# NTSB ERA11LA392: Robinson Helicopter R22 Beta, N10786, West Palm Beach, FL, July 10, 2011 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: July 10, 2011, 09:10 local (13:10 UTC) - Place: West Palm Beach, FL - Coordinates: 26.683055, -80.095558 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.6831&lon=-80.0956&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report February 6, 2012 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 81056 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA11LA392 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/81056/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=81056 - Page: https://openairdocs.org/ntsb/ERA11LA392 ## Probable cause Separation of the auxiliary fuel tank cap, which entered the tail rotor system. Contributing to the accident was the lack of a fuel tank cap restraint. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel storage](https://openairdocs.org/ntsb-findings/01022810): Aircraft › Aircraft systems · Design (probable cause); cases with it: [Robinson Helicopter R22 BETA, 1 case](https://openairdocs.org/ntsb-findings/01022810/cases.md?model=7640110), [All aircraft, 60 cases](https://openairdocs.org/ntsb-findings/01022810/cases.md) - [Design: equipment design](https://openairdocs.org/ntsb-findings/04011010): Organizational issues › Development · Manufacturer (probable cause); cases with it: [Robinson Helicopter R22 BETA, 1 case](https://openairdocs.org/ntsb-findings/04011010/cases.md?model=7640110), [All aircraft, 35 cases](https://openairdocs.org/ntsb-findings/04011010/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Robinson Helicopter R22 BETA, 14 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7640110), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338) (defining event); cases with it: [Robinson Helicopter R22 BETA, 9 cases](https://openairdocs.org/ntsb-events/338/sequence.md?model=7640110), [All aircraft, 563 cases](https://openairdocs.org/ntsb-events/338/sequence.md) - [Initial climb: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330); cases with it: [Robinson Helicopter R22 BETA, 6 cases](https://openairdocs.org/ntsb-events/330/sequence.md?model=7640110), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Autorotation: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Robinson Helicopter R22 BETA, 54 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=7640110), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis During initial climb, about 200 feet above the ground, the helicopter's auxiliary fuel tank cap separated and entered the tail rotor system. The tail rotor became unbalanced and partially separated. The pilot subsequently entered an autorotation as the horizontal and vertical stabilizers also separated, and the helicopter landed hard. The auxiliary fuel tank cap was not serviced prior to the accident flight and the pilot reported that he checked the security of the auxiliary and main fuel tank caps during preflight inspection. The separated fuel cap was recovered and did not contain a restraining chain and gasket. The main fuel tank cap remained secured throughout the accident sequence and examination of that cap revealed that it did contain a gasket but not a chain. The helicopter manufacturer ceased installing restraining chains about 18 years prior to the accident; however, the accident helicopter was produced about 10 months before that and should have left the factory with fuel tank cap restraining chains. Review of the helicopter's maintenance records did not reveal any instance of the fuel cap restraining chains being removed in the field. Additionally, the investigation could not determine if the auxiliary fuel tank cap gasket was absent prior to the accident flight or separated during impact with the tail rotor. ## Factual narrative On July 10, 2011, about 0910 eastern daylight time, a Robinson R22 BETA, N10786, operated by Ocean Helicopters Inc., was substantially damaged during an autorotation, following a system malfunction during initial climb from Palm Beach International Airport (PBI), West Palm Beach, Florida. The certified flight instructor (CFI) was not injured and the student pilot incurred minor injuries. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the planned local flight, which departed PBI about 0840. According to the CFI, he and the student pilot performed five or six quick-stops. They then proceeded with a normal takeoff. About 200 feet above the ground, the helicopter yawed right, which was unable to be corrected with left pedal input. The CFI then entered an autorotation as the helicopter continued to yaw right. He also observed that the horizontal and vertical stabilizers had separated from the tailboom and were falling to the ground. According to a Federal Aviation Administration inspector, a fuel cap separated and entered the tail rotor system, resulting in a tailrotor imbalance and partial separation. The helicopter subsequently spun during the autorotation and landed hard. During the impact, the tail rotor separated and the fuselage sustained substantial damage. The fuel cap had separated from the right fuel tank, which was the auxiliary fuel tank, and was not serviced prior to the accident flight. The separated fuel cap was recovered and was missing its restraining chain and gasket. Both pilots reported that they checked the fuel caps during preflight inspection. Additionally, the main fuel tank (left) cap had remained secured throughout the accident sequence. Examination of the main fuel tank cap revealed that it did contain a gasket, but not a chain. Review of helicopter manufacturer data revealed that on November 22, 1993, the manufacturer ceased installing restraining chains on its fuel caps; however, production of the accident helicopter was completed in January, 1993, and it should have left the factory with restraining chains attached to the fuel caps. Review of the helicopter's maintenance records did not reveal any instance of the fuel cap restraining chains being removed in the field. ## Aircraft - Registration: [N10786](https://openairdocs.org/deregistered/N10786-2020-08-28), registration cancelled 2020-08-28, S/N 2267, built 1993 (OpenAirDocs) - Reported make and model: ROBINSON HELICOPTER R22 BETA - Registry model: [Robinson Helicopter R22 BETA](https://openairdocs.org/model/robinson-helicopter-r22-beta) (registry code 7640110) (OpenAirDocs) - Registry engine: [Lycoming O-320-B2C](https://openairdocs.org/engine/lycoming-o-320-b2c) (registry code 42139, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 2267 - Airframe hours: 1427 - Engines: LYCOMING O-320 160 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Ocean Helicopters Inc - Registered owner: Airman Helicopter Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 24, 2011, 70 hours before - Departed: PBI, West Palm Beach, FL - Destination: PBI, West Palm Beach, FL - Airport: PBI, Palm Beach International ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 28; injuries: none; flight instructor, commercial; instrument ratings: helicopter; medical: class 2, without waivers/limitations; last flight review May 8, 2011; seat: left; flight hours: 300 total, 250 in this make and model, 260 as pilot in command, 60 in the last 90 days, 30 in the last 30 days, 3 in the last 24 hours - Student pilot; injuries: minor; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review May 2, 2010; seat: right; flight hours: 200 total, 12 in this make and model, 160 as pilot in command, 12 in the last 90 days, 12 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 25,000 ft broken - Temperature: 84 °F, dew point 79 °F - Altimeter: 30.04 inHg - Observed at: PBI ## 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 20110710013199A](https://openairdocs.org/incident/20110710013199A), Jul 10, 2011: Robinson Helicopter R22 BETA, West Palm Beach, FL, Substantial damage. Instructor pilot & student conducted preflight on R-22 helicopter prior to flight that started at 0840 using rotor-craft flight manual (rfm). After practicing… ## Other investigations on N10786 (1) 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. - [NTSB CEN20CA090](https://openairdocs.org/ntsb/CEN20CA090), Feb 18, 2020: Robinson R22 (N10786), Cotulla, TX, substantial damage. Probable cause: The pilot's failure to remove the right skid trailer tie-down before attempting to take off, which resulted in a dynamic roll-over. ## Docket (3 files) The files NTSB released with the investigation on December 14, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=81056. 294 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40358217&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Interview Summary (item 2, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40358218&FileExtension=.PDF&FileName=Interview%20Summary-Master.PDF - FAA Inspector Statement (item 3, .PDF, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40358219&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-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.