# NTSB LAX93FA311: Robinson R44, N445RH, El Monte, CA, July 31, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 31, 1993, 13:49 local (20:49 UTC) - Place: El Monte, CA - Location: 34.0860° N, 118.0348° W: Placed by OpenAirDocs at SAN GABRIEL VALLEY (EMT), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=34.0860&lon=-118.0348&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report April 15, 1994 - Report: Approved by Office Director - Safety recommendations: Yes - NTSB case key (mKey): 28340 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX93FA311 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28340/pdf - Page: https://openairdocs.org/ntsb/LAX93FA311 ## Probable cause FATIGUE FAILURE OF THE CYCLIC CONTROL (STICK) ASSEMBLY, WHICH RESULTED IN LOSS OF CYCLIC (PITCH & ROLL) CONTROL. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, takeoff - initial climb - rotorcraft flight control,cyclic control - fatigue (cause) - cyclic - not possible, pilot in command - Loss of control - in flight, takeoff - initial climb - In flight collision with terrain/water, descent - uncontrolled ## Analysis THE PILOT AND TWO PASSENGERS DEPARTED IN THE HELICOPTER FROM THE APPROACH END OF RUNWAY 19. WITNESSES REPORTED THAT THE HELICOPTER ACCELERATED TO ABOUT 50 KNOTS AND CLIMBED TO BETWEEN 50 AND 100 FEET ABOVE THE RUNWAY. THEY SAID IT THEN SUDDENLY PITCHED DOWN, ROLLED TO THE RIGHT, AND CRASHED ON THE RUNWAY. AN EXAMINATION OF THE WRECKAGE DISCLOSED THAT IT HAD IMPACTED IN ABOUT A 35 DEGREE NOSE DOWN ATTITUDE AND A 30 DEGREE RIGHT BANK. THE HELICOPTER WAS DESTROYED BY IMPACT AND POST IMPACT FIRE; MANY OF THE FLIGHT CONTROL SYSTEM COMPONENTS WERE FOUND FRACTURED AND/OR FIRE DAMAGED. THIS INCLUDED A FRACTURE AT THE LOWER END OF THE CYCLIC CONTROL (STICK) ASSEMBLY. METALLURGICAL EXAMINATION OF THIS FRACTURE REVEALED EVIDENCE OF FATIGUE. THE HELICOPTER, WHICH HAD BEEN CERTIFICATED IN DECEMBER 1992, HAD ACCUMULATED 174 HOURS OF FLIGHT TIME SINCE BEING MANUFACTURED. ## Factual narrative History of the Flight On July 31, 1993, at 1349 hours Pacific daylight time, a Robinson R44 helicopter, N445RH, crashed during takeoff at El Monte airport, El Monte, California. The helicopter was being operated as a visual flight rules (VFR) personal flight in the local area when the accident occurred. The helicopter, registered to, and operated by Uni West Aviation Inc., Alhambra, California, was destroyed by impact and post impact fire. The certificated private pilot, and two passengers received fatal injuries. Visual meteorological conditions prevailed. The helicopter was cleared for takeoff by the El Monte Air Traffic Control Tower (ATCT) and departed from a hover at the approach end of runway 19. Several witness reported that the pilot maintained the runway heading over the centerline. The takeoff and initial climb appeared normal. About 50 to 100 feet above the ground (AGL), and at 50 knots of airspeed, the helicopter rapidly descended to the runway in about a 35 degree nose down attitude with about a 30 degree right bank. The helicopter struck runway 19 about 1,900 feet from the departure end. An intense post crash fire erupted and the fuselage came to rest about 300 feet from the initial point of impact. The accident occurred during the hours of daylight at latitude 34 degrees 05.16 minutes north and longitude 118 degrees 02.09 minutes west. Crew Information The pilot held a private pilot certificate, with a rotorcraft helicopter rating that was issued on January 22, 1991. The most recent third class medical certificate was issued to the pilot on January 13, 1992, and contained no limitations. On the application for the medical certificate, the pilot listed his total accumulated pilot time as 210 hours, with 50 hours accrued in the previous 6 months. Complete flight records for the pilot were not recovered and the aeronautical experience listed in this report was obtained from a review of the airman FAA records on file in the Airman and Medical Records Center located in Oklahoma City. In addition, partial pilot logbook pages from Robinson Helicopters files and a portion of fire damaged logbook pages were reviewed. According to the pilot/operator report submitted by the operator, the pilot's total aeronautical experience consisted of 640 hours, of which 60 hours were accrued in the accident aircraft make and model. In the preceding 90 and 30 days prior to the accident, the report lists a total of 50 and 10 hours respectively flown. Safety Board investigators attempted to validate and reconstruct the pilot's experience. On November 11, 1992, the pilot attended a three day Robinson R22 Safety Course, conducted by Robinson Helicopters. At that time, the pilot indicated that he had accrued 425 hours of flight time. Robinson Helicopters required 500 hours of total time to act as pilot-in-command of an R44. On May 28, 1993, the pilot attended a one day R44 Pilot Check-Out training course at Robinson Helicopters. As verification that the pilot that accrued 500 hours of flight time, the pilot sent a facsimile of two pages of a logbook to Robinson Helicopters that reflected a total time of 525.2 hours. The logbook pages were not dated. At the conclusion of the R44 training, the instructor pilot from Robinson Helicopters issued the pilot a certificate of training after finding that the pilot's performance was satisfactory to fly the R44 as a 2-place helicopter for at least 50 initial hours. To qualify to carry more than 1 passenger, the pilot needed to return for another flight check after gaining the required R44 flight time. On July 22, 1993, the pilot returned to Robinson Helicopters for his second flight check in the R44. The instructor pilot did not require the pilot to produce any verification that the pilot had accrued an additional 50 hours of R44 flight time. The instructor pilot verbally acknowledged that the pilot was authorized to carry more than one passenger; however, he did not issue a new certificate of training at that time. The operator produced a copy of a pilot logbook recovered from the helicopter wreckage that was fire damaged. The logbook pages appeared to reflect flight time accumulated by the pilot in the R44. The record did not reflect the dates of various flights; however, the two pages totaled 35.0 hours. Aircraft Information The recording hour meter in the helicopter was destroyed. Examination of the fire damaged aircraft maintenance logbook revealed that the helicopter was manufactured on February 12, 1993. A 100-hour inspection was completed by Robinson Helicopters on May 21, 1993, at an hour meter reading of 104.0, 70 hours before the accident. The helicopter was purchased by the operator on May 27, 1993. At that time the helicopter had accrued 106 hours. The operator and a flight test mechanic for Robinson Helicopters reported that just prior to the accident flight, the helicopter had accumulated a total time in service of about 174 flight hours. The last entry in the maintenance logbook was July 14, 1993, at a hour meter reading of 158.9. On that date the low rotor RPM warning horn unit was replaced and the main rotor blades were re-tracked by a Robinson Helicopter mechanic. The main rotor blade tracking was accomplished by adjustment of a trailing edge tab. No portion of the flight controls, swash plate assembly, or pitch change links were disturbed. The cyclic control assembly installed in the helicopter was revision H. The fuel system is gravity-fed (no fuel pumps) from the main fuel tank. An auxiliary fuel tank (smaller and mounted higher than the main) drains into the main tank through an inter-connecting line. The tanks are metal and are mounted above a firewall separating the engine from the main transmission and fuel tank area. The main rotor mast from the transmission is mounted vertically between the two fuel tanks. Fueling records at El Monte airport established that the helicopter was last fueled just prior to departure with the addition of 15.4 gallons of 100LL octane aviation fuel, which completely filled the main fuel tank. A mechanic for Robinson Helicopters reported that the main fuel tank gage indicated full and the auxiliary tank indicated less than 1/8 full. Meteorological Information The closest official weather observation station is El Monte, California, which is located at the accident site. At 1349 hours, a surface observation was reporting in part: Sky condition and ceiling, scattered clouds at 18,000 feet; visibility, 7 miles; wind, 180 degrees at 8 knots; altimeter, 30.00 inHg. Communications Review of the air-ground radio communications tapes maintained by the FAA at the El Monte ATCT facility revealed that the aircraft communicated with the local control position. No unusual communications were noted between the local controller and the pilot during the review of the tapes. Aerodrome and Ground Facilities The El Monte airport is owned by The County of Los Angeles. The operation of the airport is contracted to Comarco Airport Services Inc. The published elevation of the airport is 296 feet mean sea level. The airport is equipped a single hard surfaced runway on a 010 to 019 degree magnetic orientation. The runway is 3,995 feet long by 75 feet wide, and is equipped with medium intensity runway lights (MIRL), runway end identifier lights (REIL), and a visual approach slope indicator (VASI) lights. An Automatic Terminal Information Service (ATIS) weather broadcast is provided on a discrete frequency of 118.75 mhz. No formal crash, fire fighting, or rescue services or facilities are located on the airport, nor are any required. A small fire truck is stationed on the airport. Wreckage and Impact Information Safety Board investigators examined the wreckage at the accident site on July 31, 1993. The examination of the impact site revealed paint marks and ground scars in the ru ## Aircraft - Registration: [N445RH](https://openairdocs.org/deregistered/N445RH-2011-04-30), registration cancelled 2011-04-30, S/N 0005, built 1993 (OpenAirDocs) - Reported make and model: ROBINSON R44 - Registry model: [Robinson Helicopter R44](https://openairdocs.org/model/robinson-helicopter-r44) (registry code 7640120) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 005 - Airframe hours: 174 - Engines: LYCOMING O-540-F1B5 260 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Benjamin F. Venti, Sr. - Registered owner: Uni West Aviation Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, May 21, 1993, 70 hours before - Departed: EMT - Destination: EMT - Airport: EMT, El Monte, runway 19, 3,995 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 30; private; medical: class 3, valid medical--no waivers/lim.; seat: right; toxicology performed; flight hours: 640 total, 60 in this make and model, 585 as pilot in command, 50 in the last 90 days, 10 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 8 knots - Visibility: 7 statute miles - Lowest ceiling: none - Altimeter: 30.00 inHg - Observed at: EMT, 1 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 19930731027339A](https://openairdocs.org/incident/19930731027339A), Jul 31, 1993: Robsin R44, El Monte, CA, Destroyed, 3 fatal. Boom sound on takeoff. Rolled right into ground and burned. Fire destroyed determination efforts. 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.