# NTSB GAA19CA347: Robinson R22, N511HE, San Antonio, TX, June 15, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: June 15, 2019, 13:20 local (18:20 UTC) - Place: San Antonio, TX - Coordinates: 29.739166, -98.451385 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.7392&lon=-98.4514&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Dynamic rollover](https://openairdocs.org/ntsb-events/231) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report November 6, 2019 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 99644 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA347 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99644/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99644 - Page: https://openairdocs.org/ntsb/GAA19CA347 ## Probable cause The pilot receiving instruction's improper cyclic control input during landing, which resulted in a dynamic rollover, and the flight instructor's improper decision to practice landings in tall grass in gusting wind conditions. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: lateral/bank control](https://openairdocs.org/ntsb-findings/01062023): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Robinson Helicopter R22 BETA, 14 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md?model=7640110), [All aircraft, 390 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Robinson Helicopter R22 BETA, 17 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7640110), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Robinson Helicopter R22 BETA, 96 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7640110), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Robinson Helicopter R22 BETA, 16 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7640110), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Wind: gusts](https://openairdocs.org/ntsb-findings/03034045): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Robinson Helicopter R22 BETA, 13 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md?model=7640110), [All aircraft, 1,199 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md) - [Runway/land/takeoff/taxi surface](https://openairdocs.org/ntsb-findings/03023000): Environmental issues › Physical environment · Decision related to condition (probable cause); cases with it: [Robinson Helicopter R22 BETA, 3 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md?model=7640110), [All aircraft, 253 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md) - [Wind: gusts](https://openairdocs.org/ntsb-findings/03034045): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Robinson Helicopter R22 BETA, 13 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md?model=7640110), [All aircraft, 1,199 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md) - [Runway/land/takeoff/taxi surface](https://openairdocs.org/ntsb-findings/03023000): Environmental issues › Physical environment · Effect on operation; cases with it: [Robinson Helicopter R22 BETA, 3 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md?model=7640110), [All aircraft, 253 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Dynamic rollover](https://openairdocs.org/ntsb-events/231) (defining event); cases with it: [Robinson Helicopter R22 BETA, 35 cases](https://openairdocs.org/ntsb-events/231/sequence.md?model=7640110), [All aircraft, 161 cases](https://openairdocs.org/ntsb-events/231/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Robinson Helicopter R22 BETA, 85 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7640110), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The flight instructor in the helicopter reported that, while the pilot receiving instruction was practicing "slope landings" in the tall grass adjacent to an asphalt runway, he was shadowing the flight controls. He added that the pilot moved the cyclic left. The instructor was unable to correct, and the helicopter experienced a dynamic rollover and impacted terrain. As a recommendation, the instructor reported that the accident could have been prevented by not practicing slope landings in tall grass. He added that the helicopter contacted the terrain sooner than expected due to the tall grass. The helicopter sustained substantial damage to the fuselage and firewall. The instructor reported that there were no preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal operation. An automated weather observation station located about 12 miles south of the accident site reported that, about 29 minutes before the accident, the wind was from 170° at 15 knots, gusting to 21 knots. The same automated station reported that, about 9 minutes after the accident, the wind was from 180° at 9 knots. The pilot was landing to the south. ## Factual narrative The flight instructor in the helicopter reported that, while the pilot receiving instruction was practicing "slope landings" in the tall grass adjacent to an asphalt runway, he was shadowing the flight controls. He added that the pilot moved the cyclic to the left. The instructor was unable to correct, and the helicopter experienced dynamic rollover and impacted terrain. As a recommendation, the flight instructor reported that the accident could have been prevented by not practicing slope landings in tall grass. He added that the helicopter contacted the terrain sooner than expected due to the tall grass. The helicopter sustained substantial damage to the fuselage and firewall. The flight instructor reported that there were no preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal operation. The automated weather observation station, located about 12 miles south of the accident, reported that, about 29 minutes before the accident, the wind was from 170° at 15 knots, gusting 21 knots. The same automated station reported that, about 9 minutes after the accident, the wind was from 180° at 9 knots. The pilot was landing to the south. ## Aircraft - Registration: [N511HE](https://openairdocs.org/deregistered/N511HE-2019-09-09), registration cancelled 2019-09-09, S/N 3738, built 2004 (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) - Registry engine: [Lycoming O-360 series](https://openairdocs.org/engine/lycoming-o-360-series) (registry code 41575, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 3738 - Year built: 2004 - Airframe hours: 5860.3 - Engines: Lycoming O-360-J2A 145 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Helicopter Experts Inc - Registered owner: Heliflight Leasing Llc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 9, 2018 - Departed: 1T8, San Antonio, TX - Destination: 1T8, San Antonio, TX - Airport: 1T8, Bulverde Airpark, runway 16, 2,890 × 40 ft, asphalt - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 58; injuries: minor; flight instructor, private, commercial; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; last flight review July 11, 2018; seat: left; restraint: 3-point; flight hours: 14,500 total, 11,000 in this make and model, 14,400 as pilot in command, 100 in the last 90 days, 35 in the last 30 days, 3 in the last 24 hours - Pilot; age 61; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review September 30, 2015; seat: right; restraint: 3-point; flight hours: 250 total, 100 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: 1,500 ft broken - Temperature: 79 °F, dew point 72 °F - Altimeter: 29.94 inHg - Observed at: KSAT, 12 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 20190615017709A](https://openairdocs.org/incident/20190615017709A), Jun 15, 2019: Robinson Helicopter R22 BETA, Bulverde, TX, Substantial damage. During slope landing with student, instructor allowed aircraft to enter into dynamic rollover. ## Docket (2 files) The files NTSB released with the investigation on July 22, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99644. 3.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40474292&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Photos (item 2, .PDF, 2 photos, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40474293&FileExtension=.PDF&FileName=Accident%20Photos-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.