LAX95LA158

NTSB accident investigation · Robinson R-22B · Lakeport, CA · April 11, 1995

Accident · No injuriesLimited investigationFinal report
Date
April 11, 1995, 10:48 local (17:48 UTC)
Place
Lakeport, CA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N4015YRobinson R-22B
Weather
Visual (VMC) · Day
Status
Completed · report September 24, 1995
Report
Approved by Office Director
FAA report
19950411007199A
Case key
29071

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

the student's misjudged landing flare and his failure to verify the validity of the low rotor warning. Factors in the accident were the company management's continued use of the helicopter in flight training operations with a known discrepancy in the main rotor warning system, and the soft nature of the soil at the autorotation landing area.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionApproach - vfr pattern - downwind
Misc rotorcraft,main rotor rpm warning system - false indicationFactor
Operation with known deficiencies in equipment - continuedCompany/operator managementFactor
Rotor rpm - not verifiedPilot in commandCause
Forced landingEmergency descent/landing
Autorotation - initiatedPilot in command
Roll overLanding - flare/touchdown
Terrain condition - softFactor
Flare - misjudgedPilot in commandCause

Analysis

The student was doing takeoffs and landings in the traffic pattern when the low rotor RPM warning horn activated. The student was unsuccessful in extinguishing the warning horn by throttle and collective manipulation and entered an autorotation. The student did not verify the main rotor RPM by the rotor tachometer. During the touchdown, about 1/4-mile southeast of the airport in a soft field, the skids dug into soft soil and the helicopter rolled over. A FAA inspector examined the aircraft and engine, which included an engine start and static run-up. The engine started normally and was exercised throughout its normal power range. Maintenance records revealed a history of false low rotor RPM warning horn activations in the helicopter dating back 9 months. After pilots would report the warning horn discrepancy to maintenance personnel, a system component would be changed and the helicopter returned to service; however, the problem persisted. The cfi's said they trained the students, including the accident pilot, how to cope with the nuisance warning.

Factual narrative

On April 11, 1995, at 1048 Pacific daylight time, a Robinson R- 22B helicopter, N4015Y, rolled over during the touchdown phase of an autorotation at the Lampson Airport, Lakeport, California. The autorotation was precipitated by the activation of a low rotor rpm warning horn, which the pilot was unable to resolve. The helicopter was operated by Resort Aviation of Lakeport, and was on a student solo instructional flight. Visual meteorological conditions prevailed and included calm wind conditions. No flight plan was filed for the operation. The helicopter sustained substantial damage; however, the student pilot, the sole occupant, was not injured. The flight originated at the Lampson airport on the day of the accident at 1015 as a local traffic pattern practice student solo operation.

A Federal Aviation Administration (FAA) airworthiness inspector from the Sacramento, California, Flight Standards District Office responded to the accident site, examined the wreckage, and interviewed both the student pilot and other company employees. In a verbal statement to the inspector, the student said he was performing takeoffs and landings in the traffic pattern for runway 28, and was on downwind when the low rotor rpm warning horn activated. The student said he was unsuccessful in extinguishing the warning horn by throttle and collective manipulation and entered an autorotation. The student reported that he did not verify the main rotor rpm by reference to the rotor tachometer. During the touchdown, about 1/4-mile southeast of the airport in a soft field, the skids dug into soft soil and the helicopter rolled over.

The inspector examined the aircraft and engine, which included an engine start and static run-up. The engine started normally and was successfully exercised throughout its normal power range.

The inspector examined the maintenance records for the helicopter and interviewed both company flight instructors and maintenance personnel. The maintenance records revealed a history of false low rotor rpm warning horn activations in the accident helicopter dating back to July of 1994. After pilots would report the warning horn discrepancy to maintenance personnel, some system component would be changed and the helicopter returned to service; however, the problem persisted. In written statements, company flight instructors reported that the accident helicopter was the only one the company had, and they felt compelled by management to fly the aircraft with the unresolved discrepancy. The instructors stated that they trained the students, including the accident pilot, how to cope with the nuisance warning.

Aircraft

Registration
N4015Y
Reported as
Robinson R-22B
Category
Helicopter
Serial number
1427
Engine
Lycoming O-290, 140 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Resort Aviation
Registered owner
Osk Development, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 30, 1994
Airport
102 · Lampson Field

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
25
Certificate
Student
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
40 total · 40 in this make and model · 40 in the last 90 days · 40 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
50 statute miles
Lowest ceiling
None
Temperature
57 °F
Altimeter
30.00 inHg

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.