# NTSB WPR19LA013: Robinson R44, N4132H, Kaneohe, HI, October 23, 2018 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: October 22, 2018, 17:10 local (Oct 23, 2018, 03:10 UTC) - Place: Kaneohe, HI - Coordinates: 21.4675, -157.803894 - Nearby events: https://openairdocs.org/map.md?lat=21.4675&lon=-157.8039&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Medical event](https://openairdocs.org/ntsb-events/850) - Highest injury: Serious injuries - Injuries: 3 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA-FASO - NTSB case key (mKey): 98531 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA013 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98531/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98531 - Page: https://openairdocs.org/ntsb/WPR19LA013 ## Probable cause The pilot’s sudden incapacitation from an undiagnosed heart condition during flight, which resulted in a hard landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Health/Fitness: predisposing condition](https://openairdocs.org/ntsb-findings/02013035): Personnel issues › Physical · Pilot (probable cause); cases with it: [Robinson Helicopter R44, 1 case](https://openairdocs.org/ntsb-findings/02013035/cases.md?model=7640120), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/02013035/cases.md) - [Impairment/incapacitation: cardiovascular](https://openairdocs.org/ntsb-findings/02012050): Personnel issues › Physical · Pilot (probable cause); cases with it: [Robinson Helicopter R44, 1 case](https://openairdocs.org/ntsb-findings/02012050/cases.md?model=7640120), [All aircraft, 69 cases](https://openairdocs.org/ntsb-findings/02012050/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, 40 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7640120), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Medical event](https://openairdocs.org/ntsb-events/850) (defining event); cases with it: [Robinson Helicopter R44, 1 case](https://openairdocs.org/ntsb-events/850/sequence.md?model=7640120), [All aircraft, 63 cases](https://openairdocs.org/ntsb-events/850/sequence.md) - [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Robinson Helicopter R44, 43 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7640120), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Robinson Helicopter R44, 16 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=7640120), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## 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](https://openairdocs.org/deregistered/N4132H-2020-02-27), registration cancelled 2020-02-27, S/N 2403, built 2015 (OpenAirDocs) - Reported make and model: Robinson R44 (Undesignat) - Registry model: [Robinson Helicopter R44](https://openairdocs.org/model/robinson-helicopter-r44) (registry code 7640120) (OpenAirDocs) - Registry engine: [Lycoming O-540-F1B5](https://openairdocs.org/engine/lycoming-o-540-f1b5) (registry code 42353, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 2403 - Year built: 2015 - Airframe hours: 1557 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: serious; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20181022020529A](https://openairdocs.org/incident/20181022020529A), Oct 22, 2018: Robinson Helicopter R44, Kaneohe, HI, Substantial damage. Part 91 air tour flight crashed onto sand bar north on Kaneohe bay, HI. Pilot experienced a medical issue in flight. ## Docket (6 files) The files NTSB released with the investigation on March 3, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98531. 34.9 MB in all. - NTSB medical factual report (item 1, PDF, 4 pages, 231 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13108669&FileExtension=pdf&FileName=WPR19LA013_Kaneohe_HI_Medical_Factual_FINAL_112919rev011222-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 2, PDF, 11 pages, 7.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13344621&FileExtension=pdf&FileName=Form%206120-1__Redacted-Rel-Rel.pdf - Operator statement (item 3, PDF, 2 pages, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13104393&FileExtension=pdf&FileName=Novictor%20Statement-Rel.pdf - News video-survivor's statements (item 4, MP4, 26.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13104898&FileExtension=mp4&FileName=News-Occupant%20Interview-Rel.mp4 - Release of aircraft wreckage, NTSB form 6120.15 (item 5, PDF, 1 page, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13345482&FileExtension=pdf&FileName=NTSB%206120-15%20Signed%20Wreckage%20Release_Redacted-Rel.pdf - Photo array of recovered wreckage-courtesy of the FAA (item 6, PDF, 5 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13104693&FileExtension=pdf&FileName=Photo%20Array-Courtesy%20of%20the%20FAA-Rel.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.