# NTSB ERA17LA163: Robinson R44, N899GB, Orlando, FL, April 20, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 20, 2017, 10:30 local (14:30 UTC) - Place: Orlando, FL - Coordinates: 28.45, -81.470558 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.4500&lon=-81.4706&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report June 25, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 95040 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17LA163 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95040/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95040 - Page: https://openairdocs.org/ntsb/ERA17LA163 ## Probable cause A partial failure of the helicopter's engine tachometer due to the separation of one of the magnet assemblies and engine roughness, which precipitated the pilot’s initiation of an off-airport autorotation, during which he applied improper aft cyclic flight control input, which was contrary to the Pilot’s Operating Handbook. The reason for the reported engine roughness could not be determined during postaccident examination and engine test-runs. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Indicating/recording systems: indep instrument (clock, etc)](https://openairdocs.org/ntsb-findings/01023120): Aircraft › Aircraft systems · Failure (probable cause); cases with it: [Robinson Helicopter R44 II, 1 case](https://openairdocs.org/ntsb-findings/01023120/cases.md?model=7640122), [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/01023120/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Robinson Helicopter R44 II, 14 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7640122), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot of other aircraft (probable cause); cases with it: [Robinson Helicopter R44 II, 3 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=7640122), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: Flight instrument malf/fail](https://openairdocs.org/ntsb-events/334); cases with it: [Robinson Helicopter R44 II, 1 case](https://openairdocs.org/ntsb-events/334/sequence.md?model=7640122), [All aircraft, 56 cases](https://openairdocs.org/ntsb-events/334/sequence.md) - [Enroute-descent: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Robinson Helicopter R44 II, 19 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7640122), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Robinson Helicopter R44 II, 26 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7640122), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Robinson Helicopter R44 II, 40 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=7640122), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis The commercial pilot was conducting a local sightseeing flight in a helicopter with two passengers onboard. He reported that, while he was flying southbound and descending from 1,000 to 600 ft, he heard a "pop" sound and noted a corresponding right yaw, followed by vibration and engine roughness. The pilot looked at the instruments, and the main rotor tachometer was indicating that the rpm had dropped to "0" and that the engine tachometer was indicating between 60% and 70%. The pilot immediately initiated an autorotation to a median, and the helicopter landed hard. The helicopter began rolling forward, and in response, the pilot applied aft cyclic control input, which was contrary to the instructions in the Pilot's Operating Handbook, which contained a caution in the emergency procedures section related to power failures that stated to "not apply aft cyclic during touchdown…to prevent possible blade strike to the" tailboom. The pilot's improper control input resulted in the main rotor blades contacting and substantially damaging the tailboom. Postaccident examination of the engine and the tail rotor drive system revealed no evidence of any preimpact mechanical failures or malfunctions that would have precluded normal operation. The engine was test-run, and it started and operated normally. One of the two main rotor tachometer indication system magnet assemblies was separated and not recovered. According to helicopter manufacturer personnel, with only one magnet assembly installed, the main rotor tachometer rpm would indicate about 50% of the actual rotor rpm. Therefore, the main rotor tachometer rpm indication was likely erroneous due to the separation of a magnet assembly from the rotor rpm sensor. The pilot's perception that the main rotor tachometer had decreased to "0" was likely in response to his seeing the needle near the lowest number on the scale. The reason for one of the magnet assemblies' separation could not be determined because it was not located. ## Factual narrative On April 20, 2017, about 1030 eastern daylight time, a Robinson R44 II, N899GB, was substantially damaged during an autorotative landing near Orlando, Florida. The commercial pilot and two passengers were not injured. Visual meteorological conditions prevailed at the time, and no flight plan was filed for the local flight that originated about 5 minutes earlier from Air Orlando Heliport (2FD7), Orlando, Florida. The revenue sightseeing flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91.During the 1st flight of the day while returning to 2FD7, the pilot stated that he was flying southbound and descending out of 1,000 feet, when at 600 feet, he heard and felt a loud "pop" that was accompanied by a yaw to the right, shaking and vibration, with engine roughness. At that time the rotor tachometer had, "dropped to zero", while the engine tachometer was "at about 60-70%." He immediately entered an autorotative descent to a median between two roads, but did not recall his airspeed during the maneuver, and landed, "…a little hard…." After touchdown the helicopter began to roll forward, which he attempted to correct with aft cyclic input. Once the helicopter was stable on the ground, he secured the engine, and then evacuated the passengers after the main rotor had stopped. Postaccident examination of the helicopter revealed the aft section of the tailboom was partially detached from the helicopter, and the leading edge of the main rotor blades exhibited slight damage. In the area of the tailboom separation point, the tail rotor drive shaft was fractured and the tail rotor push-pull tube assembly was deformed. Further examination of the tailboom revealed the arm associated with the damper assembly was bent about 90° and fractured. The damper remained connected to the support which was torn and deformed. No deformation was noted internally to structural members adjacent to the damper area. No other damage to the tail rotor drive system was noted. Examination of the engine compartment revealed one magnet assembly part number (P/N) B570-1 associated with the main rotor tachometer indicating system was separated from the Yoke Assembly, P/N C908-1, and was not recovered. The other magnet assembly remained secured to the yoke assembly. The yoke assembly was not damaged, but there was evidence of slight damage to 1 sender assembly, consistent with the magnet assembly separation. The lowest numeric marking on the dual tachometer associated with the main rotor is 50, with 2 graduated lines beneath. The engine was removed from the helicopter and taken to a repair facility where it was examined and then placed on a test stand and operated twice. The first and second engine runs lasted 15 and 25 minutes, respectively with no discrepancies noted. The engine was operated a third time, and about 10 minutes into the engine run, the left magneto failed the magneto check. The defective magneto was removed, and a replacement magneto wasinstalled. The engine was started and operated normally. Robinson Helicopter Company personnel reported there have been instances of a magnet separating from a magnet assembly which prompted issuance of Service Bulletin (SB) 86; however, they report there have not been any previous instances of the magnet assembly separating from the yoke assembly. According to the Pilot's Operating Handbook, a caution in the emergency procedures section related to power failure specifies to not apply aft cyclic during touchdown or ground slide to prevent possible blade strike to the tailcone. According to the maintenance manual, the sensor for the main rotor tachometer is an electronic Hall Effect device which senses passage of two magnets attached to main rotor gearbox input yoke assembly. Robinson personnel reported that with only 1 magnet installed, the main rotor tachometer rpm would indicate about 50% of the actual rotor rpm. ## Aircraft - Registration: [N899GB](https://openairdocs.org/deregistered/N899GB-2019-10-31), registration cancelled 2019-10-31, S/N 11190, built 2006 (OpenAirDocs) - Reported make and model: ROBINSON R44 (II) - Registry model: [Robinson Helicopter R44 II](https://openairdocs.org/model/robinson-helicopter-r44-ii) (registry code 7640122) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 11190 - Year built: 2006 - Airframe hours: 1142.9 - Engines: LYCOMING IO-540-AE1A5 260 horsepower reciprocating - Damage: Substantial damage - Flight: Other work use, Part 91 - Operator: Air Florida Helicopter Charters, Inc. - Registered owner: Aero Specialty Finance LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, March 17, 2017, 40 hours before - Departed: 2DF7, Orlando, FL - Destination: 2DF7, Orlando, FL - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 36; injuries: none; commercial; medical: class 2, with waivers/limitations; last flight review March 30, 2016; seat: front; flight hours: 1,315 total, 1,093 in this make and model, 1,243 as pilot in command, 202 in the last 90 days, 109 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 10 knots, gusting 17 - Visibility: 10 statute miles - Lowest ceiling: 30,000 ft broken - Temperature: 81 °F, dew point 61 °F - Altimeter: 30.17 inHg - Turbulence: Unknown - Observed at: MCO, 8 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 20170420004369A](https://openairdocs.org/incident/20170420004369A), Apr 20, 2017: Robinson Helicopter Company R44 II, Orlando, FL, Substantial damage. Aircraft was flying southbound at or about 600 feet. Pilot stated he heard a loud ?pop? That was accompanied by a yaw of the aircraft and noticed vibration and… ## Docket (7 files) The files NTSB released with the investigation on April 17, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95040. 14.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471977&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Initial Statement (item 2, .PDF, 543 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471978&FileExtension=.PDF&FileName=Pilot%20Initial%20Statement-Master.PDF - Record of NTSB Conversations (item 3, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471979&FileExtension=.PDF&FileName=Record%20of%20NTSB%20Conversations-Master.PDF - Excerpts from Pilot's Operating Handbook (item 4, .PDF, 172 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471980&FileExtension=.PDF&FileName=Excerpts%20from%20Pilot%27s%20Operating%20Handbook-Master.PDF - Excerpts from Illustrated Parts Catalog (item 5, .PDF, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471982&FileExtension=.PDF&FileName=Excerpts%20from%20Illustrated%20Parts%20Catalog-Master.PDF - Engine Examination and Test Run Results (item 6, .PDF, 9.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471981&FileExtension=.PDF&FileName=Engine%20Examination%20and%20Test%20Run%20Results-Master.PDF - Investigative Photographs (item 7, .PDF, 6 photos, 963 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471983&FileExtension=.PDF&FileName=Investigative%20Photographs-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.