WPR13LA222

NTSB accident investigation · Robinson Helicopter R22 Beta · Honolulu, HI · May 9, 2013

Accident · Minor injuriesLimited investigationFinal report
Date
May 8, 2013, 15:20 local (May 9, 2013, 01:20 UTC)
Place
Honolulu, HI
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N5ZKRobinson Helicopter R22 Beta
Defining event
Maneuvering: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report November 13, 2014
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20130508006689A
Case key
86843

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

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Probable cause

The mechanic’s failure to properly inspect the helicopter following maintenance performed by an apprentice, which resulted in a total loss of engine power due to the improper rigging of the mixture control assembly.

Findings · 5

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.

Engine controls: mixture controlAircraft › Aircraft power plant · Incorrect service/maintenanceRobinson Helicopter R22 BETA: 5 casesAll aircraft: 41 casesProbable cause
Engine controls: mixture controlAircraft › Aircraft power plant · Inadequate inspectionRobinson Helicopter R22 BETA: 5 casesAll aircraft: 41 casesProbable cause
Inspection: post maintenance inspectionPersonnel issues › Task performance · Maintenance personnelRobinson Helicopter R22 BETA: 1 caseAll aircraft: 57 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelRobinson Helicopter R22 BETA: 3 casesAll aircraft: 371 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 pilot reported that, while he was maneuvering the helicopter about 3,000 feet above ground level (agl), the engine suddenly experienced a total loss of power, which was immediately followed by the activation of the low rotor rpm light and horn. In response to the engine failure, the pilot lowered the collective and entered an autorotation. She began to flare the helicopter at an altitude of about 40 feet agl. The helicopter touched down on a road and skidded into a parked automobile. A postaccident examination of the helicopter revealed that the mixture cable had fracture-separated from the mixture bellcrank control arm located on the carburetor. The bellcrank was positioned near the idle/cutoff position, and the spring was inserted in the wrong direction. The helicopter airframe had undergone an overhaul about 16 hours of flight time before the accident, and, during that overhaul, a mechanic's apprentice installed the mixture hardware. The apprentice improperly rigged the mixture-to-bellcrank hardware, which prevented the mixture cable from moving freely. The repeated stress on the mixture cable resulted in it breaking after a number of operation cycles. When the failure occurred, the bellcrank spring, which is designed to force the mixture to the full-rich position, instead pulled the mixture to the idle/cutoff position, which cut off the fuel. The mechanic overseeing the apprentice reported that he did not visually observe the misrigging and that, if he had performed a tactile inspection, he would have detected the error.

Factual narrative

On May 08, 2013, about 1520 Hawaiian standard time, a Robinson R22 Beta helicopter, N5ZK, was substantially damaged when it collided with an unoccupied parked automobile following a total loss of engine power while maneuvering over Honolulu, Hawaii. HLM Aviation owned the helicopter, and Hawaii Pacific Aviation (doing business as Mauna Loa Helicopters) operated the helicopter under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The certified flight instructor (CFI) was not injured, and the passenger sustained minor injuries. The local aerial observation flight departed from Honolulu International Airport about 1455. Visual meteorological conditions prevailed and no flight plan had been filed.The CFI stated that the purpose of the flight was for her to orbit the helicopter over an area known as Punchbowl located about five nautical miles south of the airport. She departed as planned, proceeded to Punchbowl, and completed two orbits before slowing the helicopter to about 35 knots in an effort to help facilitate the passenger in taking his aerial photographs. While maneuvering about 3,000 feet above ground level (agl), the engine suddenly experienced a total loss of power, followed immediately by activation of the low rpm light and horn. The CFI reported that in response to the engine failure, she lowered the collective and entered an autorotation. She maintained a 60-knot airspeed, and maneuvered to land on a street. The pilot began the flare at an altitude of about 40 feet agl. The helicopter touched down on the road, and skidded into a parked automobile. A Federal Aviation Administration (FAA) inspector performed a post accident examination of the helicopter. He stated that the mixture cable was fracture-separated from the mixture bellcrank control arm on the carburetor. The bellcrank was positioned near the idle cutoff position, rather than the full-rich position. The spring did not drive the arm to the full rich position per design. The inspector noted that it appeared that the spring was not correctly connected to the mixture arm. The helicopter's maintenance manual stated that during inspection the mechanic must "Verify spring moves arm to full rich position." The mechanic who routinely maintains the helicopter stated that his company completed a 2,200 hour airframe overhaul of the helicopter on April 22, 2013, equating to about 16 hours of flight time prior to the accident. The mechanic recalled that at the completion of the overhaul, he inspected the helicopter which commenced with the tracking and balancing of the main rotor system, tail rotor system and engine. The mechanic further stated that he had accompanied the FAA inspector during the post accident examination. They determined that the mixture arm assembly was improperly rigged. The mixture to bellcrank hardware stackup was incorrect and did not allow the mixture cable to move freely and the spring was installed so that the arm was driven to the idle cutoffposition. The mechanic opined that the combination of the repeated stress on the mixture cable resulted in it breaking after a number of operation cycles. When the failure did occur, the bellcrank spring, which is designed to force the mixture to the full rich position, instead cut off the fuel by pulling the mixture to idle cutoff. The mechanic remarked that the rigging of the carburetor was accomplished by an apprentice who was under his supervision. The mechanic did not visually observe the misrigging, and reported that if he had performed a tactile inspection, he would have detected the error.

Aircraft

Registration
N5ZK
Reported as
Robinson Helicopter R22 Beta
Category
Helicopter
Serial number
2158
Airframe hours
8,800
Engine
Lycoming O-320-B2C, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Aerial observation · Part 91
Operator
Hawaii Pacific Aviation, doing business as Mauna Loa Helicopters
Registered owner
HLM Aviation
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 22, 2013 · 15 hours before
Departed
Honolulu, HI
Destination
Honolulu, HI

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
30
Injuries
None
Certificates
Commercial, Flight instructor
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Seat
Right
Flight hours
391 total · 319 in this make and model · 313 as pilot in command · 26 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 9 knots
Visibility
9 statute miles
Lowest ceiling
5,000 ft overcast
Temperature
81 °F, dew point 64 °F
Altimeter
29.96 inHg
Observed at
PHNL, 5 nm away

Docket · 3

The files NTSB released with the investigation on October 7, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.5 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.