# NTSB ERA21LA387: Robinson Helicopter R44 II, N212HT, Miami, FL, September 28, 2021 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: September 28, 2021, 19:00 local (23:00 UTC) - Place: Miami, FL - Coordinates: 25.647564, -80.433225 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=25.6476&lon=-80.4332&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) operating: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Minor injuries - Injuries: 1 minor, 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA FSDO - NTSB case key (mKey): 103995 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21LA387 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103995/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103995 - Page: https://openairdocs.org/ntsb/ERA21LA387 ## Probable cause The pilot’s loss of helicopter control after landing. Also causal was the pilot’s intentional operation of the helicopter without the required training, experience, and endorsements. ## 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 R44 II, 40 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7640122), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/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 R44 II, 25 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=7640122), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Robinson Helicopter R44 II, 99 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7640122), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Experience/qualifications: qualification/certification](https://openairdocs.org/ntsb-findings/02031010): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Robinson Helicopter R44 II, 5 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md?model=7640122), [All aircraft, 280 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Standing-engine(s) operating: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Robinson Helicopter R44 II, 11 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7640122), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## Analysis The pilot landed the helicopter following a local sightseeing flight with three friends. Review of surveillance video revealed that, after touchdown, the passenger in the helicopter’s left front seat began removing his shoulder harnesses and headset. The passenger moved the headset to his front when the helicopter began a rapid yaw to its left and rotated around the main rotor mast. After one full revolution, the helicopter lifted rapidly from the ground and climbed immediately out of the camera’s view as it continued to rotate rapidly around the main rotor mast. Seconds later, the helicopter descended back into view in an uncontrolled descent. The main rotor disc severed the tailboom in two places ahead of the tail section, which included the tailrotor and tailrotor gearbox, before ground contact. The pilot stated that he had reduced the throttle to idle after touchdown; however, review of the video indicated that the helicopter’s main rotor speed remained constant at its maximum rpm throughout the approach, landing, ground operation, and the accident sequence. The accident helicopter make and model was the subject of a Federal Aviation Administration Special Federal Aviation Regulation (SFAR), which specified academic, flight training, qualification, and currency requirements for pilots acting as pilot-in-command. Review of the pilot’s logbook revealed that he had not received the proper endorsements for operating the helicopter as pilot-in-command as a student pilot, nor had he complied with the annual requirements of the SFAR after receiving his private pilot certificate. Additionally, at the time of the accident, he did not meet the currency requirements specified by the SFAR for carrying passengers in the accident helicopter make/model. Examination of the helicopter revealed no evidence of preimpact mechanical anomalies that would have precluded normal operation. Based on the available information, the pilot’s loss of control and the helicopter’s uncontrolled takeoff was likely due to his misapplication of collective control after landing or his failure to guard the collective against the passenger’s interference. The pilot displayed a history of intentional noncompliance with regulations, including the SFAR and medical certificate requirements. The pilot's loss of helicopter control after landing is consistent with his lack of recent flight experience and his failure to comply with the training and currency requirements of the SFAR. ## Factual narrative On September 28, 2021, at 1900 eastern daylight time, a Robinson R44 II helicopter, N212HT, was substantially damaged when it was involved in an accident near Miami, Florida. The private pilot sustained minor injuries and the three passengers were not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot provided a detailed statement and was interviewed by telephone. He said a colleague wanted to take two of his friends for a helicopter ride and the pilot agreed. The pilot rented the helicopter from an individual at Palm Beach County Park Airport (LNA), West Palm Beach, Florida, flew to Miami Executive Airport (TMB), Miami, Florida, picked up the three passengers, flew around the Miami area, and returned to TMB, where he landed the helicopter to deplane the passengers. According to the pilot, he lowered the collective and began the shutoff procedure. He said he first reduced the throttle to idle and applied collective friction. The pilot further said his recollection of events from this point was “blurry,” as the helicopter began “spinning” and the helicopter subsequently impacted the ground on its left side. In a written statement, a passenger stated that, once on the ground, the pilot “was reducing the engine and preparing for shutdown [when] suddenly we started spinning.” He said the pilot attempted to regain control, but the spinning was “very powerful” before the helicopter became airborne and then crashed. A flight instructor and his student witnessed the event from the ground. The instructor said that he saw the helicopter rotating around the mast “out of control” before it descended to ground contact. The student stated that he observed the passenger onboard the accident helicopter remove his shoulder harnesses and headset when the helicopter “made a strong turn to the left,” rotated “uncontrollably” around the main rotor mast, and “took off without control” before “plummeting” to the ground. Surveillance video captured the accident sequence from a front quartering view toward the right side of the cockpit. The “coning” of the rotor system reduced to a flat rotor disc after touchdown, and the passenger in the helicopter’s left front seat could be seen removing his shoulder harnesses and headset. The passenger moved the headset to his front when the helicopter began a rapid yaw to its left and rotated around the main rotor mast. After one full revolution, the helicopter lifted rapidly from the ground and climbed immediately out of the camera’s view as it continued to rotate rapidly around the main rotor mast. Seconds later, the helicopter descended back into view in an uncontrolled descent. The main rotor disc severed the tailboom in two places ahead of the tail section, which included the tailrotor and tailrotor gearbox, before ground contact. The pilot held a private pilot certificate with a rating for rotorcraft-helicopter, which was issued based on his pilot certificateissued by the State of Israel. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued March 10, 2021. The pilot declared 220 total hours of flight experience on that date. Review of the pilot’s logbook by an FAA aviation safety inspector revealed an estimated 178 total hours of flight experience logged, with an estimated 100 total hours of experience in the accident helicopter make and model, and 78 in the Robinson R22. Those hours were accrued over a 10-year span, with two flights recorded in 2021. One flight was recorded May 1, 2021, in a Robinson R44 helicopter, and the other was recorded in Israel on July 3, 2021, in a Robinson R22 helicopter. The July flight was annotated as a “checkride.” The pilot had obtained logbook endorsements for FAA Special Federal Aviation Regulation (SFAR) 73 Awareness training for the Robinson R22/R44 model helicopters on August 20, 2012, and December 6, 2013; however, his logbook did not contain any of the required endorsements to act as pilot-in-command as a solo student pilot nor had the pilot obtained the proper endorsements to act as pilot-in-command in either the Robinson R22 or the Robinson R44 after receiving his private pilot certificate as required by (SFAR) 73 2 (B)1 and (B)2, which was an annual requirement at his experience level. Additionally, at the time of the accident, the pilot did not meet recency of flight experience requirements to carry passengers in the R44. The inspector’s review also revealed that the pilot conducted six flights between April 2020 and January 2021 without a valid medical certificate. The 1051 recorded weather observation at TMB included wind from 090° at 7 knots. The temperature was 26°C and the dewpoint was 19°C. The helicopter was examined at the accident site by FAA aviation safety inspectors, and all major components were accounted for at the scene. The helicopter rested on its left side, with the cockpit and cabin area largely intact. The left windscreen was fractured and separated. Control continuity was confirmed from the flight controls to the main rotor head, and to the tailrotor through the severed sections of the tailboom. A video study was completed by a National Transportation Safety Board performance engineer. A comparison of the manufacturer’s published maximum main rotor rpm operating limit of 408 rpm and the video frame rate revealed that, throughout the approach and landing and the uncontrolled takeoff and impact, the observed rotor speed was constant and close to the nominal speed of 408 rpm. During the telephone interview, the pilot was reminded of what he wrote in his written statement, and he said he didn’t remember anything in addition to what he had written. He had no recollection of his front seat passenger removing his seatbelts or headset, and only remembered what he was told after the accident. The pilot was asked if his left hand was guarding the collective control, or if he was perhaps using his lefthand to shut off radios or some other task, and he said he could not remember where his left hand was placed when the helicopter started to rotate around the mast. The pilot was asked if his watch or clothing could have interfered with the collective control, and he said “no”. When asked about the performance and handling of the helicopter, the pilot said, “Everything went well. Just like the many other times that I’ve flown it.” ## Aircraft - Registration: [N212HT](https://openairdocs.org/deregistered/N212HT-2023-01-16), registration cancelled 2023-01-16, S/N 12217, built 2008 (OpenAirDocs) - Reported make and model: ROBINSON HELICOPTER COMPANY 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-AE1A5](https://openairdocs.org/engine/lycoming-io-540-ae1a5) (registry code 41899, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 12217 - Year built: 2008 - Airframe hours: 818.6 - Engines: Lycoming IO-540-AE1A5 245 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Iftach Shimonovich, doing business as Lantana Helicopters - Registered owner: Airman Helicopter Inc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, March 5, 2021 - Destination: Same as departure - Airport: TMB, Miami Exec ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: none; private; instrument ratings: helicopter; medical: class 2, without waivers/limitations; seat: right; restraint: 4-point; flight hours: 178 total, 100 in this make and model, 1 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 90° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 32 °F, dew point 32 °F - Altimeter: 29.95 inHg - Observed at: TMB - METAR: 282353Z 09007KT 10SM CLR 26/19 A2995 ## 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 20210928016819A](https://openairdocs.org/incident/20210928016819A), Sep 28, 2021: Robinson Helicopter Company R44 II, Miami, FL, Destroyed. On September 28, 2021, N212HT, an R44 landed on alpha helipad on ifc north ramp, Miami executive airport. While maneuvering to the ramp and landing, the pilot… ## Docket (12 files) The files NTSB released with the investigation on August 15, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103995. 35.8 MB in all. - Mfr regarding absent NTSB form 6120.1 (item 1, PDF, 2 pages, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14376921&FileExtension=pdf&FileName=NTSB%20Form%206120%20Memorandum%20for%20Record-Rel.pdf - Pilot's statement (item 2, PDF, 4 pages, 968 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14695124&FileExtension=pdf&FileName=KASHY,%20JOSEPH%20EREZ%20(Statement)_Redacted-Rel.pdf - Memorandum for record a�� telephone interview, pilot, duty officer (item 3, PDF, 1 page, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14728476&FileExtension=pdf&FileName=Memorandum%20Of%20Record%20pilot%20statement%20Mr.%20Kashy-Rel.pdf - Memorandum for record a�� interview with pilot (item 4, PDF, 2 pages, 302 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14377002&FileExtension=pdf&FileName=Memorandum%20for%20Record%20James%20Kashy%20Pilot-Rel.pdf - Witness statement - j. simones (item 5, PDF, 2 pages, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14695239&FileExtension=pdf&FileName=Witness%20Statement_Redacted-Rel.pdf - Witness statement - c. colitto (item 6, PDF, 1 page, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14377299&FileExtension=pdf&FileName=HELICOPTER%20ACCIDENT%20STATEMENT-Rel.pdf - Memorandum for record pilot qualifications review (item 7, PDF, 1 page, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14727383&FileExtension=pdf&FileName=Memorandum%20for%20Record%20Joseph%20Kashy%20Pilot%20Qualifications-Rel.pdf - Maintenance record excerpt - 100 hour inspection (item 8, PDF, 1 page, 19.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14377473&FileExtension=pdf&FileName=100-hour%20Inspection_Redacted-Rel.pdf - Video file (item 9, MP4, 10.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14378312&FileExtension=mp4&FileName=IFC_NVR_Air%20Sal%20Parking_IFC_NVR_20210928190614_20210928190644_3309185-Rel.mp4 - Investigative photographs (item 10, PDF, 5 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14378460&FileExtension=pdf&FileName=Photo%20Array%20Template%20-%20done-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 11, PDF, 1 page, 508 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14378284&FileExtension=pdf&FileName=N212HT%20Release_Redacted-Rel.pdf - Video study (item 12, PDF, 7 pages, 368 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14392294&FileExtension=pdf&FileName=Miami_Video_Study_final-Rel.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.