ERA12LA346

NTSB accident investigation · Robinson Helicopter R44 · Destin, FL · May 19, 2012

Accident · No injuriesLimited investigationFinal report
Date
May 19, 2012, 15:40 local (20:40 UTC)
Place
Destin, FL
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N444WTRobinson Helicopter R44
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report May 9, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20120519009399A
Case key
83707

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The partial loss of engine power due to a stuck (open) exhaust valve in the No. 5 cylinder. Contributing to the accident was the operator’s failure to follow the engine manufacturer’s directives concerning cooling of the engine after flight.

Findings · 4

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.

Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Damaged/degradedAll aircraft: 373 casesProbable cause
Terrain: sloped/uneven terrainEnvironmental issues › Physical environment · Effect on operationAll aircraft: 270 cases
Engine (reciprocating)Aircraft › Aircraft power plant · Incorrect use/operationAll aircraft: 497 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · Flt operations/dispatcherAll aircraft: 191 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

The helicopter reached about 200 feet above ground level in the initial climb when the pilot noticed that the engine needle in the dual tachometer (engine/main rotor rpm) had "spiked" and then remained "at the top of the gauge." The pilot turned the helicopter around to return to the airport, and, during the turn, the low rotor rpm warning alarm sounded. The pilot responded by lowering the collective control and increasing throttle but then determined that an airport landing could not be completed because the helicopter had already lost altitude. The pilot selected a forced landing area in a sand pit and responded to another low rotor rpm alarm by again lowering the collective. She attempted to cushion the landing with the available rotor rpm, but the helicopter landed hard, and the main rotor blades severed the tailboom. Examination of the helicopter revealed that the engine had a stuck (open) number 5 exhaust valve caused by buildup of oil carbon deposits. This is an issue with the Robinson Helicopters if the engine is not cooled down properly after flight. Air tour operations seem to be prone to carbon buildup mainly due to quick multiple shutdowns. The operator has established a postflight cool down procedure to prevent further problems. On January 19, 1988, Textron Lycoming published Service Letter No. L197A, Recommendations to Avoid Valve Sticking. The guidance offered included, "Rapid engine cool down from low power altitude changes, low power landing approach and/or engine shutdown too soon after landing or ground runs should be avoided."

Factual narrative

On May 19, 2012, about 1540 central daylight time, a Robinson R44 helicopter, N444WT, was substantially damaged during a forced landing after takeoff from Destin-Fort Walton Beach Airport (DTS), Destin, Florida. The certificated commercial pilot and two passengers were not injured. Visual meteorological conditions prevailed, and a company flight plan was filed for the flight. The local sightseeing flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to the pilot, the helicopter had reached approximately 200 feet above ground level (agl) in the initial climb when she noticed that the engine needle in the dual tachometer (engine/main rotor rpm) had "spiked" and then remained "at the top of the gauge." She turned that helicopter to return to the airport, and during the turn, the low rotor rpm warning horn sounded. The pilot responded by lowering the collective control and increasing throttle, but then determined that an airport landing could not be completed due to the resultant loss of altitude. The pilot selected a forced landing area in a sand pit, and responded to another low rotor rpm alarm by again lowering the collective. She attempted to cushion the landing with the available rotor rpm, but the helicopter landed hard, and the main rotor blades severed the tailboom. The helicopter came to rest upright, and the occupants egressed without injury. In interviews and written statements provided to the local sheriff's department, the passengers each stated that the helicopter was "leaning to the right" during the takeoff, and that the helicopter "beeped and descended" twice before it landed hard in the sand. The helicopter was removed from the site, and a detailed examination of the wreckage was scheduled. According to Federal Aviation Administration (FAA) and operator records, the helicopter was manufactured in 2000 and had accrued 1,668 total aircraft hours as of the date of the accident. Its most recent annual inspection was completed April 12, 2012. The pilot held an FAA commercial pilot certificate with ratings for rotorcraft-helicopter and instrument helicopter. She also held a flight instructor certificate with ratings for rotorcraft-helicopter and instrument helicopter. Her most recent FAA second class medical certificate was issued March 16, 2012. The pilot reported 433 total hours of flight experience, of which 143 hours were in the accident helicopter make and model. The helicopter was examined on June 6 and 7, 2012 by FAA inspectors, and the results of that examination were summarized in an email from one of the inspectors who stated, "The engine had a stuck (open) number #5 exhaust valve caused by buildup of oil carbon deposits. This is an issue with the Robinson Helicopters if the engine is not cooled down properly after flight. Air tour operations seem to be prone to carbon buildup mainly due to quick multiple shutdowns. The operator has established a post flight cool down procedure toprevent further problems." On January 19, 1988, Textron Lycoming published Service Letter No. L197A, Recommendations to Avoid Valve Sticking. The guidance offered included, "Rapid engine cool down from low power altitude changes, low power landing approach and/or engine shutdown too soon after landing or ground runs should be avoided."

Aircraft

Registration
N444WT
Reported as
Robinson Helicopter R44
Category
Helicopter
Serial number
0895
Airframe hours
1,668
Engine
Lycoming VO-540, 250 horsepower, reciprocating
Damage
Substantial damage
Flight
Other work use · Part 91
Operator
Timberview Helicopters
Registered owner
Timberview Helicopters
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 12, 2012
Departed
KDTS · Destin, FL
Destination
KDTS · Destin, FL
Flight plan
Company VFR
Airport
KDTS · Destin, runway 14, 5,001 × 100 ft

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
38
Injuries
None
Certificates
Commercial, Flight instructor
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
April 17, 2012
Seat
Right
Flight hours
433 total · 143 in this make and model · 336 as pilot in command · 22 in the last 90 days · 12 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
90° at 9 knots, gusting 16
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 55 °F
Altimeter
29.96 inHg
Observed at
DTS, 5 nm away

Docket · 7

The files NTSB released with the investigation on March 22, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.0 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.