# NTSB ERA19TA153: Robinson R22, N689M, Bradenton Beach, FL, April 13, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Final report - Date: April 13, 2019, 12:20 local (16:20 UTC) - Place: Bradenton Beach, FL - Coordinates: 27.450555, -82.686111 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.4506&lon=-82.6861&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Settling with power/vortex ring state](https://openairdocs.org/ntsb-events/244) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 99277 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19TA153 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99277/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99277 - Page: https://openairdocs.org/ntsb/ERA19TA153 ## Probable cause The pilot's improper decision to execute a low altitude turn that resulted in a strong tailwind and to reduce the airspeed to 0 knots and the flight instructor's diverted attention and inadequate monitoring, which resulted in the helicopter settling with power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Robinson Helicopter R22, 7 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7640102), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Attention/monitoring: attention](https://openairdocs.org/ntsb-findings/02021510): Personnel issues › Psychological · Instructor/check pilot (probable cause); cases with it: [Robinson Helicopter R22, 2 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md?model=7640102), [All aircraft, 226 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Robinson Helicopter R22, 2 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7640102), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Robinson Helicopter R22, 4 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=7640102), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Robinson Helicopter R22, 2 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=7640102), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/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: Settling with power/vortex ring state](https://openairdocs.org/ntsb-events/244) (defining event); cases with it: [Robinson Helicopter R22, 1 case](https://openairdocs.org/ntsb-events/244/sequence.md?model=7640102), [All aircraft, 52 cases](https://openairdocs.org/ntsb-events/244/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Robinson Helicopter R22, 9 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7640102), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot stated that during an instructional flight, he was flying the helicopter about 100 ft above water while the flight instructor took photographs. The pilot executed a 180° turn into a tailwind. The flight instructor stated that the pilot then pulled back on the cyclic and the airspeed reduced to 0 knots. The pilot indicated that immediately after the turn, the helicopter lost power and/or lift and that “the wind might have shifted.” The helicopter quickly settled with power and impacted the water, which resulted in substantial damage to the main rotor, fuselage, and tailboom. The flight instructor stated that there were no preimpact mechanical malfunctions with the helicopter. He further reported that the accident happened so fast that he did not have time to take the controls and recover. The pilot’s low altitude turn into the tailwind and reduction in airspeed led to the helicopter settling with power. The flight instructor's diverted attention likely precluded adequate monitoring and delayed his recognition of the conditions that led to the helicopter settling with power and thus provide appropriate remedial action. ## Factual narrative On April 13, 2019, about 1220 eastern daylight time, a Robinson R22, N689M, was substantially damaged during impact with water while maneuvering near Bradenton Beach, Florida. The flight instructor and private pilot were not injured. The instructional flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the flight that departed Buchan Airport (X36), Englewood, Florida, about 1100. The flight was destined to Clearwater Airport (CLW), Clearwater, Florida. The private pilot stated that he was receiving instruction to prepare for a commercial pilot practical examination. As part of the lesson, the private pilot was flying about 100 ft above the water while the flight instructor took pictures of boats. The private pilot then executed a 180°-turn to obtain a better angle for a photograph. Immediately after the turn, the helicopter lost power and or lift and the pilot assumed "I got into settling with power, because the wind might have shifted." The private pilot tried to level the helicopter before impact with the water, but there was not enough time. The helicopter came to rest inverted in the water and both pilots egressed. The flight instructor stated that the pilot made a turn into a downwind, which put the helicopter in a tailwind. The pilot then pulled back into 0 airspeed and as a result the helicopter settled into its own downwash. The accident happened so quickly that the flight instructor had no time to take the controls and correct. He added that there were no preimpact mechanical malfunctions with the helicopter. Examination of the helicopter by a Federal Aviation Administration inspector revealed damage to the main rotor, fuselage and tailboom. The recorded wind at an airport located about 8 miles southeast of the accident site, at 1253, was from 190° at 15 knots. ## Aircraft - Registration: [N689M](https://openairdocs.org/aircraft/N689M), registered now, S/N 689M (OpenAirDocs) - Reported make and model: Robinson R22 (UNDESIGNAT) - Registry model: [Robinson Helicopter R22](https://openairdocs.org/model/robinson-helicopter-r22) (registry code 7640102) (OpenAirDocs) - Category: Helicopter - Serial number: 689M - Year built: 1979 - Airframe hours: 7084 - Engines: Lycoming O-320 160 hp reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Boatphoto Helicopter Llc - Registered owner: Boatphoto Helicopter Llc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, March 16, 2019 - Departed: X36, Englewood, FL - Destination: CLW, Clearwater, FL - Equipment: Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 42; injuries: none; commercial, flight instructor; medical: class 2, without waivers/limitations; last flight review February 18, 2018; seat: left; restraint: 3-point; flight hours: 1,476 total, 1,414 as pilot in command, 160 in the last 90 days, 70 in the last 30 days, 6 in the last 24 hours - Pilot; age 48; injuries: none; private; medical: class 2, without waivers/limitations; last flight review February 18, 2018; seat: right; restraint: 3-point; flight hours: 354 total, 999,999 in this make and model, 242 as pilot in command, 41 in the last 90 days, 30 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 15 knots - Visibility: 10 statute miles - Lowest ceiling: 4,400 ft broken - Temperature: 84 °F, dew point 70 °F - Altimeter: 29.97 inHg - Observed at: SRQ, 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 20190413002729A](https://openairdocs.org/incident/20190413002729A), Apr 13, 2019: Robinson Helicopter Company R22, Bradenton, FL, Substantial damage. On April 13, 2019, about 1230 eastern standard time (EST), a Robinson R22, N689M, impacted the water following an in-flight loss of control near coquina beach… ## Docket (5 files) The files NTSB released with the investigation on May 15, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99277. 5.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (Pilot) (item 1, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472943&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20(Pilot)-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (CFI) (item 2, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472944&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20(CFI)-Master.PDF - Interview Summary (item 3, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472945&FileExtension=.PDF&FileName=Interview%20Summary-Master.PDF - Photo Array (item 4, .PDF, 2 photos, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472946&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Weather Report (item 5, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472947&FileExtension=.PDF&FileName=Weather%20Report-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.