# NTSB LAX08CA159: Robinson R22, N268SH, Salt Lake City, UT, May 31, 2008 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: May 31, 2008, 08:10 local (14:10 UTC) - Place: Salt Lake City, UT - Coordinates: 40.619445, -111.992774 - Nearby events: https://openairdocs.org/map.md?lat=40.6194&lon=-111.9928&mi=10 - Phase of flight: [Emergency descent](https://openairdocs.org/ntsb-phases/600) (OpenAirDocs' grouping) - Defining event: [Autorotation: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report June 30, 2008 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 68140 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX08CA159 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68140/pdf - Page: https://openairdocs.org/ntsb/LAX08CA159 ## Probable cause The student's improper use of the anti torque pedals during a practice hover autorotation, which resulted in the helicopter rolling over. Additional causes of the accident were the certificated flight instructor's inadequate supervision of the maneuver and delayed remedial action. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Attention/monitoring: monitoring other person](https://openairdocs.org/ntsb-findings/02021535): Personnel issues › Psychological · Instructor/check pilot (probable cause); cases with it: [Robinson Helicopter R22 BETA, 15 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md?model=7640110), [All aircraft, 200 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Robinson Helicopter R22 BETA, 35 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=7640110), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/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 R22 BETA, 14 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7640110), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Autorotation: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Robinson Helicopter R22 BETA, 67 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7640110), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Landing-flare/touchdown: Roll over](https://openairdocs.org/ntsb-events/097); cases with it: [Robinson Helicopter R22 BETA, 21 cases](https://openairdocs.org/ntsb-events/097/sequence.md?model=7640110), [All aircraft, 261 cases](https://openairdocs.org/ntsb-events/097/sequence.md) ## Analysis The student pilot made several approaches and a practice hover autorotation before repositioning the helicopter to a different area of the airport. They planned to perform more hover autorotations and the certified flight instructor (CFI) continued to guard the flight controls. The CFI initiated the hover auto without communication, which was a deviation from their normal procedures. In response to the movement the student depressed the left [improper] anti-torque pedal and the helicopter began to spin. The CFI could not regain control and the helicopter rolled. The CFI reported no pre impact mechanical malfunctions or failures with the helicopter ## Factual narrative In a written statement, the certificated flight instructor (CFI) reported that the purpose of the flight was to provide the student pilot training. The student pilot made several approaches and a practice hover autorotation before repositioning the helicopter to a different area of the airport. They planned to perform more hover autorotations and the CFI continued to guard the flight controls. The CFI deviated from the normal procedure they had practiced of communicating and counting down before rolling the throttle to the closed position. The CFI initiated the hover auto without communication. In response to the movement the student depressed the left [improper] anti-torque pedal and the helicopter began to spin. The CFI could not regain control and the helicopter rolled. The CFI further stated that the accident could have been prevented if he had briefed the student more thoroughly on the maneuver and if he had assumed authority of the controls earlier in the maneuver. The CFI reported no pre impact mechanical malfunctions or failures with the helicopter ## Aircraft - Registration: [N268SH](https://openairdocs.org/deregistered/N268SH-2017-10-06), registration cancelled 2017-10-06, S/N 4233, built 2007 (OpenAirDocs) - Reported make and model: Robinson R22 - Registry model: [Robinson Helicopter R22 BETA](https://openairdocs.org/model/robinson-helicopter-r22-beta) (registry code 7640110) (OpenAirDocs) - Registry engine: [Lycoming O-360-J2A](https://openairdocs.org/engine/lycoming-o-360-j2a) (registry code 42314, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 4233 - Engines: Lycoming O-360-J2A reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Upper Limit Aviation - Registered owner: Tumbleweed Leasing Co., Inc - Airworthiness certificate: Standard, Normal - Departed: SLC, Salt Lake City, UT - Destination: U42, Salt Lake City, UT - Airport: U42, Salt Lake City Municipal 2 Air ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 32; flight instructor, commercial; instrument ratings: helicopter; medical: class 2; flight hours: 370 total, 370 in this make and model, 135 in the last 90 days, 58 in the last 30 days - Student pilot; age 27; student; medical: class 2; flight hours: 28 total, 28 in this make and model, 28 in the last 90 days, 16 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 4 knots - Visibility: 10 statute miles - Temperature: 61 °F ## 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 20080531835529A](https://openairdocs.org/incident/20080531835529A), May 31, 2008: Robsin R22, Salt Lake City, UT, Substantial damage. (-23) During a 14CFR part 141 training flight it was decided to perform a practice hovering autoration. The CFI and the student discussed the manuver and then… ## Other investigations on N268SH (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 WPR11CA189](https://openairdocs.org/ntsb/WPR11CA189), Apr 6, 2011: Robinson Helicopter R22 Beta (N268SH), Salt Lake City, UT, substantial damage. Probable cause: The student pilot's inadvertent action of pulling out the engine's mixture control lever to idle cutoff that resulted in a complete loss of engine power. 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.