# NTSB ERA16LA216: Robinson Helicopter R44, N141TM, Chatham, MA, June 17, 2016

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: June 17, 2016, 12:45 local (16:45 UTC)
- Place: Chatham, MA
- Coordinates: 41.71389, -69.98278 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=41.7139&lon=-69.9828&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Defining event: [Maneuvering-low-alt flying: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340)
- Highest injury: Serious injuries
- Injuries: 2 serious
- Status: Completed, report September 6, 2017
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: Robinson Helicopter Company, Lycoming Engines, FAA/FSDO
- NTSB case key (mKey): 93400
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA216
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93400/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93400
- Page: https://openairdocs.org/ntsb/ERA16LA216

## Probable cause

The inadequate maintenance of the lower forward clutch actuator bearing for a prolonged period of time, which resulted in a bearing failure. Contributing to the accident was an erroneous maintenance entry, which resulted in the helicopter being operated beyond its mandatory airframe overhaul time.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Aircraft](https://openairdocs.org/ntsb-findings/01020000): Aircraft › Aircraft systems · Fatigue/wear/corrosion (probable cause); cases with it: [Robinson Helicopter R44, 1 case](https://openairdocs.org/ntsb-findings/01020000/cases.md?model=7640120), [All aircraft, 63 cases](https://openairdocs.org/ntsb-findings/01020000/cases.md)
- [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Robinson Helicopter R44, 4 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=7640120), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md)
- [Record-keeping: aircraft/maintenance logs](https://openairdocs.org/ntsb-findings/02062515): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Robinson Helicopter R44, 1 case](https://openairdocs.org/ntsb-findings/02062515/cases.md?model=7640120), [All aircraft, 21 cases](https://openairdocs.org/ntsb-findings/02062515/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Maneuvering-low-alt flying: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330); cases with it: [Robinson Helicopter R44, 7 cases](https://openairdocs.org/ntsb-events/330/sequence.md?model=7640120), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md)
- [Maneuvering-low-alt flying: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Robinson Helicopter R44, 7 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7640120), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md)
- [Maneuvering-low-alt flying: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Robinson Helicopter R44, 5 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7640120), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)
- [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Robinson Helicopter R44, 13 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7640120), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)
- [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Robinson Helicopter R44, 16 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=7640120), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md)

## Analysis

The commercial pilot reported that, during an aerial photography flight, the helicopter was about 300 ft above a pond when it experienced an engine overspeed, followed by a loss of engine power. The pilot subsequently entered an autorotation to shallow water. Examination of the engine revealed that the No. 2 cylinder head rocker shaft bosses, the No. 2 intake valve upper spring, and the No. 3 intake valve spring seat were fractured, consistent with an engine overspeed. Examination of the airframe revealed that the engine cooling fan shaft had separated. Without the resistance of the fan shaft, the engine oversped, which resulted in sufficient engine damage for the engine to lose total power. The aft face of the fan shaft's lower sheave exhibited caked-on grease, consistent with grease leaking beyond the lower forward clutch actuator bearing seal for a prolonged period of time. Metallurgical examination of the bearing revealed that its rollers were seized, and no grease was recovered, consistent with a lack of lubrication. The helicopter manufacturer's maintenance manual required that the entire airframe be overhauled every 2,200 hours, which would include an overhaul of the engine cooling fan driveshaft lower bearing and seal. Review of maintenance records revealed that, due to a maintenance logbook entry error (time since overhaul) that occurred about 9 years before the accident and was carried forward, the helicopter had been operated about 52 hours beyond the mandatory airframe overhaul time limit. The manual also required that the lower clutch actuator bearings be lubricated every 300 hours or 3 years, whichever occurred first. Although the failed bearing had been lubricated with grease both about 1 year and 2 years preceding the accident, there was no record indicating that the bearing had been lubricated with grease during the preceding 4 years 11 months and 685.1 hours of operation, which likely damaged or degraded the bearing and led to its failure during the accident flight.

## Factual narrative

On June 17, 2016, about 1245 eastern daylight time, a Robinson R44, N141TM, operated by Ryan Rotors, was substantially damaged during a forced landing to a pond, following a total loss of engine power while maneuvering near Chatham, Massachusetts. The commercial pilot and passenger were seriously injured. The local aerial photography 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 flight that originated Plymouth Municipal Airport (PYM), Plymouth, Massachusetts, about 1026.The pilot reported that the passenger hired him so that she could take aerial photographs of real estate. The helicopter was over a saltwater pond, about 300 feet above ground level, approaching homes near the shoreline. At that time, the pilot felt a lateral shudder followed by the clutch light illuminating. The helicopter then began a violent yaw and the low oil pressure light illuminated. The pilot subsequently performed an autorotation to shallow water near the shoreline. Review of data downloaded and plotted from a handheld GPS revealed that the helicopter proceeded along the north shore of Cape Cod after departing PYM, then transitioned to the south shore near Dennis, Massachusetts. The helicopter continued along the south shore and in the Chatham, Massachusetts area, completing many circuits, consistent with aerial photography. The last two data points recorded indicated a GPS altitude of 402 feet and 268 feet, respectively. Examination of the wreckage by a Federal Aviation Administration inspector revealed that the helicopter came to rest on its left side at the edge of a pond. The inspector observed substantial damage to the airframe and also noted that a rocker arm was protruding from the engine crankcase. The wreckage was examined again at a recovery facility. Examination of the engine revealed that the No. 2 and No. 3 cylinders exhibited damage consistent with engine overspeed. Specifically, the No. 2 cylinder head rocker shaft bosses were fractured and the No. 2 intake valve upper spring was fractured. The No. 3 intake valve spring seat was also fractured. Examination of the airframe revealed that the engine cooling fan shaft had separated. Examination of the aft face of lower sheave revealed caked on grease, consistent with grease leaking beyond the lower forward clutch actuator bearing seal over a period of time. Metallurgical examination of the bearing revealed that its rollers were seized and no grease was recovered, consistent with a lack of lubrication (For more information, see Material Laboratory Factual Report in the NTSB Public Docket). The seal and bearing housing were severely damaged during the accident, which precluded determination of the exact point on the seal that was compromised. Review of maintenance records that the helicopter's most recent 100-hour inspection was completed on April 23, 2016. At that time, the helicopter's totaltime airframe (TTAF) was noted as 2,192.4 hours and time since the airframe was overhauled (TSOH) was noted as 1,637.4 hours. Review of the helicopter's hour meter after the accident revealed that it had flown an additional 59.5 hours since that inspection, resulting in a TTAF of 2,251.9 and TSOH of 1,696.9 hours. Further review of the aircraft logbook revealed that an extensive repair and annual/100-hour inspection was completed on July 12, 2006, at the manufacturer's facility. Although the engine was overhauled during the repair, the airframe was not. An employee of the manufacturer correctly noted repair (verses overhaul) in the airframe logbook entry, but incorrectly noted the TSOH as 4.2 hours rather than 559.2 hours. The erroneous TSOH recording carried forward throughout the aircraft logbook. At the time of the accident, the TTAF and TSOH for the airframe were both 2,251.9 hours. The helicopter manufacturer required the airframe to be overhauled by the manufacturer every 2,200 hours, during which, the engine cooling fan driveshaft lower bearing and seal would have been overhauled. Review of Robinson Helicopter Company Service Bulletin (SB)-42 revealed a requirement to service the lower clutch actuator bearings with grease every 300 hours or annually, whichever occurred first, to prevent failure due to lack of lubrication. The SB was superseded by an addition to the maintenance manual that required a similar procedure of every 300 hours or every 3 years, whichever occurred first. Review of the maintenance records revealed that the lower clutch actuator bearings were most recently serviced on December 17, 2015, at a TTAF of 2,095.1 hours. They were previously serviced on September 17, 2014 at a TTAF of 1,885.4 hours and May 11, 2011 at a TTAF of 1244.3. Prior to that, the last recorded servicing was on June 13, 2006 at a TTAF 559.2 hours, resulting in no recorded servicing during a period of 4 years 11 months and 685.1 hours of operation. Further, the maintenance manual also contained instructions to check the condition of the lower clutch actuator bearing seals at every 100-hour or annual inspection. The was no record of the failed seal having ever been replaced.

## Aircraft

- Registration: [N141TM](https://openairdocs.org/deregistered/N141TM-2018-07-31), registration cancelled 2018-07-31, S/N 1216, built 2002 (OpenAirDocs)
- Reported make and model: ROBINSON HELICOPTER R44 (UNDESIGNAT)
- Registry model: [Robinson Helicopter R44](https://openairdocs.org/model/robinson-helicopter-r44) (registry code 7640120) (OpenAirDocs)
- Registry engine: [Lycoming 0-540F1 SERIE](https://openairdocs.org/engine/lycoming-0-540f1-serie) (registry code 41531, reciprocating) (OpenAirDocs)
- Category: Helicopter
- Serial number: 1216
- Year built: 2002
- Airframe hours: 2192.4
- Engines: LYCOMING O-540 305 horsepower reciprocating
- Damage: Substantial damage
- Flight: Aerial observation, Part 91
- Operator: Ryan Rotors Inc
- Registered owner: Ryan Rotors Inc
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, April 23, 2016, 60 hours before
- Departed: PYM, Plymouth, MA
- Destination: PYM, Plymouth, MA
- Equipment: Handheld GPS

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 48; injuries: serious; commercial, flight instructor; medical: class 2, with waivers/limitations; last flight review May 25, 2016; seat: right; restraint: 3-point; flight hours: 8,560 total, 725 in this make and model, 8,320 as pilot in command, 70 in the last 90 days, 40 in the last 30 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 60° at 8 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 70 °F, dew point 48 °F
- Altimeter: 30.00 inHg
- Observed at: CQX, 1 nm away

## 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 20160617006799A](https://openairdocs.org/incident/20160617006799A), Jun 17, 2016: Robinson Helicopter R44, Chatham, MA, Destroyed. Departed plymouth airport for a scenic photo flight after approximately one hour the helicopter maneuvered for a photo pass and I spoke to the pilot who was…

## Docket (12 files)

The files NTSB released with the investigation on May 8, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93400. 27.9 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 408 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451931&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- Interview Summaries (item 2, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451932&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF
- GPS Device - Specialist's Factual Report (item 3, .PDF, 3 photos, 648 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451933&FileExtension=.PDF&FileName=GPS%20Device%20-%20Specialist%27s%20Factual%20Report-Master.PDF
- GPS Device - Attachment 1 (tabular data) (item 4, .CSV, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451934&FileExtension=.csv&FileName=GPS%20Device%20-%20Attachment%201%20(tabular%20data)-Master.csv
- Materials Laboratory Factual Report (item 5, .PDF, 28 photos, 13.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451935&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report-Master.PDF
- Excerpts from Maintenance Records (item 6, .PDF, 10.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451936&FileExtension=.PDF&FileName=Excerpts%20from%20Maintenance%20Records-Master.PDF
- Helicopter Manufacturer Service Bulletin (item 7, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451937&FileExtension=.PDF&FileName=Helicopter%20Manufacturer%20Service%20Bulletin-Master.PDF
- Excerpts from Maintenance Manual (item 8, .PDF, 297 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451938&FileExtension=.PDF&FileName=Excerpts%20from%20Maintenance%20Manual-Master.PDF
- Weather Report (item 9, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451939&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 280 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451940&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF
- Evidence Control Form (item 11, .PDF, 335 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451941&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.PDF
- Photo Array (item 12, .PDF, 8 photos, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451942&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.

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