ERA22LA131

NTSB accident investigation · Robinson Helicopter R44 · Miami Beach, FL · February 19, 2022

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
February 19, 2022, 13:10 local (18:10 UTC)
Place
Miami Beach, FL
Injuries
3 serious
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N544SBRobinson Helicopter R44
Defining event
Maneuvering-low-alt flying: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/ FSDO, Lycoming Engines, Robinson Helicopter Company
FAA report
20220219002139A
Case key
104679

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A loss of engine power due to a stuck valve, which resulted in an autorotation and a hard landing in water.

Findings · 1

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine (reciprocating)Aircraft › Aircraft power plant · MalfunctionRobinson Helicopter R44: 3 casesAll aircraft: 497 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The helicopter pilot was flying about 450 ft above ground level over water paralleling a coastline. The engine suddenly developed a violent shaking and vibration, and engine power was lost. The pilot entered an autorotation, flew toward shallow water, and impacted the water hard about 10 seconds after the onset of the vibration. Examination of the engine revealed no evidence of preimpact mechanical malfunction; however, the examination and teardown were significantly limited due to corrosion as a result of postaccident saltwater immersion. Engine manufacturer guidance indicated that the helicopter was at an increased risk of stuck valves due to being operated in a region with high ambient temperatures, in addition to operating at lower altitudes and slower airspeeds. Within the year preceding the accident, a total of four engine cylinders had been overhauled and replaced due to stuck valves and low compression. The postaccident examination found no evidence of a stuck intake or exhaust valve. Given the engine’s repeated history of stuck valves and low compression, combined with the pilot’s reported sensations felt during the loss of power, and the lack of any evidence of catastrophic engine failure, it is likely the engine again experienced a stuck valve, which resulted in the loss of engine power and a forced landing in water. At the time of the accident, the helicopter was 37 flight hours past its manufacturer-required 100-hour inspection interval. Had the inspection intervals been followed, it is possible evidence of valve sticking may have been identified, as it had been several instances within the year before the accident.

Factual narrative

On February 19, 2022, at 1310 eastern standard time, a Robinson Helicopter R44, N544SB, was substantially damaged when it was involved in an accident near Miami Beach, Florida. The pilot and two passengers sustained serious injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, about an hour before the accident, he had departed a helipad in Marathon, Florida, and was returning along the coastline to North Perry Airport (HWO), Hollywood, Florida. As he flew overwater parallel to the South Miami Beach area, he experienced a sudden and violent left to right shaking and vibration, which was followed by a loss of engine power and a low rotor rpm warning light and horn. The pilot attempted to increase engine power; but realized that the engine had lost power and initiated an autorotation. He maneuvered the helicopter toward an area of shallow water between two groups of people and the helicopter impacted water about 10 seconds after the vibration began. The pilot assisted his passengers in evacuating the helicopter, and they received additional assistance from beachgoers to reach the shore. The pilot recalled that he was flying about 420 ft to 450 ft above ground level at an airspeed about 85-95 knots when the loss of engine power occurred. Before the loss of power, the helicopter had been functioning normally without issue. A Federal Aviation Administration inspector examined the helicopter at the accident site and recovery facility. The fuselage, tail boom, and tail rotor sustained substantial damage. One main rotor blade remained intact with little damage and the other had fractured about mid-span. The National Transportation Safety Board examined the helicopter at the recovery facility. Examination of the helicopter’s flight controls found no anomalies that would have prevented normal control or would have contributed to the vibration. The engine and its accessories displayed significant saltwater corrosion consistent with the engine being submerged in the ocean post-accident. Examination of the engine revealed no evidence of a catastrophic failure of the engine core or its accessories. All cylinders were removed from the engine case and dissembled in order to examine the individual exhaust and intake valves, springs, and pistons. No anomalies were found within the cylinders, with exception of varying amounts of corrosion to the valves, cylinder walls, and pistons. The level of corrosion was consistent with the engine being submerged in saltwater. According to maintenance records, four cylinders were replaced in the year preceding the accident. From March 1, 2021, through December 11, 2021, the Nos. 2, 4, and 6 cylinders (and a second time, the No. 2 cylinder) were removed, overhauled, and reinstalled. According to the maintenance endorsements and interviews with the mechanic who performed the work, the cylinder replacements were due to low compression and stuck pistonvalve issues. The pilot reported that he experienced a similar engine malfunction and vibration sensation while in hover flight months before the accident flight. He could not recall exactly when the event occurred; however, he believed it was around the time of one of the cylinder replacements. During this past event, he was able to perform an autorotation from a hover and landed without incident. After the event, a burnt intake valve was discovered. He recalled that a total of 4 intake valves were discovered burnt over the year before the accident. The most recent 100-hour inspection occurred on August 1, 2021, at hour meter time of 1,509.5. The most recent annual inspection was completed on March 1, 2021.The hour meter at the time of the accident was 1,646.6. According to the Robinson Helicopter R44 maintenance manual, Chapter 2, inspection intervals are required at 100 hours’ time in service or 12 calendar months; whichever occurs first. The Textron Lycoming Service Instruction, No. 1425A, dated January 19th, 1988, Suggested Maintenance Procedures to Reduce the Possibility of Valve Sticking, stated in part: Operating in high ambient temperatures, slow flight with reduced cooling, or high lead content of fuel, can promote deposit build-up reducing valve guide clearance and result in valve sticking. If any of the conditions are present or hesitation is observed, the service instruction recommended inspection and cleaning of the valves. Exposing the engine to sudden cool down, as in a rapid descent with the power reduced, or shutting the engine down before it has sufficiently cooled down can also induce valve sticking.

Aircraft

Registration
N544SB
Reported as
Robinson Helicopter R44 (NO SERIES)
Category
Helicopter
Serial number
1759
Built
2007
Airframe hours
1,646
Engine
Lycoming O-540-F1B5, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Hd Aviation Services LLC
Registered owner
Hd Aviation Services LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 1, 2021 · 137 hours before
Departed
NONE · Marathon, FL
Destination
HWO · Hollywood, FL
Airport
None
Equipment
ADS-B

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
60
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 1, With waivers/limitations
Last flight review
October 7, 2021
Seat
Right
Restraint
3-point
Flight hours
2,060 total · 475 in this make and model · 1,937 as pilot in command · 52 in the last 90 days · 20 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 70 °F
Altimeter
30.12 inHg
Observed at
MIA, 10 nm away
METAR
KMIA 191853Z VRB06KT 10SM SCT030 29/21 A3012 RMK AO2 SLP200 T02890206 $

Docket · 13

The files NTSB released with the investigation on September 20, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 31.2 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.