WPR10LA232

NTSB accident investigation · Robinson Helicopter R22 Beta · Mendon, UT · May 7, 2010

Accident · No injuriesLimited investigationFinal report
Date
May 7, 2010, 17:32 local (23:32 UTC)
Place
Mendon, UT
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N393LERobinson Helicopter R22 Beta
Defining event
Maneuvering: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 28, 2011
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20100507004589A
Case key
75959

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

A loss of engine power due to a failure of the magnetos as a result of inadequate maintenance.

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.

Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelRobinson Helicopter R22 BETA: 2 casesAll aircraft: 320 casesProbable cause
Terrain: rough terrainEnvironmental issues › Physical environment · Contributed to outcomeRobinson Helicopter R22 BETA: 4 casesAll aircraft: 442 casesProbable cause
Ignition system: magneto/distributorAircraft › Aircraft power plant · Not serviced/maintainedRobinson Helicopter R22 BETA: 2 casesAll aircraft: 101 casesProbable cause

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

The certified flight instructor (CFI) and student pilot departed on a local area training flight and found a suitable area to perform practice autorotations. During the first autorotation, the engine experienced a loss of power. The CFI assumed control of the helicopter and the student attempted to restart the engine. During the touchdown, the right skid caught on the terrain, and the helicopter rolled to the right. The CFI indicated that it appeared the grass-covered terrain was flat and would make a good emergency landing spot; however, upon touchdown he realized that the terrain was rough. A post accident examination and test run of the engine by a Federal Aviation Administration (FAA) inspector did not reveal any operational anomalies with the helicopter. Disassembly of the magnetos revealed evidence of internal arcing. The magneto manufacturer and engine manufacturer had issued service bulletins related to the inspection of the magnetos every 100 hours and 500 hours. The 500-hour inspection required that the magnetos be removed from the engine, disassembled, inspected, and serviced. According to the FAA inspector, review of the maintenance records for the helicopter showed that neither service bulletin had been complied with.

Factual narrative

On May 7, 2010, at 1732 mountain daylight time, a Robinson R22 Beta, N393LE, collided with terrain following a loss of engine power near Mendon, Utah. The certified flight instructor (CFI) and student were not injured; the helicopter sustained substantial damage. Mountain Ridge Helicopters was operating the helicopter under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed, and no flight plan was filed. The CFI reported that he and the student were practicing autorotations. They entered into the first autorotation, rolled the throttle to idle, and the engine lost power. The CFI force-landed the helicopter in a field, and it rolled onto its right side. The CFI indicated that it appeared the grass-covered terrain was flat and would make a good emergency landing spot; however, upon touchdown he realized that the terrain was rough. A Federal Aviation Administration (FAA) inspector examined the helicopter. The engine was test run, and no anomalies were identified. During the examination and testing, the magneto internal timing and the magneto timing to engine was not verified prior to the removal and disassembly of the magnetos. Disassembly of the magnetos showed evidence of internal arcing. The last annual/100-hour inspection was on April 22, 2010, at a total time of 999.8 hours. The engine was equipped with TCM S4LSC-200 (left) and S4LSC-204T (right) magnetos. According to TCM Service Bulletin No. 515, Maintenance Intervals for all TCM and Bendix Aircraft Magnetos and Related Equipment (as well as Textron Lycoming Service Bulletin No. 515, All Textron Lycoming aircraft engines employing TCM and Bendix S-20, S-200, S-1200, D-2000, and D-3000 series magnetos and components), magnetos must be inspected at each 100-hour and 500-hour interval. The 500-hour inspection requires that the magneto be removed from the engine, disassembled, inspected, and serviced in accordance with the TCM Service Support Manual. According to the FAA inspector, review of the maintenance documentation for the helicopter showed that neither TCM SB 515 nor Textron Lycoming SB 515 was complied with.

Aircraft

Registration
N393LE
Reported as
Robinson Helicopter R22 Beta
Category
Helicopter
Serial number
4393
Airframe hours
1,000
Engine
Lycoming O-360-J2A, 145 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Mountain Ridge Helicopters LLC
Registered owner
Mountain Ridge Helicopters LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 22, 2010 · 45 hours before
Departed
LGU · Logan, UT
Destination
LGU · Logan, UT

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Student pilot
Age
24
Injuries
None
Certificate
Student
Medical
Class 2, With waivers/limitations
Seat
Right
Flight hours
22 total · 22 in this make and model · 22 in the last 90 days · 11 in the last 30 days
Role
Flight instructor
Age
30
Injuries
None
Certificates
Commercial, Flight instructor
Medical
Class 1, Without waivers/limitations
Last flight review
July 11, 2008
Seat
Left
Flight hours
1,208 total · 906 in this make and model · 1,149 as pilot in command · 140 in the last 90 days · 33 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
52 °F, dew point 9 °F
Altimeter
30.18 inHg
Observed at
LGU, 5 nm away

Docket · 3

The files NTSB released with the investigation on February 4, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.1 MB in all.

FAA reports on this event · 1

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

Other investigations on N393LE · 1

Matched to the same aircraft by N-number and date.