PDF · 1 page · 137 KBToxicology report student under instructionItem 15 · PDF · 1 page · 185 KBCertificate of party representative Robinson helicopters CEN22FA151Item 16 · PDF · 1 page · 5.9 MBCertificate of party representative Lycoming engines CEN22FA151Item 17 · PDF · 1 page · 171 KBNTSB release of wreckage N514CD CEN22FA151Item 18 · PDF · 2 pages · 122 KBRobinson email of safety accomplishments CEN22FA151Item 19 · PDF · 2 pages · 86 KBCEN22FA151 factual revisions memo CEN22FA151Item 20 · PDF · 1 page · 92 KBOriginal final report CEN22FA151Item 21 · PDF · 10 pages · 1.3 MB

FAA reports on this event · 1

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