WPR22FA001

NTSB accident investigation · Robinson Helicopter R22 · Chandler, AZ · October 1, 2021

Accident · FatalClass 3 · FieldFinal report
Date
October 1, 2021, 07:40 local (14:40 UTC)
Place
Chandler, AZ · Airport
Injuries
2 fatal, 2 uninjured
Phase of flight
Approach
Aircraft
N412TLRobinson Helicopter R22N2868HPiper PA-28-181
Defining events
Approach: Midair collisionApproach-VFR pattern base: Midair collision
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Piper, Robinson Helicopter Company, FAA
Case key
104018

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 failure of the pilots onboard the airplane to see and avoid the helicopter while maneuvering in the traffic pattern, which resulted in a midair collision.

Findings · 4

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.

N412TL · Robinson Helicopter R22

Performance/control parameters: descent rateAircraft › Aircraft oper/perf/capability · Related operating infoRobinson Helicopter R22: 5 casesAll aircraft: 242 casesProbable cause

N2868H · Piper PA-28-181

Performance/control parameters: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Incorrect use/operationPiper PA-28-181: 6 casesAll aircraft: 809 casesProbable cause
Attention/monitoring: monitoring other aircraftPersonnel issues › Psychological · Flight crewPiper PA-28-181: 6 casesAll aircraft: 231 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.

N412TL · Robinson Helicopter R22

N2868H · Piper PA-28-181

Analysis

A low-wing airplane and a helicopter, both of which were operating as instructional flights with flight instructors onboard, were performing takeoffs and landings at the tower-controlled airport in day visual meteorological conditions. The helicopter was performing right traffic patterns to the taxiway that paralleled the runway, while the airplane was performing right traffic patterns, outside of and above the helicopter pattern, to the runway. The helicopter had been cleared for “the option” to the taxiway, while the airplane was cleared to land shortly thereafter. After receiving landing clearance, the instructor onboard the airplane elected to conduct a simulated engine failure to a full-stop landing, reducing the engine power to idle abeam the approach end of the runway, but did not advise the tower controller of his intentions. While on final approach, the instructor took control of the airplane and entered a forward slip. The instructor and student then heard and felt a loud “bang” and the instructor declared an emergency, thinking that the airplane had impacted birds. Flight track information, witness statements, and damage to the airplane indicated that the airplane descended into the helicopter while both aircraft were on final approach for landing. Review of tower control communications indicated that the accident airplane had been advised and was aware of helicopters operating to the parallel taxiway. The tower controller cleared the airplane to land behind a twin-engine airplane, and advised of a helicopter low and to the airplane's right (the accident helicopter). The circumstances of the accident are consistent with the failure of the pilots onboard the airplane to see and avoid the helicopter during landing approach, resulting in a collision with the helicopter. It is possible that the airplane’s low-wing configuration and steep descent while in the forward slip may have contributed to the pilots’ failure to see the helicopter below them.

Factual narrative

The Chandler Municipal Airport (CHD) FAA contract tower (FCT) had a Letter of Agreement (LOA), dated August 2020, with the helicopter operator that specified responsibilities, defined terms, and established the procedures for operations of helicopters within the CHD class D airspace. The provision of the letter applied only to helicopters conducting operations by persons authorized by the helicopter operator and only when CHD control tower was in operation. The LOA established a helicopter traffic pattern to taxiway C. (see Figure 2.) The helicopter traffic pattern altitude was 1,900 ft msl and the fixed wing traffic pattern altitude was 2,300 ft msl. Figure 2. View of helicopter and airplane traffic pattern On October 1, 2021, about 0740 mountain standard time, a Piper PA-28-181 airplane, N2868H, and a Robinson Helicopter Company R22 helicopter, N412TL, were involved in a midair collision near Chandler, Arizona. The airplane sustained minor damage and the flight instructor and student pilot onboard were not injured. The flight instructor and student pilot onboard the helicopter were fatally injured, and the helicopter was destroyed. Both aircraft were operated as Title 14 Code of Federal Regulations Part 91 instructional flights. The flight instructor and student on board the airplane requested and received clearance from the tower controller to perform takeoffs and landings from runway 4L, remaining in the airport traffic pattern. After completing three touch-and-go landings, the tower controller instructed the airplane to switch to runway 4R and issued a frequency change. The instructor and student continued to perform touch-and-go takeoffs and landings from runway 4R, and the instructor recalled the controller requesting that the airplane extend their crosswind leg for helicopter traffic during one of their patterns. During the accident approach, the airplane was cleared for landing behind a twin-engine airplane. The instructor stated that he scanned the area for traffic, and abeam the runway numbers on the downwind leg of the traffic pattern, reduced engine power to idle to simulate a loss of engine power. On final approach for landing, the instructor took control of the airplane to demonstrate a slip and they heard and felt a loud bang. The instructor declared an emergency, thinking that the airplane had hit birds. During the landing flare, the flight instructor noticed the left wing continued to descend and used aileron inputs to keep the wing up. After the airplane touched down, it veered left and exited the runway before it came to a stop between runway 04R and 04L. Once the airplane came to a stop, he and the student pilot exited the airplane. Witnesses reported that an airplane on final approach descended on top of a helicopter and impacted the helicopter’s main rotor blades. The helicopter descended, impacted terrain, and a post-impact fire ensued. Review of air traffic control communications revealed that, about 0732, the accidentairplane was advised to extend the upwind leg for helicopters operating in the parallel taxiway pattern; one of the pilots acknowledged. About 737:06, the accident helicopter was cleared to land on the taxiway. At 0737:52, the controller cleared the airplane to land behind the twin-engine airplane, and also stated that a helicopter was present at low level, ahead of the airplane to the right, proceeding southbound. The accident airplane acknowledged. At 0740:41, the instructor onboard the airplane declared an emergency following the collision. Recorded Automatic Dependent Surveillance-Broadcast (ADS-B) data provided by the Federal Aviation Administration (FAA) showed that both aircraft appeared to be on a base to final turn, with the airplane on the approach to runway 04R and the helicopter on the approach to taxiway C (parallel to and to the right of runway 04R). The data showed that the flight paths of the aircraft intersected about 0740:15 at an altitude of about 1,400 ft mean sea level (msl), as seen in Figure 1. Figure 1. View of helicopter and airplane ADS-B flight track data The Maricopa County Office of the Medical Examiner in Phoenix, Arizona, performed an autopsy of the helicopter flight instructor and student pilot. The flight instructor and student pilot’s cause of death was multiple blunt impact injuries. The helicopter flight instructor toxicology testing performed at the FAA Forensic Sciences Laboratory found no drugs of abuse. The helicopter student pilot’s toxicology testing performed by the FAA Forensic Sciences Laboratory detected amphetamine at 7 ng/ml in the student pilot’s urine. Amphetamine is a Schedule II controlled substance that stimulates the central nervous system. It is available by prescription for the treatment of attention deficit disorder and narcolepsy. It carries a boxed warning about its potential for abuse and has warnings about an increased risk of sudden death and the potential for mental health and behavioral changes. In some preparations, the prescription drug is metabolized to amphetamine; commonly marketed names include Adderall, Dexedrine, and Vyvanse. After a single 30 mg oral dose, early blood levels averaged 0.111 ug/ml and average blood levels in adults using the long-acting prescription orally for a week were about 0.065 ug/ml. At the time of the accident, the airplane flight instructor had accumulated about 425 total hours of flight experience, of which 32 hours were as a flight instructor. Examination of the airplane accident site revealed that the airplane came to rest upright on the dirt field between runways 04R and 04L, on a heading of about 345° magnetic. The helicopter impacted terrain about .5 mile southwest of the approach end of runway 04R. Postaccident examination of the airplane did not reveal evidence of any mechanical anomalies that would have precluded normal operation. Flight control continuity was established from the cockpit to all primary flight controls. The airplane’s noselanding gear and tire, as well as the left main landing gear, had separated from the airplane and were located near the helicopter wreckage. Both tires were cut consistent with contact from the helicopter’s main rotor blades. A piece of the helicopter’s canopy was found lodged in the hat channel on the underside of the airplane. The helicopter came to rest on its left side on a heading of about 053° magnetic, at an elevation of 1,236 ft msl. No visible ground scars were observed surrounding the wreckage. All major structural components of the helicopter were located within about 15 ft of the main wreckage. Postaccident examination of the helicopter was limited due to impact damage and post-crash fire.

Aircraft · 2

Registration
N412TL
Reported as
Robinson Helicopter R22
Category
Helicopter
Serial number
4689
Built
2015
Airframe hours
4,775.3
Engine
Lycoming O-360-J2A, 145 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Quantum Helicopters
Registered owner
Delta Leasing Inc DBA
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · September 28, 2021 · 14 hours before
Destination
Same as departure
Airport
CHD · Chandler Muni, runway 04R, 4,870 × 75 ft, asphalt
Equipment
ADS-B

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.

Registration
N2868H
Reported as
Piper PA-28-181
Category
Airplane
Serial number
28-7990508
Built
1979
Airframe hours
5,509.7
Engine
Lycoming O-360-4AM, reciprocating
Damage
Minor damage
Flight
Instructional · Part 91
Operator
Flight Operations Academy LLC
Registered owner
Flight Operations Academy LLC
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
100 hour · July 26, 2021
Destination
Same as departure
Equipment
Onboard weather, Handheld GPS, Electronic flight bag or handheld device, ADS-B, Stall warning system

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 · 4

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor, aircraft N412TL
Age
27
Injuries
Fatal
Certificates
Commercial, Flight instructor
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
May 25, 2021
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
566 total · 513 in this make and model · 468 as pilot in command · 213 in the last 90 days · 88 in the last 30 days · 5 in the last 24 hours
Role
Student pilot, aircraft N412TL
Age
34
Injuries
Fatal
Certificate
Student
Medical
Class 2, Without waivers/limitations
Seat
Right
Restraint
3-point
Toxicology
Performed
Flight hours
26 total · 26 in this make and model · 26 in the last 90 days · 21 in the last 30 days
Role
Flight instructor, aircraft N2868H
Age
43
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
August 23, 2021
Seat
Right
Restraint
3-point
Flight hours
425 total · 115 in this make and model · 344 as pilot in command · 46 in the last 90 days · 14 in the last 30 days · 3 in the last 24 hours
Role
Student pilot, aircraft N2868H
Age
49
Injuries
None
Certificate
Student
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
15 total · 15 in this make and model · 14 in the last 90 days · 8 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
40° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
68 °F, dew point 48 °F
Altimeter
30.00 inHg
Observed at
KCHD
METAR
KCHD 011347Z 04004KT 10SM SKC 20/09 A3000

Docket · 17

The files NTSB released with the investigation on September 29, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 47.1 MB in all.

FAA reports on this event · 2

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