# NTSB FTW95FA016: Robinson R22 Beta, N80546, Eunice, LA, October 14, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 14, 1994, 09:20 local (14:20 UTC) - Place: Eunice, LA - Coordinates: 30.489582, -92.410316 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.4896&lon=-92.4103&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report June 13, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 19192 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW95FA016 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/19192/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=19192 - Page: https://openairdocs.org/ntsb/FTW95FA016 ## Probable cause THE PILOT'S FAILURE TO PROPERLY USE CARBURETOR HEAT, THE FORMATION OF CARBURETOR ICE, AND FAILURE OF THE PILOT TO MAINTAIN ROTOR RPM AFTER LOSS OF ENGINE POWER, WHICH RESULTED IN A LOSS OF CONTROL AND COLLISION WITH TERRAIN. A FACTOR RELATED TO THE ACCIDENT WAS: THE WEATHER CONDITION, WHICH WAS CONDUCIVE TO CARBURETOR ICING. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - nonmechanical, cruise - weather condition - carburetor icing conditions (contributing factor) - fuel system,carburetor - ice (cause) - carburetor heat - not used, pilot in command (cause) - use of inappropriate medication/drug, pilot in command - Forced landing, emergency descent/landing - autorotation - initiated, pilot in command - Loss of control - in flight, emergency descent/landing - rotor rpm - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled ## Analysis A DOCTOR TOOK OFF FROM A LOCAL HOSPITAL, AND THE HELICOPTER WAS OBSERVED FLYING WESTBOUND ABOUT TWO BLOCKS FROM THE HOSPITAL. ACCORDING TO A WITNESS, A LOSS OF ENGINE POWER OCCURRED. HE REPORTED THAT THE HELICOPTER TURNED RIGHT TOWARD A FIELD; HOWEVER, THE WITNESS INDICATED THAT THE HELICOPTER WENT OUT OF CONTROL, AND THEN CRASHED IN A DITCH NEXT TO A ROAD. AN EXAM OF THE HELICOPTER AND ENGINE DID NOT DISCLOSE ANY PREIMPACT MECHANICAL ANOMALIES; HOWEVER, THE CARBURETOR HEAT WAS FOUND IN THE OFF POSITION. THE TEMPERATURE AND DEW POINT WERE 63 AND 59 DEGREES, RESPECTIVELY. ACCORDING TO ICING PROBABILITY CHARTS, CONDITIONS WERE CONDUCIVE FOR SERIOUS CARBURETOR ICING. TOXICOLOGY TESTS WERE POSITIVE FOR FLUOXETINE AND NORFLUOXETINE (PROZAC). TESTS OF A BLOOD SPECIMEN (CLOT) SHOWED 0.2 MG/KG OF FLUOXETINE AND 0.3 MG/KG OF NORFLUOXETINE; TESTS OF A LIVER SPECIMEN SHOWED 6.2 MG/KG FLUOXETINE AND 15 MG/KG NORFLUOXETINE. THE PRESCRIPTION DRUG, PROZAC, IS AN ANTIDEPRESSANT AND WAS NOT APPROVED FOR USE WHILE FLYING. ## Factual narrative HISTORY OF FLIGHT On October 14, 1994, at 0920 central daylight time, a Robinson R22 Beta helicopter, N80546, was destroyed during a forced landing near Eunice, Louisiana. The private pilot was fatally injured. Instrument meteorological conditions prevailed for the personal flight. The pilot, who was a doctor, took off from a local hospital, and according to a witness two blocks from the hospital, was flying westbound along a road. The witness reported, "the pilot tried to keep the plane up, but something went wrong with the engine." The witness further reported the helicopter turned right towards a field, but the pilot "was unable to get the plane up so he crashed in the ditch" that parallels the road. AIRCRAFT INFORMATION A review of the airframe and engine records did not reveal any anomalies or uncorrected maintenance defects prior to the flight. WRECKAGE AND IMPACT INFORMATION Ground scars, were found on the north downslope side of a ditch that parallels a east and west oriented road. The aircraft came to rest on the road inverted 18 feet from the initial ground scars. There was a post impact fire. The transmission with the main rotor system came to rest on a station wagon 39 feet from the initial ground scar and on line with the main wreckage. A witness pulled it off the station wagon and put out the fire. The tail boom was separated from the main fuselage and was found 16 feet west of the main wreckage. See enclosed wreckage diagram for wreckage distribution details. The carburetor heat was off. Examination of the helicopter and engine did not disclose any mechanical anomalies. METEOROLOGICAL INFORMATION The temperature was 63 degrees Fahrenheit with a dew point of 59 at the time of the accident. According to the carburetor icing probability chart this places the airplane in the serious icing range at cruise power. The copy of the chart is enclosed with this report. MEDICAL AND PATHOLOGICAL INFORMATION The autopsy was performed by Emil M. Laga, M.D., New Iberia, Louisiana. Toxicological result was positive for Fluoxetine and Norfluoxetine (prozac). In the opinion of Dr. Salazar, regional flight surgeon for the southwest region, the levels of 6.2 mg/kg Fluoxetine, and 15 mg/kg Norfluoxetine detected in the liver are above therapeutic levels. The two medications described are on the Federal Aviation Administration's prohibited usage list for pilots. The manufacturer warns that these medications "may cause dizziness or drowsiness. Patients should be instructed to observe caution while driving or performing tasks requiring alertness, coordination or physical dexterity." ADDITIONAL DATA The wreckage was released to the owner's representative. ## Aircraft - Registration: [N80546](https://openairdocs.org/deregistered/N80546-1996-10-31), registration cancelled 1996-10-31, S/N 1204 (OpenAirDocs) - Reported make and model: ROBINSON R22 BETA - Registry model: [Robinson Helicopter R22 BETA](https://openairdocs.org/model/robinson-helicopter-r22-beta) (registry code 7640110) (OpenAirDocs) - Category: Helicopter - Serial number: 1204 - Airframe hours: 509 - Engines: LYCOMING O-320-B2C 131 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Ardoin, James A. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 22, 1994, 41 hours before - Destination: VILLE PLATTE, LA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; private; medical: class 3, valid medical--no waivers/lim.; seat: right; toxicology performed; flight hours: 80 total, 80 in this make and model, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 40° at 10 knots - Visibility: 7 statute miles - Lowest ceiling: 900 ft overcast - Temperature: 63 °F, dew point 59 °F - Altimeter: 30.00 inHg - Observed at: LFT, 28 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 19941014034859A](https://openairdocs.org/incident/19941014034859A), Oct 14, 1994: Robsin R22BETA, Eunice, LA, Destroyed, 1 fatal. Lost power after departing helipad. Allowed rotor speed decay on autorotation. Carb icing. No fly medical drug. ## Docket (15 files) The files NTSB released with the investigation on June 7, 1995, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=19192. 2.7 MB in all. - Supplement A (item 1, .PDF, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40020834&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 2, .PDF, 312 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40020835&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement G (item 3, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40020837&FileExtension=.PDF&FileName=Supplement%20G-Master.PDF - Supplement K (item 4, .PDF, 322 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40020836&FileExtension=.PDF&FileName=Supplement%20K-Master.PDF - Witness Statements (item 5, .PDF, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418783&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Charts (Icing Probability Curves) (item 6, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40020839&FileExtension=.PDF&FileName=Charts%20(Icing%20Probability%20Curves)-Master.PDF - Drawings (Wreckage Diagram) (item 7, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40020840&FileExtension=.PDF&FileName=Drawings%20(Wreckage%20Diagram)-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418784&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418782&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 10, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418781&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1: Road helicopter flew along. Looking back along route of flight. (item 11, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40020844&FileExtension=.PDF&FileName=Photo%201%3A%20%20Road%20helicopter%20flew%20along.%20%20Looking%20back%20along%20route%20of%20flight.-Master.PDF - Photo 2: Initial Ground Scars. Fuselage scar on left. Main rotor blade on right. (item 12, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40020845&FileExtension=.PDF&FileName=Photo%202%3A%20%20Initial%20Ground%20Scars.%20%20Fuselage%20scar%20on%20left.%20%20Main%20rotor%20blade%20on%20right.-Master.PDF - Photo 3: Looking from initial ground scars. The main rotor system was removed from station wagon by witness. (item 13, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40020846&FileExtension=.PDF&FileName=Photo%203%3A%20%20Looking%20from%20initial%20ground%20scars.%20%20The%20main%20rotor%20system%20was%20removed%20from%20station%20wagon%20by%20witness.-Master.PDF - Photo 4: Looking from station wagon towards initial ground scars. (item 14, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40020847&FileExtension=.PDF&FileName=Photo%204%3A%20%20Looking%20from%20station%20wagon%20towards%20initial%20ground%20scars.-Master.PDF - Photo 5: Tailboom seperated with tail rotor system attached. (item 15, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40020848&FileExtension=.PDF&FileName=Photo%205%3A%20%20Tailboom%20seperated%20with%20tail%20rotor%20system%20attached.-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.