# NTSB MIA04FA115: Robinson R22 Beta, Miami, FL, August 2, 2004 - Type: NTSB accident investigation - Date: August 2, 2004, 13:36 UTC, 09:36 local - Place: Miami, FL - Coordinates: 25.617221, -80.587219 - Highest injury: Fatal - Injuries: 1 fatal, 1 minor - Status: Completed - Report: Approved by Office Director, December 20, 2005 - Parties: Helicenter International Corporation, FAA Flight Standards District Office, Robinson Helicopter Company, Textron Lycoming - NTSB case key (mKey): 59846 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA04FA115 - NTSB report (PDF): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/59846/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=59846 - Page: https://openairdocs.org/ntsb/MIA04FA115 ## Probable cause The failure of company maintenance personnel to secure the push/pull tube to the left lug of the non-rotating portion of the swashplate assembly following maintenance, and the inability of the pilot to control the helicopter resulting in the in-flight collision with terrain. ## Analysis The purpose of the flight was to conduct an introductory flight to a potential student. The 6,271 hour certified flight instructor (CFI) demonstrated the preflight inspection step by step following the checklist for the prospective accident student; the inspection included examination of the swash plate assembly for security of the flight control push/pull tubes. No preflight inspection discrepancies were later reported by the accident student. The engine was started, and the flight departed to the west climbing to 500 feet msl, then descended to 300 feet. The student reported that while flying straight and level at 60 knots while he was looking outside, the helicopter banked left and nose down, "... making it impossible for the instructor to control the aircraft." The CFI commented several times "what happened", and attempted to recover from the left and nose down attitude but was unable. The CFI moved the cyclic control in an attempt to recover, but due to his (student's) confusion, could not recall what position he was moving it to. The student perceived the helicopter impacted the ground first with the left skid. The student did not notice any change in engine sound from the time of takeoff to the moment the helicopter banked left. Postaccident examination of the helicopter revealed the left forward push/pull tube was not connected to the swashplate assembly; the lug was not fractured. The rod-end and securing hardware of the left push/pull tube was not located. The securing hardware which secures the aft push/pull rod to the swashplate assembly was found to be loose; the threads of the bolt did not extend beyond the end of the nut and a palnut was not in position. NTSB examination of the swashplate assembly revealed no elongation of the hole of the left forward lug; linear impressions on the interior surface were consistent with the threads of the bolt. The impressions on the interior surface of the left forward lug were located in the area were the bolt shank is located. Four days before the accident, tracking and balancing of the main rotor was accomplished. The bracket used during the tracking procedure was installed to the left and aft lugs of the swashplate assembly, contrary to the procedure specified in the maintenance manual. The mechanic who performed the work could not recall if he used a new metal self locking nut when reinstalling the push/pull rods. Robinson Helicopter Company personnel reported that "...if either of the forward push/pull tubes were to become disconnected at the lower swashplate, it is assumed that the helicopter would be uncontrollable." Postaccident review of the operator's facility and several helicopters by NTSB and FAA personnel revealed several had the push/pull tubes installed on the incorrect side of the lugs at the swashplate assembly, and the securing hardware was incorrectly installed. Additionally, FAA personnel noted discrepancies with the maintenance records. One of the helicopters which had the push/pull tubes incorrectly installed, had been previously inspected on five separate occasions by one of the mechanics who had performed the last tracking and balancing of the main rotor on the accident helicopter. Installation of the bracket used during the last main rotor tracking and balancing required the removal of the bolts at the left and aft lugs of the swash plate. Proper installation of the bracket requires removal of hardware that secures 2 of 3 flight control push/pull tubes to the swashplate. ## Factual narrative HISTORY OF FLIGHT On August 2, 2004, about 0936 eastern daylight time, a Robinson R22 Beta helicopter, N2566W, registered to a private individual and leased to Helicenter International Corporation, dba Helicenter International Academy, collided with terrain in Everglades National Park, Miami, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 local, instructional flight from the Kendall-Tamiami Executive Airport, Miami, Florida. The helicopter was destroyed by a postcrash fire and the certified flight instructor (CFI) was fatally injured. The dual student (student) sustained minor injuries. The flight originated about 0925, from the Kendall-Tamiami Executive Airport. According to a transcription of communications with the Kendall-Tamiami Executive Airport (KTMB) Air Traffic Control Tower (ATCT), an occupant of the helicopter established initial contacted with the facility at 0925:10, which the controller acknowledged. At 0925:17, an occupant then requested "...spot two request whiskey departure." At 0925:20, the controller responded "november six six whiskey proceed as requested on whiskey departure use caution." That transmission was acknowledged by an occupant who used the last 3 of the registration of the helicopter; there were no further recorded transmissions received by the KTMB ATCT from the accident helicopter. The student reported that the purpose of the flight was for him to become familiar with rotorcraft operations; the flight duration was intended to be approximately 20-30 minutes. Before departure, both fuel tanks were topped off. The CFI demonstrated to him and several other students the preflight inspection of the helicopter step by step using the checklist, which included checking the flight controls. While following the checklist, the CFI pointed out the component on the helicopter. With respect to the hardware that secures the push/pull tubes to the swashplate assembly, the student later reported to the NTSB that the CFI stepped on the frame of the helicopter and visually inspected the hardware and mentioned that it needed to be tight, secure, and safetied. The student did not report any discrepancies that were found during the preflight inspection. The engine was started, and the flight departed to the west climbing to 500 feet mean sea level (msl). The flight continued westbound and after passing a radar ball located near "QEEZY" which is a fan marker and non-directional beacon, he noted the helicopter was descending and brought that to the CFI's attention who reported he was intentionally descending to 300 feet. While flying at that altitude at 60 knots, the CFI maneuvered the helicopter left and right then while flying northbound straight and level at 300 feet while the student was looking outside, the helicopter banked left and nose down, "...making it impossible for the instructor to control the aircraft...." The CFI responded several times with, "what happened", and tried to recover. The student noted that the CFI moved the cyclic control in an attempt to recover but due to his (student's) confusion, could not recall what position he was moving it to. The CFI was unable to recover from the attitude and when the helicopter was close to the ground, he (student) closed his eyes and perceived the helicopter impacted the ground first with the left skid. He wasn't sure of the airspeed and couldn't recall the impact. Following the impact which was later determined to have occurred approximately 11 minutes after the flight departed, the student released his restraint, exited the helicopter, then heard the CFI ask for assistance. He went back to the helicopter, released the CFI's restraint, and pulled him from the wreckage. He then called 911 using the CFI's cell phone; several calls were disconnected; however, rescue units arrived and both were transported to a hospital. The student further reported he did not notice any change in engine sound from the time of takeoff to the moment the helicopter banked left and nose down. Review of radar data revealed that after takeoff, the flight proceeded in a westerly direction, climbed to 500 feet, turned to a southwesterly direction and descended initially to approximately 400 feet then to 100 feet. A gap in radar returns was noted south of the accident site but the location and time of the subsequent returns were consistent with the performance capability of the helicopter. The radar data further indicates that the helicopter was noted to maneuver for approximately 45 seconds at 100 feet south-southwest of the accident site. The last radar return associated with the helicopter occurred at 0936:09. PERSONNEL INFORMATION A review of CFI's Federal Aviation Administration (FAA) airman file pertaining to rotorcraft certificates and ratings revealed he was issued a private pilot certificate with a rotorcraft helicopter rating on January 15, 1982. He obtained a commercial pilot certificate with rotorcraft helicopter rating on March 22, 1982, and on October 30, 1985, obtained his initial flight instructor certificate with rotorcraft-helicopter rating. Since the initial CFI certificate was issued, he has continuously renewed it, with the last renewal occurring on June 3, 2003. He added an airplane single engine rating to his CFI certificate on August 5, 2003, which qualified as a flight review in accordance with 14 CFR Part 61.56. He was the holder of a 2nd class medical certificate issued on April 13, 2004, with the medical restriction, "must wear corrective lenses." He listed a total civilian flight time of 6,300 hours on the application for his last medical certificate. There were no FAA enforcement actions or previous accident/incident records associated with his pilot certificate. The CFI attended the FAA-Approved Flight Instructor Refresher Clinic at Robinson Helicopter Company, located in Torrance, California, from March 12-15, 2003. The "Instructor/Pilot Evaluation" form dated March 14, 2003, indicates he was rated "above average" in straight autorotations, 180 autorotations, and hovering autorotations. He was also rated "above average" in overall handling and maneuvering with the comment, "smooth & safe." With respect to simulated engine out procedures he was rated "average." The CFI became employed by Helicenter International Corporation as an independent subcontractor on September 22, 2003. A review of his resume provided by the operator indicates at the time, he had a total rotorcraft flight time of 5,291 hours, of which 5,195 hours were as pilot-in-command. Of the total rotorcraft flight hours, more than 2,000 hours were in Robinson model helicopters. Since employment, the operator reported he had flown a total of 826.9 hours, of which 644.7 hours were in the Robinson R22 model helicopter. A review of copies of the CFI's pilot logbooks that begin with an entry dated November 26, 2003, to the last entry dated July 31, 2004, revealed he logged a total rotorcraft helicopter time of approximately 6,271 hours, and 5,739.0 hours as a flight instructor. He also logged approximately 6,152 hours as pilot-in-command. Prior to the accident flight, the student seated in the right seat did not possess any pilot certificate, and had never been in a helicopter. He is a 2nd Lieutenant in the Dominican Republic Army, and was at Helicenter International Corporation to receive flight training. AIRCRAFT INFORMATION The helicopter was manufactured in 1986 by Robinson Helicopter Company as a R22 Beta, and designated serial number 0616. A standard airworthiness certificate in the normal category was issued on December 18, 1986. The helicopter was purchased by the current owner on August 22, 2003, and leased to Helicenter International Corporation for a 1-year period beginning on August 12, 2003. An individual from Helicenter International Corporation flew the helicopter to their fac ## Sequence of events - Airframe/component/system failure/malfunction, cruise - normal - rotorcraft flight control,cyclic control rod - separation - maintenance,installation - inadequate, company maintenance personnel (cause) - Loss of control - in flight, descent - uncontrolled - aircraft control - not possible, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Aircraft - Registration: N2566W, a cancelled registration (https://openairdocs.org/deregistered/N2566W-2006-12-05) (OpenAirDocs) - Reported make and model: Robinson R22 Beta - Registry model: Robinson Helicopter R22 BETA (registry code 7640110, https://openairdocs.org/model/robinson-helicopter-r22-beta) (OpenAirDocs) - Registry engine: Lycoming 0-320 series (registry code 41508, https://openairdocs.org/engine/lycoming-0-320-series) (OpenAirDocs) - Category: Helicopter - Serial number: 0616 - Airframe hours: 3180.16 - Engines: Lycoming O-320-B2C 131 horsepower - Damage: Destroyed - Flight: Instructional, Part 91 - Operator: Helicenter International Corporation - Departed: KTMB, Miami, FL - Destination: KTMB, Miami, FL - FAA reports: 20040802023289A (https://openairdocs.org/incident/20040802023289A) (OpenAirDocs) ## Flight crew - Flight instructor; age 44; flight engineer, commercial, flight instructor; medical class 2; hours: 44 30 days, 4 30 days in this make and model, 177 90 days, 19 90 days in this make and model, 5,739 instructor, 6,152 pic ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 6 knots - Visibility (statute miles): 10 - Lowest ceiling (ft AGL): 9000 - Temperature (°F): 80.6 ## Docket (37 files) On NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=59846 - Materials Laboratory 15 - Factual Report 04-0108 swashplate (.PDF, 9 pages, 779 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40218519&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%2004-0108%20swashplate-Master.PDF - Flight Path Diagram (.PDF, 2 pages, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40218542&FileExtension=.PDF&FileName=Flight%20Path%20Diagram-Master.PDF - Source Radar Data for Flight Path Diagram (ZIP, 869 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40218543&FileExtension=zip&FileName=Source%20Radar%20Data%20for%20Flight%20Path%20Diagram-Master - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (.PDF, 6 pages, 282 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393862&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Supplement S (.PDF, 1 pages, 336 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229183&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Transcript of Radio Communications (.PDF, 5 pages, 181 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393863&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Redacted.PDF - Statement from Yonatan Martinez (.PDF, 1 pages, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393864&FileExtension=.PDF&FileName=Statement%20from%20Yonatan%20Martinez-Redacted.PDF - Report from Robinson Helicopter Company (.PDF, 75 pages, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393865&FileExtension=.PDF&FileName=Report%20from%20Robinson%20Helicopter%20Company-Redacted.PDF - Pages from R22 Pilot's Operating Handbook and FAA Approved Rotorcraft Flight Manual (.PDF, 3 pages, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393866&FileExtension=.PDF&FileName=Pages%20from%20R22%20Pilot%27s%20Operating%20Handbook%20and%20FAA%20Approved%20Rotorcraft%20Flight%20Manual-Redacted.PDF - Records of NTSB Conversations (.PDF, 10 pages, 321 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393867&FileExtension=.PDF&FileName=Records%20of%20NTSB%20Conversations-Redacted.PDF - Documents provided by Helicenter International Corporation (.PDF, 30 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393868&FileExtension=.PDF&FileName=Documents%20provided%20by%20Helicenter%20International%20Corporation-Redacted.PDF - Pilot Logbooks (.PDF, 37 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40232278&FileExtension=.PDF&FileName=Pilot%20Logbooks-Master.PDF - Documents provided by Robinson Helicopter Company (.PDF, 12 pages, 572 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393869&FileExtension=.PDF&FileName=Documents%20provided%20by%20Robinson%20Helicopter%20Company-Redacted.PDF - Statement and Documents from Ken Martin (.PDF, 6 pages, 634 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393870&FileExtension=.PDF&FileName=Statement%20and%20Documents%20from%20Ken%20Martin-Redacted.PDF - Aircraft Logbook - N2566W (.PDF, 17 pages, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393871&FileExtension=.PDF&FileName=Aircraft%20Logbook%20-%20N2566W-Redacted.PDF - Main Rotor Tracking and Balance Chart (.PDF, 4 pages, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229151&FileExtension=.PDF&FileName=Main%20Rotor%20Tracking%20and%20Balance%20Chart-Master.PDF - Non-Routine Inspection Sheets (.PDF, 2 pages, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229152&FileExtension=.PDF&FileName=Non-Routine%20Inspection%20Sheets-Master.PDF - Documents provided by Heliflight, Inc. (.PDF, 41 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393873&FileExtension=.PDF&FileName=Documents%20provided%20by%20Heliflight,%20Inc.-Redacted.PDF - Statements of George Interian (.PDF, 3 pages, 190 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393874&FileExtension=.PDF&FileName=Statements%20of%20George%20Interian-Redacted.PDF - Statement from Jairo Becerra (.PDF, 2 pages, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393875&FileExtension=.PDF&FileName=Statement%20from%20Jairo%20Becerra-Redacted.PDF - Excerpts from the Robinson R22 Illustrated Parts Catalog (.PDF, 9 pages, 307 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229157&FileExtension=.PDF&FileName=Excerpts%20from%20the%20Robinson%20R22%20Illustrated%20Parts%20Catalog-Master.PDF - Excerpts from Maintenance Manual (.PDF, 22 pages, 528 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40238937&FileExtension=.PDF&FileName=Excerpts%20from%20Maintenance%20Manual-Master.PDF - FAA Record of Conversation with Mike Ratto (.PDF, 1 pages, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393876&FileExtension=.PDF&FileName=FAA%20Record%20of%20Conversation%20with%20Mike%20Ratto-Redacted.PDF - Excerpts from Aircraft Logbook - N122AK (.PDF, 5 pages, 295 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393877&FileExtension=.PDF&FileName=Excerpts%20from%20Aircraft%20Logbook%20-%20N122AK-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (.PDF, 2 pages, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393878&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Toxicological Report (.PDF, 1 pages, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393879&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (.PDF, 2 pages, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393880&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1: Digital Photograph. Aerial view of the accident site area. (.PDF, 1 pages, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40232442&FileExtension=.PDF&FileName=Photo%201%3A%20%20Digital%20Photograph.%20%20Aerial%20view%20of%20the%20accident%20site%20area.-Master.PDF - Photo 2: Digital Photograph. Aerial view of the main wreckage. (.PDF, 1 pages, 467 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40232443&FileExtension=.PDF&FileName=Photo%202%3A%20%20Digital%20Photograph.%20%20Aerial%20view%20of%20the%20main%20wreckage.-Master.PDF - Photo 3: Digital Photograph. View of the main wreckage looking down the energy path. (.PDF, 1 pages, 483 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40232444&FileExtension=.PDF&FileName=Photo%203%3A%20%20Digital%20Photograph.%20%20View%20of%20the%20main%20wreckage%20looking%20down%20the%20energy%20path.-Master.PDF - Photo 4: Digital Photograph. View of the main wreckage. (.PDF, 1 pages, 479 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40232445&FileExtension=.PDF&FileName=Photo%204%3A%20%20Digital%20Photograph.%20%20View%20of%20the%20main%20wreckage.-Master.PDF - Photo 5: Digital Photograph. View of the swashplate assembly. (.PDF, 1 pages, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40232446&FileExtension=.PDF&FileName=Photo%205%3A%20%20Digital%20Photograph.%20%20View%20of%20the%20swashplate%20assembly.-Master.PDF - Photo 6: Digital Photograph. View of the swashplate assembly. (.PDF, 1 pages, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40232447&FileExtension=.PDF&FileName=Photo%206%3A%20%20Digital%20Photograph.%20%20View%20of%20the%20swashplate%20assembly.-Master.PDF - Photo 7: Digital Photograph. View of the airspeed indicator. (.PDF, 1 pages, 384 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40232448&FileExtension=.PDF&FileName=Photo%207%3A%20%20Digital%20Photograph.%20%20View%20of%20the%20airspeed%20indicator.-Master.PDF - Photo 8: Digital Photograph. View of the swashplate assembly. (.PDF, 1 pages, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40232449&FileExtension=.PDF&FileName=Photo%208%3A%20%20Digital%20Photograph.%20%20View%20of%20the%20swashplate%20assembly.-Master.PDF - Photo 9: Digital Photograph. View of the aft lug of the swashplate assembly. Note the bent bolt and gap between rod end and lug face. (.PDF, 1 pages, 356 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40232450&FileExtension=.PDF&FileName=Photo%209%3A%20%20Digital%20Photograph.%20%20View%20of%20the%20aft%20lug%20of%20the%20swashplate%20assembly.%20%20Note%20the%20bent%20bolt%20and%20gap%20between%20rod%20end%20and%20lug%20face.-Master.PDF - Photo 10: Digital Photograph. View of the skids. (.PDF, 1 pages, 472 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40232451&FileExtension=.PDF&FileName=Photo%2010%3A%20%20Digital%20Photograph.%20%20View%20of%20the%20skids.-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- From OpenAirDocs.org, an independent open copy of NTSB and FAA data. The NTSB's own report is the official record of an investigation.