# NTSB ERA16LA055: Robinson R22, N8560M, Venice, FL, December 1, 2015 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: December 1, 2015, 15:30 local (20:30 UTC) - Place: Venice, FL - Coordinates: 27.1, -82.433334 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.1000&lon=-82.4333&mi=10 - Phase of flight: [Emergency descent](https://openairdocs.org/ntsb-phases/600) (OpenAirDocs' grouping) - Defining event: [Autorotation: Hard landing](https://openairdocs.org/ntsb-events/092) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report May 23, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 92385 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA055 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92385/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92385 - Page: https://openairdocs.org/ntsb/ERA16LA055 ## Probable cause The flight instructor's failure to maintain control of the helicopter during an autorotation, which resulted in a hard landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Robinson Helicopter R22, 18 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7640102), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Autorotation: Hard landing](https://openairdocs.org/ntsb-events/092) (defining event); cases with it: [Robinson Helicopter R22, 13 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=7640102), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) - [After landing: AC/prop/rotor contact w person](https://openairdocs.org/ntsb-events/081); cases with it: [Robinson Helicopter R22, 1 case](https://openairdocs.org/ntsb-events/081/sequence.md?model=7640102), [All aircraft, 61 cases](https://openairdocs.org/ntsb-events/081/sequence.md) ## Analysis The flight instructor was preparing the pilot for her commercial rotorcraft-helicopter practical test. The instructor stated that they were returning to the airport when the engine shut down. The instructor entered an autorotation, which terminated in a hard landing. The instructor stated that he assumed the pilot pulled the mixture control instead of the carburetor heat because he saw it pulled after the helicopter came to a full stop on the ground; however, he never actually saw her pull the mixture control. The pilot stated that the instructor rolled the throttle to idle to simulate an in-flight loss of engine power as part of her checkride preparation. Both she and the instructor were operating the controls for the autorotation. The pilot said she was not sure what happened, but they landed hard and a section of windscreen popped out. She then pulled the mixture to shut off the engine, while the instructor used the rotor brake to stop the main rotor blades. The pilot exited the helicopter to recover the windshield and was subsequently struck in the head by a main rotor blade. Although the instructor's and pilot's accounts varied regarding the events leading up to the autorotation, they both reported that the autorotation ended in a hard landing, and that there were no mechanical issues with the helicopter or the engine that contributed to the accident. ## Factual narrative On December 1, 2015, about 1530 eastern standard time, a Robinson R22, N8560M, made a forced landing to a field near Venice, Florida. The flight instructor sustained minor injuries and the private pilot was seriously injured. The helicopter was registered to N8560M, LLC, and operated by Helicopter Academy under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions existed near the accident site at the time of the accident and no flight plan was filed. The flight originated from the Venice Municipal Airport (VNC), Venice, Florida, about 1430.The flight instructor reported that he was preparing the pilot for her commercial rotorcraft-helicopter checkride. They had practiced several maneuvers before heading back to the airport. While en route to the airport, the instructor was asking the pilot where she would land in the event of an engine failure when he noticed that the manifold pressure had dropped below 18 inches of mercury, which necessitated activation of the carburetor heat. The instructor did not recall if he told the pilot to turn the carburetor heat on, but remembered looking back outside because they were discussing forced landing areas. The instructor said the pilot then accidentally "pulled the mixture" versus the carburetor heat and "shut off the engine." He immediately took control of the helicopter, entered an autorotation, and landed "hard." The windshield popped out and the helicopter rocked back and forth before it came to rest. The instructor said the pilot then exited the helicopter and ran toward the front. The main rotor blades were still moving and struck the pilot's head. The instructor said he never saw the pilot actually pull the mixture control in flight. He assumed that she did, because when he went to shut the engine down, the mixture control's safety gate was on the floor and the mixture control was pulled out. The pilot stated that while returning to Venice, the instructor asked her where she would land if they had an engine failure. She said the beach, but the instructor pointed out a more suitable spot. The instructor then called out "3-2-1" and rolled off the throttle to simulate an engine failure. The pilot said that both of them were on the controls and the autorotation looked good until they were about 250 feet from the landing spot. The helicopter landed hard, but she did not know why. Once on the ground, the pilot said she "pulled the mixture" while the instructor had his hand on the rotor-brake. She then exited the helicopter to go retrieve the windshield that had popped off during landing. While standing out in front of the helicopter, one of the main rotor blades struck her on the left side of the head, fracturing her orbital bone. Both the instructor and pilot reported there were no mechanical deficiencies that would have precluded normal operation of the helicopter or engine. The instructor held a commercial pilot certificate forrotorcraft-helicopter and was also a certified flight instructor in rotorcraft-helicopter. He reported a total flight experience of 700 hours, of which, 600 hours were in the R22. The instructor's last Federal Aviation Administration (FAA) second class medical was issued on August 11, 2015. The pilot held a private pilot certificate for rotorcraft-helicopter. She reported a total flight experience of 150 hours, of which, 150 hours were in the R22. The pilot's last FAA second class medical was issued on June 6, 2015. Weather reported at VNC at 1535 was wind 310 degrees at 6 knots, clear skies, and visibility great than 10 miles. The temperature was 79 degrees F and the dewpoint was 72 degrees F. ## Aircraft - Registration: [N8560M](https://openairdocs.org/aircraft/N8560M), registered now, S/N 0476 (OpenAirDocs) - Reported make and model: ROBINSON R22 (UNDESIGNAT) - Registry model: [Robinson Helicopter R22](https://openairdocs.org/model/robinson-helicopter-r22) (registry code 7640102) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 0476 - Year built: 1985 - Airframe hours: 8358.6 - Engines: LYCOMING O-320 SERIES 130 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 9, 2015 - Departed: VNC, Venice, FL - Destination: VNC, Venice, FL - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 38; injuries: minor; flight instructor, commercial, private; medical: class 2, without waivers/limitations; last flight review April 16, 2015; seat: left; restraint: 4-point; flight hours: 700 total, 600 in this make and model, 650 as pilot in command, 200 in the last 90 days, 60 in the last 30 days, 10 in the last 24 hours - Pilot; age 31; injuries: serious; private; medical: class 2, without waivers/limitations; seat: right; restraint: 4-point; flight hours: 150 total, 150 in this make and model, 100 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 6 knots - Visibility: 10 statute miles - Temperature: 79 °F, dew point 72 °F - Altimeter: 29.96 inHg - Observed at: VNC, 1 nm away ## Other investigations on N8560M (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 LAX90LA157](https://openairdocs.org/ntsb/LAX90LA157), Apr 29, 1990: Robinson R22 (N8560M), Mammoth Lakes, CA, substantial damage. Probable cause: PILOT'S ENCOUNTER WITH A STRONG DOWNDRAFT WHILE CRUISING AT AN INADEQUATE ALTITUDE. A CONTRIBUTING FACTOR WAS THE HIGH ALTITUDE WHICH LIMITED AVAILABLE ENGINE POWER FOR RECOVERY. ## Docket (4 files) The files NTSB released with the investigation on April 12, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92385. 1.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 557 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451057&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation - Ronald Vasconcelos, CFI (item 2, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451058&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Ronald%20Vasconcelos,%20CFI-Master.PDF - Record of Conversation - Agnes Jolumo (item 3, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451059&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Agnes%20Jolumo-Master.PDF - Photo Array (item 4, .PDF, 2 photos, 906 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451060&FileExtension=.PDF&FileName=Photo%20Array-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.