NYC08FA134

NTSB accident investigation · Robinson R22 Beta II · Wilmington, NC · March 13, 2008

Accident · FatalField investigationFinal report
Date
March 13, 2008, 09:40 local (13:40 UTC)
Place
Wilmington, NC
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N2215RRobinson R22 Beta II
Defining event
Enroute-cruise: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report August 12, 2010
Report
Approved by Office Director
Parties
FAA/FSDO, Robinson Helicopter Company, Lycoming
Case key
67659

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 pilot's failure to maintain proper rotor rpm after a partial loss of engine power.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

While the helicopter was en route at an estimated 200 hundred feet, a witness on the ground heard the engine "spitting and sputtering." Another witness saw parts “shedding” from the helicopter, then saw it reverse direction and descend until she lost sight of it behind a building. The helicopter subsequently impacted the ground in a vacant lot and erupted into flames. A postflight examination of the engine revealed no mechanical anomalies. The carburetor air temperature gauge was reported to be inoperative and interpolation of a carburetor icing probability chart revealed atmospheric conditions conducive to "serious icing" at glide power. However, the position of the carburetor heat could not be determined and the investigation could not establish the role that carburetor icing may have played in the accident. An examination of the two main rotor blades revealed that each had a section missing, beginning about equidistant from the rotor hub. Both sections were subsequently located away from the main wreckage. Both main rotor blades were also coned upwards from the hub, which, in conjunction with the missing blade sections, was consistent with a low rotor rpm condition. An examination of the tail rotor driveshaft, and the push-pull tube running along it, revealed that they had become entwined, consistent with a “whirl” condition. According to a representative of the manufacturer, such a whirl mode could occur if an overspeed occurs; the manufacturer's maximum operating main rotor rpm limitation is 102%. The event likely began with a partial loss of engine power, followed by the pilot’s delayed response to a low rotor rpm condition, which then resulted in the coning of the main rotor blades and a loss of main rotor blade material.

Factual narrative

History of flight

On March 13, 2008, at 0940 eastern daylight time, a Robinson R22 Beta II, N2215R, was substantially damaged during a forced landing in Wilmington, North Carolina. The certificated commercial pilot was fatally injured. Day visual meteorological conditions prevailed, and no flight plan was filed for the local flight which departed Wilmington International Airport (ILM), Wilmington, North Carolina. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

According to airport personnel, the pilot was planning to fly south in order to take aerial photographs of a business and then proceed to another location to pick up a student for a training lesson.

A witness, located about 1/2 mile from the accident scene, observed the helicopter when it passed overhead, and noted that "the engine was spitting and sputtering." The witness also noted that the helicopter appeared to be "about 50 feet above the pine trees," which were estimated to be 150 feet in height. Another witness stated that the helicopter appeared to be "just above the top of a billboard sign" when she first noticed it. She stated that she "saw parts shedding to the south then [it] started to reverse direction." The witness then lost sight of the helicopter behind the roof of a building and observed smoke. According to another witness, he saw the helicopter as "parts began to fall off," it impacted the ground, then "blew up into flames."

There was no radar track of the helicopter, and no onboard recording devices were located.

Personnel information

The pilot held a commercial pilot certificate with ratings for airplane single-engine land, airplane multiengine land, rotorcraft-helicopter, and instrument airplane and helicopter. He did not hold a flight instructor certificate. The pilot’s most recent second-class medical certificate was issued on February 7, 2008.

According to the pilot’s logbook, he had accumulated 542 total helicopter flight hours, with 433 flight hours in the accident helicopter make and model. He completed the Robinson Helicopter Company Pilot Safety Course on November 16, 2006, with a rating of "average."

Aircraft information

The helicopter, serial number 3084, was registered to and operated by Maintenance Services LLC, Rocky Point, North Carolina. It was a two-seat, single main rotor, single-engine helicopter that was constructed primarily of metal, was equipped with skid type landing gear, and was manufactured in February, 2000. The helicopter was powered by a Lycoming O-360-J2A engine, serial number, L-37378-36A.

The maximum gross weight of the helicopter was 1,370 pounds. The helicopter was issued a standard airworthiness certificate on May 11, 2000.

The tail rotor was powered through a tail rotor drive shaft that was 141 inches in length and enclosed in a tapered tail boom. The drive shaft was attached on the forward end to a flex plate (coupling) in the rear of the fuselage just aft of the drive pulley, and at the aft end, to another flex plate just forward of the tail rotor gearbox.

A single bearing was mounted on the tail rotor drive shaft about 44 inches aft of the forward flex plate, and was attached to the airframe via an arm, a clip, and bolts with washers. The purpose of the assembly was to dampen shaft oscillations.

According to the helicopter maintenance logbook, the helicopter’s most recent annual inspection was completed in accordance with manufacturer's maintenance manual checklist on December 14, 2007, at 1,389 hours of operation. The engine’s most recent inspection, a 100-hour inspection, was completed on October 13, 2007. The last maintenance accomplished on the accident helicopter was on March 6, 2008, and consisted of an engine oil and oil filter replacement by the accident pilot at 1,461 total hours.

Meteorological information

The 0953 recorded weather at ILM, located approximately 8 miles north of the accident site, included winds from 230 degrees at 4 knots, visibility 10 miles, clear skies, temperature 17 degrees C, dew point 4 degrees C, and an altimeter setting of 30.03 inches of mercury.

Wreckage and impact information

The helicopter impacted the ground in an open lot approximately 3 feet from several storage trailers. The helicopter exhibited impact damage and post-impact fire damage. The debris path was on a heading of 342 degrees and the helicopter came to rest heading about 140 degrees. The main wreckage consisted of the fuselage, main rotor assembly, tail boom, and tail rotor. The tail cone was separated from the fuselage at a right angle and no leading edge damage was found on the tail rotor blades. Several pieces of the main rotor blade, the empennage, and the helicopter anti-collision beacon were collocated approximately 350 feet south of the main wreckage. The wreckage was examined at the accident site and then recovered to a secure facility at ILM for further examination.

Examination of the helicopter revealed spanwise coning of the two main rotor blades. One of the main rotor blades was missing a section of the trailing edge, approximately 6 inches chordwise by 40 inches spanwise, starting about 26 inches from the blade hub. The other main rotor blade was missing a section of the trailing edge, approximately 6 inches chordwise by 61 inches spanwise, starting about 24 inches from the blade hub. One of the separated main rotor blade sections exhibited an impression, consistent in shape, to the leading edge of the vertical stabilizer.

The main rotor system was rotated through the main gear box without binding. The drive belts between the engine and transmission were not identified in the burnt wreckage.

The empennage, consisting of the vertical and horizontal stabilizer, was detached from the aft bulkhead of the tailcone.

The tail rotor drive shaft forward flex plate exhibited rotational distortion and crumpling, and was separated from both connecting yokes. The aft flex plate was not damaged.

The tail rotor drive shaft damper bearing assembly, which consisted of a housing, an inner and outer race, and bearings, was damaged. The damper bearing inner race was in place on the drive shaft and was able to rotate in place. The outer race and bearings were separated and could not be located. The bearing housing remained attached to the arm. It could not be determined if the damper assembly operated as intended prior to the accident sequence.

The interior of the tail cone, in the vicinity of the forward flex plate, displayed rotational scoring around the entire circumference. The electrical wires had been pulled through the grommets and the push/pull tube was wrapped around the drive shaft.

The tail rotor gear box rotated smoothly, and the pitch control bell crank support was separated from the gearbox.

The engine crankshaft was rotated using the cooling fan, and continuity of the crankshaft to the rear gears and to the valve train was confirmed. Thumb compression and suction was produced on cylinders 1, 3, and 4. Cylinder 2 produced minimal compression and further examination revealed the intake valve springs were compressed to a height of 1.4 to 1.5 inches but were unbroken. Both the inner and outer springs were discolored consistent with thermal damage. Cylinder 2 was removed from the crankcase and no damage was noted to the intake or exhaust valves, cylinder wall, piston, or connecting rod. The interior of all cylinders were inspected using a lighted boroscope; no anomalies were found. The carburetor bowl was separated from its upper housing and was approximately 2 feet from the front of the engine. The main fuel nozzle was broken off and the fuel lines were separated. The mixture control cable was detached but was in the full rich mixture position. The throttle control rod remained attached to the throttle control arm but was separated from the throttle control forward of the firewall.

Aircraft

Registration
N2215R
Reported as
Robinson R22 Beta II
Category
Helicopter
Serial number
3084
Airframe hours
1,389
Engine
Lycoming O-360-J2A, 145 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Operator
Maintenance Services LLC
Registered owner
Maintenance Services LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 14, 2007
Departed
ILM · Wilmington, NC
Destination
ILM · Wilmington, NC

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
51
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, With waivers/limitations
Last flight review
May 30, 2007
Seat
Right
Toxicology
Performed
Flight hours
1,254 total · 413 in this make and model · 967 as pilot in command · 76 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 39 °F
Altimeter
30.03 inHg
Observed at
ILM, 10 nm away

Docket · 20

The files NTSB released with the investigation on June 15, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports.