# NTSB ERA19LA287: Robinson R44, N21EH, Sanford, ME, September 28, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: September 28, 2019, 10:35 local (14:35 UTC) - Place: Sanford, ME - Coordinates: 43.39389, -70.708053 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.3939&lon=-70.7081&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Defining event: [Taxi-from runway: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Lycoming Engines, FAA/FSDO, Robinson Helicopter - NTSB case key (mKey): 100346 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA287 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100346/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100346 - Page: https://openairdocs.org/ntsb/ERA19LA287 ## Probable cause The student pilot's failure to maintain helicopter control while hover-taxiing in gusting wind conditions. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Robinson Helicopter R44, 3 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=7640120), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Robinson Helicopter R44, 40 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7640120), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Wind: gusts](https://openairdocs.org/ntsb-findings/03034045): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Robinson Helicopter R44, 5 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md?model=7640120), [All aircraft, 1,199 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Taxi-from runway: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Robinson Helicopter R44, 43 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7640120), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Robinson Helicopter R44, 56 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7640120), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis After completing a three-leg cross-country training flight in the helicopter, the solo student was hover-taxiing about 15 ft above the taxiway surface. Witnesses reported that gusting winds prevailed and that they saw the helicopter enter a spin, followed by a nose-low impact with the ground. The helicopter was substantially damaged. The pilot was seriously injured and unable to recall the accident sequence. Postaccident examination of the airframe and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. ## Factual narrative On September 28, 2019, about 1035 eastern daylight time, a Robinson R44 helicopter, N21EH, was substantially damaged when it impacted the ground while taxiing at Sanford Seacoast Regional Airport (SFM), Sanford, Maine. The pilot sustained serious injuries. The solo instructional flight was conducted under Title 14 Code of Federal Regulations Part 91. Day, visual meteorological conditions prevailed, and no flight plan was filed. The flight originated at Laconia Municipal Airport (LCI), Laconia, New Hampshire about 1000. A witness reported that the helicopter was taxiing about 15 ft above a taxiway when it began to spin at a high rate of speed. The helicopter then went vertical and crashed nose first in the grass, adjacent to the paved surface. Another witness observed the helicopter enter a spin to the left, then to the right before going vertical into the ground. A third witness reported that the weather was "clear but windy." The witnesses were met by first responders and assisted the pilot at the scene. An inspector with the Federal Aviation Administration responded to the accident site and examined the wreckage. Substantial damage was noted on the main rotor blades, tail rotor assembly, and fuselage. There was no fire. The inspector reported that the pilot was completing a three-leg cross-country flight when the accident occurred. He was receiving instruction on the R44 and was not rated in helicopters. The pilot was asked on two occasions during his recovery about the circumstances of the accident; he had no recollection of the event. The wreckage was recovered to a storage facility for further examination. The nose of the helicopter was crushed in a manner consistent with a nose-low impact with the ground. The tail boom was partially separated from the airframe. The engine was secured to the airframe. The main rotor system remained attached and the blades were impact-damaged along the length of both blades. Flight control continuity was established from the main and tail rotor assemblies to the cockpit. Both tail rotor blades remained attached to the tail rotor system. The engine received minor damage during the accident sequence and test run on the airframe. The engine started immediately and was operated for about 1 minute before it was shut down. No mechanical anomalies were noted that would have precluded normal operation of the airframe or engine. At 1056, the recorded wind at SFM was variable at 4 knots; however, witnesses reported that at the time of the accident, the wind had "picked up" and there were "gusts." ## Aircraft - Registration: [N21EH](https://openairdocs.org/deregistered/N21EH-2020-02-13), registration cancelled 2020-02-13, S/N 0881, built 2000 (OpenAirDocs) - Reported make and model: Robinson R44 (Undesignat) - Registry model: [Robinson Helicopter R44](https://openairdocs.org/model/robinson-helicopter-r44) (registry code 7640120) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 0881 - Year built: 2000 - Airframe hours: 1886 - Engines: Lycoming O-540-F1B5 225 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: York County Helicopters, doing business as York County Helicopters - Registered owner: Southern Maine Helicopter Llc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 18, 2019, 17 hours before - Departed: LCI, Laconia, NH - Destination: SFM, Sanford, ME - Airport: SFM, Sanford Seacoast Regional - Equipment: Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 50; injuries: serious; private; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; seat: right; restraint: 3-point; flight hours: 222 total, 44 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 68 °F, dew point 57 °F - Altimeter: 30.05 inHg - Observed at: SFM ## 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 20190928022409A](https://openairdocs.org/incident/20190928022409A), Sep 28, 2019: Robinson Helicopter R44, Sanford, ME, Substantial damage. Pilot who was seriously injured does not remember the events of the accident. A witness stated that he observed the helicopter maneuvering near the area of the… ## Docket (10 files) The files NTSB released with the investigation on May 6, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100346. 52.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483480&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - NTSB Memorandum for Record - Tremblay (item 2, .PDF, 277 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483481&FileExtension=.PDF&FileName=NTSB%20Memorandum%20for%20Record%20-%20Tremblay-Master.PDF - Witness Statement - Gingras (item 3, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483482&FileExtension=.PDF&FileName=Witness%20Statement%20-%20Gingras-Master.PDF - Witness Statement - Hill (item 4, .PDF, 293 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483483&FileExtension=.PDF&FileName=Witness%20Statement%20-%20Hill-Master.PDF - Sanford ME Police Incident Report (item 5, .PDF, 11.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483484&FileExtension=.PDF&FileName=Sanford%20ME%20Police%20Incident%20Report-Master.PDF - NTSB Memorandum of Record - Wreckage Exam (item 6, .PDF, 470 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483485&FileExtension=.PDF&FileName=NTSB%20Memorandum%20of%20Record%20-%20Wreckage%20Exam-Master.PDF - Photo Array (item 7, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483486&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Excerpts - Maintenance Logbooks (item 8, .PDF, 32.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483488&FileExtension=.PDF&FileName=Excerpts%20-%20Maintenance%20Logbooks-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 769 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483489&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40483490&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.