# NTSB WPR09FA076: Robinson Helicopter R44 II, N168SH, West Valley City, UT, January 9, 2009 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: January 8, 2009, 20:52 local (Jan 9, 2009, 03:52 UTC) - Place: West Valley City, UT - Coordinates: 40.630832, -112.056663 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.6308&lon=-112.0567&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report November 9, 2009 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA FSDO - NTSB case key (mKey): 73209 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09FA076 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73209/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73209 - Page: https://openairdocs.org/ntsb/WPR09FA076 ## Probable cause The pilot’s inadvertent VFR flight into IMC conditions, which resulted in his spatial disorientation and loss of control of the helicopter. Also causal was the flight instructor’s delay in taking remedial action. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Ceiling/visibility/precip: clouds](https://openairdocs.org/ntsb-findings/03035025): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Robinson Helicopter R44 II, 1 case](https://openairdocs.org/ntsb-findings/03035025/cases.md?model=7640122), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/03035025/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Robinson Helicopter R44 II, 8 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=7640122), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Robinson Helicopter R44 II, 99 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7640122), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Robinson Helicopter R44 II, 10 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=7640122), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/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 R44 II, 3 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=7640122), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401); cases with it: [Robinson Helicopter R44 II, 9 cases](https://openairdocs.org/ntsb-events/401/sequence.md?model=7640122), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Enroute: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Robinson Helicopter R44 II, 74 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7640122), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Robinson Helicopter R44 II, 95 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7640122), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot and the instructor reported that the flight began as an instrument flight rules (IFR) cross-country training flight. After encountering turbulence and head winds, they elected to terminate the IFR flight plan about 10 miles from their intended destination, reverse course, and return under night visual flight rules (VFR). The instructor stated that on the return trip, he was not instructing the pilot and was "just a passenger." During the return trip, they made an intermediate stop and refueled the helicopter. The weather conditions on departure from the refueling stop were winds light and variable, visibility 4 miles, and ceiling about 2,000 feet above ground level (6,321 feet mean sea level [msl]). About 15 minutes into the flight, the helicopter was at about 6,100 feet msl when it entered clouds and the pilot lost visual contact with the ground. The instructor reported that the pilot "became quickly disoriented losing positive control of the aircraft." The pilot reported that the helicopter entered the clouds and "began to rotate immediately." The flight instructor took the controls and attempted to regain control of the helicopter, but was unable to do so before the helicopter impacted the ground. ## Factual narrative HISTORY OF FLIGHT On January 8, 2009, approximately 2052 mountain standard time, a Robinson Helicopter Company R44 II, N168SH, impacted terrain following a loss of control in cruise flight near West Valley City, Utah. The flight instructor and the commercial pilot receiving instruction were seriously injured. The helicopter sustained substantial damage. The helicopter was registered to Majestic Helicopters LLC, Eagle Mountain, Utah, and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. A flight plan was not filed and night visual meteorological conditions prevailed for the helicopter’s departure from Tooele, Utah, about 2037, with an intended destination of Bountiful, Utah. Instrument meteorological conditions (IMC) prevailed in the vicinity of the accident site at the time of the accident. Both the pilot and the instructor reported that the flight began as an instrument flight rules (IFR) cross-country training flight. They departed from Bountiful about 1650, and flew to Provo, Utah, where they stopped to refuel the helicopter. The pilot filed an IFR flight plan from Provo to Wendover, Utah. After departure from Provo, the pilot put on foggles (a view limiting device) and flew to Staco intersection, where he removed the foggles and continued towards Wendover. After encountering turbulence and head winds, they elected to terminate the IFR flight plan about 10 miles from Wendover, reverse course, and return to Bountiful under visual flight rules (VFR). The instructor reported that on the return trip from Wendover, he was not instructing the pilot and that he was "just a passenger." They landed at Tooele, refueled the helicopter and departed VFR for Bountiful. According to the instructor, the weather conditions at Tooele were winds light and variable, visibility 4 miles, and ceiling about 2,000 feet above ground level (6,321 feet mean sea level [msl]). The planned flight path was from Tooele northeast to Garfield Stack, then south along Highway 111 to circle south around the Salt Lake City Class B airspace, then north to Bountiful. The helicopter was heading south along Highway 111 at about 6,100 feet msl when the "cloud ceiling dropped causing helicopter to enter a cloud, visual of ground was lost." The pilot "became quickly disoriented losing positive control of the aircraft." The flight instructor took the controls and attempted to regain control of the helicopter, but was unable to do so before the helicopter impacted the ground. The pilot reported that he was flying the final leg of the flight back to Bountiful when the weather conditions began to deteriorate. The helicopter entered the clouds and "began to rotate almost immediately." He turned on the emergency locator transmitter (ELT) switch and the helicopter impacted the ground. PERSONNEL INFORMATION The pilot, age 24, held a commercial pilot certificate with a helicopter rating. The pilot’s most recent second-class medical certificate was issued onJanuary 9, 2008, with no limitations. He reported that he had about 209 hours of flight experience of which 144 hours were in the same make and model as the accident helicopter. The pilot had 44 hours of night flight experience and 39 hours of simulated instrument experience. The instructor, age 23, held a commercial pilot certificate with helicopter and instrument helicopter ratings. Additionally, he held a flight instructor certificate with helicopter and helicopter instrument ratings. The instructor’s most recent third-class medical certificate was issued on April 25, 2008, with the limitation, must wear corrective lenses. The instructor completed an NTSB Pilot/Operator Aircraft Accident Report Form, but did not provide any record of his flight experience. Total flight time data extracted from the instructor's medical certificate application dated April 25, 2008, indicated that the pilot reported a total flight time of 294 hours at that time. AIRCRAFT INFORMATION The 2007 model Robinson R44 II helicopter, S/N 11658, was powered by one 245-horsepower Lycoming IO-540-AE1A5 reciprocating engine, S/N L-31782-48A. The helicopter was approved for day and night VFR operations. At the time of the accident, the airframe and engine had accumulated 445.4 hours total time. The last annual inspection was completed on November 24, 2008, at an airframe and engine total time of 416.4 hours. The most recent maintenance documented on the helicopter was the removal and reinstallation following repair of the artificial horizon on November 29, 2008, at an airframe total time of 418.9 hours. The repair order form for the artificial horizon stated that the work performed included installing a new inclinometer bubble, replacing the roll gimbal bearings, and function testing and recalibrating the unit in accordance with the manufacturer’s specifications. METEOROLOGICAL INFORMATION At 2053, the reported weather conditions at Salt Lake City International Airport (elevation 4,227 feet), located approximately 11 nautical miles north of the accident site, were wind from 310 degrees at 7 knots; visibility 6 miles in light rain and mist; ceiling overcast 1,500 feet; temperature 2 degrees Celsius; dew point -1 degree Celsius; and altimeter setting 30.03 inches of Mercury. WRECKAGE AND IMPACT INFORMATION The helicopter came to rest on its left side oriented on a southwesterly heading near the crest of a snow covered hill just east of 6600 South Highway 111. Rising terrain was observed to the south and west of the accident site. A large impact crater was observed immediately in front (to the southwest) of the main wreckage. The crater measured about 15 feet in length and 6 feet in width and was 8 to 12 inches deep. Separated portions of the landing skids were located within the impact crater. No additional ground scars were located at the accident site. The rotor head and mast remained attached to the transmission. Both main rotor blades exhibited extensive impact damage. Thetail boom remained attached to the fuselage and was bent downward. The tail rotor gearbox and tail rotor assembly remained attached to the tail boom, however, they had sustained impact damage. The tail rotor blades were mostly separated. The horizontal and vertical stabilizers were separated and found adjacent to the main wreckage. The bottom of the fuselage exhibited severe upward deformation. The left and right landing skids were separated. The forward landing skid mounts were impact damaged and compressed upwards and outboard of the fuselage. The aft landing skid mounts were separated. The engine remained attached to the fuselage. The engine firewall appeared to be impact damaged. ADDITIONAL INFORMATION Robinson Helicopter Company Safety Notice SN-18, revised June 1994, titled "LOSS OF VISIBILITY CAN BE FATAL," states in part: Flying a helicopter in obscured visibility due to fog, snow, low ceiling, or even a dark night can be fatal. Helicopters have less inherent stability and much faster roll and pitch rates than airplanes. Loss of the pilot’s outside visual references, even for a moment, can result in disorientation, wrong control inputs, and an uncontrolled crash. Robinson Helicopter Company Safety Notice SN-26, revised June 1994, titled "NIGHT FLIGHT PLUS BAD WEATHER CAN BE DEADLY," states in part: When it is dark, the pilot cannot see wires or the bottom of the clouds, nor low hanging scud or fog. Even when he does see it, he is unable to judge its altitude because there is no horizon for reference. He doesn't realize it is there until he has actually flown into it and suddenly loses his outside visual references and his ability to control the attitude of the helicopter. Both the pilot and the instructor reported that the artificial horizon required repeated adjustments during the flight. With the helicopter in level flight, the horizon indicator would gradually creep up to 2 to 4 degrees of climb, and the pilot would readjust it to level flight. The pilot and the instructor both stated that they did not think this problem had anything to do with the accident and that although the helicopter was equipped for IFR training, it was not certified for flight in IMC. ## Aircraft - Registration: [N168SH](https://openairdocs.org/deregistered/N168SH-2013-01-31), registration cancelled 2013-01-31, S/N 11658, built 2007 (OpenAirDocs) - Reported make and model: ROBINSON HELICOPTER COMPANY R44 II - Registry model: [Robinson Helicopter R44 II](https://openairdocs.org/model/robinson-helicopter-r44-ii) (registry code 7640122) (OpenAirDocs) - Registry engine: [Lycoming IO-540-AE1A5](https://openairdocs.org/engine/lycoming-io-540-ae1a5) (registry code 41899, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 11658 - Airframe hours: 445 - Engines: LYCOMING IO-540-AE1A5 245 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 24, 2008, 29 hours before - Departed: TVY, Tooele, UT - Destination: BTF, Bountiful, UT ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 23; injuries: serious; commercial, flight instructor; instrument ratings: helicopter; medical: class 3, with waivers/limitations; last flight review February 20, 2008; seat: left; flight hours: 294 total - Pilot; age 24; injuries: serious; commercial; medical: class 2, without waivers/limitations; last flight review October 26, 2008; seat: right; flight hours: 209 total, 144 in this make and model, 151 as pilot in command, 73 in the last 90 days, 23 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 310° at 7 knots - Visibility: 6 statute miles - Lowest ceiling: 1,500 ft overcast - Temperature: 36 °F, dew point 30 °F - Altimeter: 30.03 inHg - Observed at: SLC, 11 nm away ## Docket (15 files) The files NTSB released with the investigation on September 17, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73209. 4.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 558 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319065&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1, CFI (item 2, .PDF, 725 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319066&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1,%20CFI-Redacted.PDF - Pilot Interview (item 3, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319067&FileExtension=.PDF&FileName=Pilot%20Interview-Redacted.PDF - CFI Interview (item 4, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319068&FileExtension=.PDF&FileName=CFI%20Interview-Redacted.PDF - Weather Reports and Records (item 5, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319069&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Excerpts from Police Report (item 6, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319070&FileExtension=.PDF&FileName=Excerpts%20from%20Police%20Report-Redacted.PDF - Maintenance Records Excerpts (item 7, .PDF, 564 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319071&FileExtension=.PDF&FileName=Maintenance%20Records%20Excerpts-Redacted.PDF - Robinson Safety Notices (item 8, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319072&FileExtension=.PDF&FileName=Robinson%20Safety%20Notices-Master.PDF - Wreckage Exam Notes (item 9, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319073&FileExtension=.PDF&FileName=Wreckage%20Exam%20Notes-Master.PDF - Photo 1. Fuselage with ground scar. (item 10, .PDF, 241 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319074&FileExtension=.PDF&FileName=Photo%201.%20Fuselage%20with%20ground%20scar.-Master.PDF - Photo 2. Fuselage. (item 11, .PDF, 290 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319075&FileExtension=.PDF&FileName=Photo%202.%20%20Fuselage.-Master.PDF - Photo 3. Bottom of fuselage with tail boom. (item 12, .PDF, 280 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319076&FileExtension=.PDF&FileName=Photo%203.%20%20Bottom%20of%20fuselage%20with%20tail%20boom.-Master.PDF - Photo 4. Impact crater. (item 13, .PDF, 330 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319077&FileExtension=.PDF&FileName=Photo%204.%20%20Impact%20crater.-Master.PDF - Photo 5. Main rotor head. (item 14, .PDF, 217 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319078&FileExtension=.PDF&FileName=Photo%205.%20%20Main%20rotor%20head.-Master.PDF - Photo 6. Night picture of wreckage. (item 15, .PDF, 834 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319079&FileExtension=.PDF&FileName=Photo%206.%20%20Night%20picture%20of%20wreckage.-Master.PDF 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.