WPR17LA211

NTSB accident investigation · Robinson Helicopter R22 · Long Beach, CA · September 20, 2017

Accident · Serious injuriesLimited investigationFinal report
Date
September 20, 2017, 13:09 local (20:09 UTC)
Place
Long Beach, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Emergency descent
Aircraft
N7514SRobinson Helicopter R22
Defining event
Autorotation: Hard landing
Weather
Visual (VMC) · Day
Status
Completed · report November 15, 2018
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration FSDO, Robinson Helicopter Company
FAA report
20170920021779A
Case key
96052

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 student pilot's failure to maintain rotor rpm during the crosswind landing approach and his subsequent improper decision to initiate an autorotation instead of applying corrective control inputs after the helicopter experienced normal airframe vibration. Also causal was his failure to raise the collective during the landing flare, which resulted in a hard landing.

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.

Performance/control parameters: prop/rotor parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedRobinson Helicopter R22 BETA: 37 casesAll aircraft: 182 casesProbable cause
Wind: crosswindEnvironmental issues › Conditions/weather/phenomena · Effect on operationRobinson Helicopter R22 BETA: 1 caseAll aircraft: 1,008 cases

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

During the final phase of a crosswind landing approach, the solo student pilot felt the helicopter shudder and heard the low rotor rpm horn sound. Instead of applying corrective control inputs, he immediately initiated an autorotation. He did not raise the collective control during the flare, as required, and the helicopter then landed hard and rolled over. Postaccident examination did not reveal any preimpact anomalies with the airframe or engine that would have precluded normal operation, and the engine appeared to be operating at the time of ground impact. Airframe vibration during the final phase of a landing approach is not an unusual phenomenon, and a low rotor rpm warning under high-load conditions (such as when landing with a crosswind) can also occur if rotor speed and engine power are not properly managed. The pilot improperly decided to initiate an autorotation instead of applying corrective control inputs to address the vibrations and improperly performed the landing flare.

Factual narrative

The FAA Helicopter Flying Handbook (FAA-H-8083-21A) discusses the transverse flow effect as follows: "As the helicopter accelerates in forward flight, induced flow drops to near zero at the forward disk area and increases at the aft disk area. These differences in lift between the fore and aft portions of the rotor disk are called transverse flow effect. This increases the angle of attack (AOA) at the front disk area causing the rotor blade to flap up, and reduces AOA at the aft disk area causing the rotor blade to flap down. Because the rotor acts like a gyro, maximum displacement occurs 90° in the direction of rotation. The result is a tendency for the helicopter to roll slightly to the right as it accelerates through approximately 20 knots or if the headwind is approximately 20 knots. Transverse flow effect is recognized by increased vibrations of the helicopter at airspeeds just below effective translational lift (ETL) on takeoff and after passing through ETL during landing. To counteract transverse flow effect, a cyclic input to the left may be needed." The handbook also states that during normal landing approaches, "helicopters require near maximum power to land because the inertia of the helicopter in a descent must be overcome by lift in the rotor system." The sections of the Pilot's Operating Handbook (POH) which describe procedures for power loss at all altitudes, and autorotation's to power recovery, all instruct the pilot to raise the collective just before touchdown to cushion the landing. Regarding activation of the stall warning horn and caution light, the POH states the following: "A horn and an illuminated caution light indicate that rotor RPM may be below safe limits. To restore RPM, immediately roll throttle on, lower collective and, in forward flight, apply aft cyclic...." Neither the pilot nor the operator submitted a Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2). The helicopter was manufactured in 2002 and equipped with a Lycoming O-360-J2A engine, serial number L-37717-36A. On May 9, 2012, both a helicopter overhaul and engine rebuild were completed. A 100-hour inspection was completed on August 25, 2017, about 20 flight-hours before the accident. During the inspection, the engine's no. 1 cylinder was removed due to low compression, repaired, and re-installed. At the time of inspection, the airframe and engine had accumulated 1,370.4 flight hours since overhaul/rebuild. The most recent maintenance event was for an inspection following a rotor blade overspeed (<114 %). The inspection was completed on September 8, 2017, about 10 flight hours before the accident. The helicopter was equipped with a governor system which was designed to maintain engine speed by sensing changes and applying corrective throttle control inputs through a friction clutch. The system could be overridden by the pilot through manual throttle manipulation. The governor switch was found in the "ON" position at the accident site. OnSeptember 20, 2017, at 1309 Pacific daylight time, a Robinson R22 Beta helicopter, N7514S, landed hard and rolled over following an autorotation at Long Beach Airport (Daugherty Field), Long Beach, California. The student pilot sustained serious injuries, and the helicopter sustained substantial damage. The helicopter was registered to Spitzer Helicopter LLC, and operated by Revolution Aviation, under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed, and no flight plan had been filed. The local flight departed Long Beach about 1305. The student departed earlier in the morning with his instructor from their operational base in Santa Ana, California. They planned to fly to Long Beach Airport, where the instructor would disembark, and the student would perform a series of solo maneuvers and flights in the traffic pattern. After arriving at Long Beach and landing on helicopter pad 1 they performed a pedal turn, to determine how the helicopter would perform with the left crosswind, and then departed for a flight in the traffic pattern. After landing, the instructor got out of the helicopter, and waited on the grass area adjacent to the pad. From there he watched the student perform a series of low hovering maneuvers, all of which progressed uneventfully. The other helicopters in the area had by then departed, and the student and instructor agreed that the student should depart and perform one circuit in the traffic pattern and land on pad 3, which was a larger pad that the student was more familiar with. The departure and landing were uneventful, and once on the ground, the student and instructor gave each other the "thumbs-up", and the student departed for another flight in the pattern. The instructor reported that the flight appeared normal, and during the landing approach the descent path and speed were appropriate. However, as the helicopter approached the pad, it started to slow down. He thought the student was going to land just short of the pad, however the nose then began to yaw to the left and right by a few degrees, and the helicopter suddenly began to descend. He described the descent as rapid and uncontrolled, as if the helicopter had lost all lift. The helicopter then hit the ground slightly left-side-low and rolled onto its right side. The student recounted similar observations, reporting that as he approached to within about 40 ft of the pad, the helicopter started to shudder, and then the low rotor RPM horn sounded. He reacted by immediately lowering the collective and initiating an autorotation. Just prior to striking the ground, he pulled back on the cyclic, but did not apply any collective control. He stated that he did not hear any unusual engine sounds, and he did not specifically look at the engine and rotor tachometer during the event, which transpired very quickly. A special aviation routine weather report was issued immediately after theaccident. It indicated wind from 170° at 9 knots. Pad 3 is oriented east-west, and the left traffic pattern was in use, therefore the helicopter would have encountered an almost direct left crosswind during the landing approach. The student pilot held a third-class aviation medical certificate issued on July 27, 2017. Following the accident, he reported 45 total flight hours, all in helicopters, including 2 hours of solo flight time. The helicopter was recovered from the accident site and examined by the NTSB investigator-in-charge and technical representatives from Robinson Helicopter Company (RHC). A complete examination report is contained within the public docket. Drivetrain and flight control continuity was established, and the engine did not exhibit any indications of catastrophic failure. The engine spark plugs displayed dark gray deposits consistent with normal operation, and normal wear signatures when compared to the Champion AV-27 chart. The crankshaft was rotated by hand using the engine cooling fan, and mechanical rotational continuity was established throughout. All valves and their associated rockers moved freely and about equal amounts, cylinder compression was obtained on all four cylinders in proper firing order, and sparks were observed at each spark plug lead. The upper frame sustained crush damage, causing the upper sheave to meet the frame tubes adjacent to the clutch actuator. Rotational scoring was observed on the outer radius of the sheave with corresponding scoring to the frame tubes. The scoring damage was consistent with engine operation at the time of impact. The governor controller was tested at the facilities of RHC in accordance with the factory calibration and functional test specifications. The unit passed all tests.

Aircraft

Registration
N7514S
Reported as
Robinson Helicopter R22 (BETA)
Category
Helicopter
Serial number
3333
Built
2002
Airframe hours
1,390.66
Engine
Lycoming O-360 J2A, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Revolution Aviation
Registered owner
Spitzer Helicopter LLC
Airworthiness certificate
Standard, Normal
Last inspection
Condition · August 25, 2017 · 20 hours before
Departed
LGB · Long Beach, CA
Destination
LGB · Long Beach, CA
Airport
LGB · Long Beach /Daugherty Field/, runway H3, 300 × 35 ft, asphalt
Equipment
None

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
Student pilot
Age
41
Injuries
Serious
Certificate
Student
Instrument ratings
Helicopter
Medical
Class 3, Without waivers/limitations
Seat
Right
Restraint
3-point
Flight hours
45 total · 45 in this make and model · 43 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 63 °F
Altimeter
29.88 inHg
Observed at
KLGB, 1 nm away

Docket · 9

The files NTSB released with the investigation on October 22, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.4 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.