# NTSB GAA16CA009: Robinson Helicopter R44 II, N779DZ, Ketchikan, AK, October 6, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: October 6, 2015, 07:15 local (15:15 UTC) - Place: Ketchikan, AK - Coordinates: 55.782501, -131.668334 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=55.7825&lon=-131.6683&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) start-up: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report December 3, 2015 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA Juneau FSDO - NTSB case key (mKey): 92139 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16CA009 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92139/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92139 - Page: https://openairdocs.org/ntsb/GAA16CA009 ## Probable cause The pilot's failure to maintain directional control during the engine start sequence, which resulted in the helicopter sliding on a steel deck and impacting a crane. Contributing to the accident was the absence of traction material on the helicopter operations portion of the steel deck. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [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) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Robinson Helicopter R44 II, 17 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7640122), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Airport facilities/design: runway/landing area condition](https://openairdocs.org/ntsb-findings/03017035): Environmental issues › Operating environment · Effect on operation (probable cause); cases with it: [Robinson Helicopter R44 II, 1 case](https://openairdocs.org/ntsb-findings/03017035/cases.md?model=7640122), [All aircraft, 61 cases](https://openairdocs.org/ntsb-findings/03017035/cases.md) - [Object/animal/substance: ground equipment](https://openairdocs.org/ntsb-findings/03022050): Environmental issues › Physical environment · Effect on equipment; cases with it: [Robinson Helicopter R44 II, 3 cases](https://openairdocs.org/ntsb-findings/03022050/cases.md?model=7640122), [All aircraft, 52 cases](https://openairdocs.org/ntsb-findings/03022050/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) start-up: 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) - [Standing-engine(s) start-up: Ground collision](https://openairdocs.org/ntsb-events/200); cases with it: [Robinson Helicopter R44 II, 3 cases](https://openairdocs.org/ntsb-events/200/sequence.md?model=7640122), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md) ## Analysis The helicopter pilot reported that during the engine start sequence on an offshore barge with a bare steel deck, the main rotor system clutch was engaging, and the throttle was applied to maintain 60 percent engine revolutions per minute. He reported that the skid and tundra/snow board equipped helicopter began a rapid right yaw, left pedal was applied simultaneously with throttle closure, but the helicopter rapidly yawed left resulting in the vertical stabilizer and tail rotor blade system impacting a crane stationed on the deck. The pilot then shut down the helicopter without further incident. A postflight inspection revealed substantial damage to the vertical stabilizer and the tail rotor blade system. The pilot reported there were no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. ## Factual narrative The helicopter pilot reported that during the engine start sequence on an offshore barge with a bare steel deck, the main rotor system clutch was engaging, and the throttle was applied to maintain 60 percent engine revolutions per minute. He reported that the skid and tundra/snow board equipped helicopter began a rapid right yaw, left pedal was applied simultaneously with throttle closure, but the helicopter rapidly yawed left resulting in the vertical stabilizer and tail rotor blade system impacting a crane stationed on the deck. The pilot then shut down the helicopter without further incident. A postflight inspection revealed substantial damage to the vertical stabilizer and the tail rotor blade system. The pilot reported there were no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. The operator reported as a safety recommendation, "One other factor that needs to be discussed is mission oriented versus safety oriented. This was nearly the last flight of this project and although it was discussed that this helicopter was being operated on the steel deck of the barge, it is industry standard to have non-skid matting for the helicopter to land on. The pilot elected to disregard the bother of having some sort of non-skid matting. Mission oriented became more important than safety oriented." AIRCRAFT INFORMATION The skids were equipped with tundra/snow boards, which were installed under a Federal Aviation Administration supplemental type certificate. ADDITIONAL INFORMATION Robinson Helicopter Company R44 II Pilot's Operating Handbook The Robinson Helicopter Company R44 II pilot's operating handbook lists the engine start and run-up procedures. A caution for starting the engine and run-up states; On slippery surfaces, be prepared to counter nose-right rotation with left pedal as governor increases revolutions per minute. ## Aircraft - Registration: [N779DZ](https://openairdocs.org/aircraft/N779DZ), registered now, S/N 10149, built 2003 (OpenAirDocs) - Reported make and model: ROBINSON HELICOPTER COMPANY R44 II (II) - Registry model: [Robinson Helicopter R44 II](https://openairdocs.org/model/robinson-helicopter-r44-ii) (registry code 7640122) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 10149 - Year built: 2003 - Airframe hours: 2467.9 - Engines: Lycoming IO-540-AE1A5 205 horsepower reciprocating - Damage: Substantial damage - Flight: Part 135 - Operator: Pollux Aviation Ltd, doing business as Pollux Aviation Ltd - Registered owner: Pollux Aviation Ltd - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, September 27, 2015 - Departed: Ketchikan, AK - Destination: Ketchikan, AK ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 27; injuries: none; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane, helicopter; medical: class 2, without waivers/limitations; last flight review April 7, 2015; seat: right; flight hours: 1,914.5 total, 669.2 in this make and model, 1,759.3 as pilot in command, 195.8 in the last 90 days, 96 in the last 30 days, 1.6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 46 °F, dew point 45 °F - Altimeter: 29.87 inHg - Observed at: PAKT, 26 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 20151006017949A](https://openairdocs.org/incident/20151006017949A), Oct 6, 2015: Robinson Helicopter Company R44 II, Neets Bay, AK, Substantial damage. Description: Helicopter was being operated off a metal barge in Neets Bay, Alaska to support remote helipad construction and or repair. As the pilot started… ## Other investigations on N779DZ (1) 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. - [NTSB ANC21LA080](https://openairdocs.org/ntsb/ANC21LA080), Aug 31, 2021: Robinson Helicopter R44 II (N779DZ), Pelican, AK, substantial damage. Probable cause: The pilot’s loss of control while landing on a remote helipad. ## Docket (3 files) The files NTSB released with the investigation on November 12, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92139. 3.1 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=40433776&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Photos (item 2, .PDF, 488 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433777&FileExtension=.PDF&FileName=Accident%20Photos%20-Master.PDF - Miscellaneous Information (item 3, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433778&FileExtension=.PDF&FileName=Miscellaneous%20Information-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.