WPR19LA013

NTSB accident investigation · Robinson R44 · Kaneohe, HI · October 23, 2018

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
October 22, 2018, 17:10 local (Oct 23, 2018, 03:10 UTC)
Place
Kaneohe, HI
Injuries
3 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4132HRobinson R44
Defining event
Enroute-cruise: Medical event
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
FAA-FASO
FAA report
20181022020529A
Case key
98531

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 sudden incapacitation from an undiagnosed heart condition during flight, which resulted in a hard landing.

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

The pilot of the helicopter briefly lost consciousness during the air tour flight and began preparing for a precautionary landing. Shortly thereafter, he lost consciousness again and was awakened by first responders following the accident. The pilot and both passengers sustained serious injuries, and the helicopter was substantially damaged. Following a mitral valve replacement about 6 years before the accident, the pilot had been required to provide periodic cardiovascular evaluations to the Federal Aviation Administration to maintain his medical certification, and his cardiologist reported that his valve was in good condition and had placed no restrictions on his activities. During the hospital stay following the accident, the pilot experienced complete heart block, which required the placement of a permanent pacemaker. Therefore, it is likely that, during the flight, the pilot experienced a sudden incapacitation from an undiagnosed heart condition. Based on the medical findings, the pilot’s sudden incapacitation from complete heart block would not have been predicted.

Factual narrative

On October 22, 2018, about 1710 Hawaiian standard time, a Robinson R44 helicopter, N4132H, was substantially damaged when it was involved in an accident near Kaneohe, Hawaii. The pilot and two passengers were seriously injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 air tour flight. The pilot reported that, about 20 minutes into the flight, he felt himself lose consciousness; moments later, he regained consciousness and control of the helicopter. The pilot turned inland and prepared for a precautionary landing. Seconds later, he lost consciousness again, and was awakened by first responders following the accident. The pilot did not recall the descent or impact, and he remembered that, “before everything went black,” he was in a “dream-like state” during which he was piloting a helicopter and knew he was in an emergency situation, but the nature of the emergency was not clear. The passengers stated in an interview, that they remember the pilot slumping over during the flight, and the front seat passenger grabbing the controls to slow the descent before impacting the sandbar. The helicopter landed on a sandbar in about 2 ft of water and came to rest on its left side. The main rotor mast was bent forward, both skids exhibited impact damage, and the tailboom was bent to one side. The wreckage was relocated the next day to a secured location for examination. The pilot began working for the operator in May 2018 and had not reported any medical problems during that time. The pilot possessed a current second-class Federal Aviation Administration (FAA) airman medical certificate with no restrictions. FAA medical records indicated that, in 2012, during an aviation medical examination, an asymptomatic heart murmur was detected. In the same year, the pilot reported having a history of mitral valve replacement surgery. In 2013, the pilot received a special issuance medical certificate that required providing periodic cardiovascular evaluations to the FAA. His cardiologist reported that his valve was in good condition and had placed no restrictions on the pilot’s activities. During the hospital stay following the accident, the pilot had episodes of complete heart block, which required placement of a permanent pacemaker.

Aircraft

Registration
N4132H
Reported as
Robinson R44 (Undesignat)
Category
Helicopter
Serial number
2403
Built
2015
Airframe hours
1,557
Engine
Lycoming O-540-F1B5, 235 horsepower, reciprocating
Damage
Substantial damage
Flight
Other work use · Part 91
Operator
Novictor Aviation, doing business as Novictor Aviation
Registered owner
Higgins Leasing, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · October 13, 2018
Departed
PHNL · Honolulu, HI
Destination
PHNL · Honolulu, HI
Flight plan
Company VFR
Airport
PHNG · Kaneohe Bay Marine Corps Air S
Equipment
Unknown

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
57
Injuries
Serious
Certificates
Private, Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
October 3, 2018
Seat
Right
Restraint
3-point
Toxicology
Performed
Flight hours
2,878 total · 1,451 in this make and model · 2,791 as pilot in command · 273 in the last 90 days · 176 in the last 30 days · 80 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 73 °F
Altimeter
29.93 inHg
Observed at
PHNG, 2 nm away

Docket · 6

The files NTSB released with the investigation on March 3, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 34.9 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.