WPR22LA363

NTSB accident investigation · Robinson Helicopter R44 · Cedar City, UT · September 30, 2022

Accident · No injuriesClass 3 · LimitedFinal report
Date
September 30, 2022, 13:10 local (19:10 UTC)
Place
Cedar City, UT
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N297SURobinson Helicopter R44
Defining event
Landing: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
FAA FSDO
FAA report
20220930011209A
Case key
106041

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

A partial loss of engine power due to a damaged cylinder intake valve and subsequent collision with terrain during an autorotation.

Findings · 1

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 flight instructor and student had just completed a series of uneventful practice maneuvers and decided to perform off-airport landings at a location that the instructor had used before. After a series of reconnaissance orbits, low passes, and power checks over the landing area and, with the helicopter operating normally, the instructor decided to proceed with a landing. The student was maneuvering at low altitude while attempting to land when they felt a jolt, and the helicopter yawed to the left. The instructor took over the controls, and attempted to maneuver away from trees but the helicopter began to vibrate and yawed aggressively to the left with an accompanying reduction in engine speed. The helicopter began to descend with the low rotor rpm horn sounding, and the instructor performed an autorotation, during which the main rotor blade cut through the tail. Postaccident examination revealed a damaged engine intake valve that would have resulted in a partial loss of engine power. The helicopter’s response during the event was consistent with a loss of engine power, although due to the altitude and environmental conditions, the helicopter was being operated at the upper limits of its performance envelope.

Factual narrative

On September 30, 2022, about 1310 mountain daylight time, a Robinson R44 Cadet, N297SU, sustained substantial damage when it was involved in an accident near Cedar City, Utah. The flight instructor and student pilot were not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor and student had just completed a series of practice maneuvers and decided to practice off-airport landings at a location that the instructor had used before. They performed a series of reconnaissance orbits, low passes, and power checks over the landing area and, with the helicopter operating normally, the flight instructor decided to proceed with a landing. The student pilot began to maneuver the helicopter for landing, but he had moved to a sloped area, so the flight instructor asked him to pull to a hover of about 7 ft. They hovered there and noted the manifold pressure gauge was indicating between 20.8 and 21.1 inches of mercury. They initiated a departure when the “full throttle” light illuminated. The manifold pressure gauge indicated 22.5 inches of mercury, and the instructor lowered the collective control and the light extinguished. This resulted in the helicopter descending to about 3 ft. Concerned that they might strike surrounding trees, the instructor asked the student to pull into a 5 ft hover, and taxi forward to clear the tail and then perform a pedal turn to allow the helicopter to face a clearing in the trees so they could climb out. As the student pushed forward on the cyclic to begin the departure, they felt a jolt, and the helicopter yawed to the left. The instructor was concerned that they might have struck a tree, and he took the controls. Due to the confined area and the helicopter already moving forward and climbing, he continued to apply forward cyclic. The helicopter began to vibrate and yawed aggressively to the left with an accompanying reduction in engine speed. The helicopter began to descend, and the engine speed gauge needle indicated it had now descended below the main rotor speed and was continuing to drop. The instructor lowered the collective and rolled on the throttle, but the engine did not respond, and with the low rotor rpm warning sounding, he initiated an autorotation. During the landing flare the helicopter contacted the trees, and the pilot applied aft cyclic to stop it from tipping forward down the hill. The main rotor blades cut through the tail as the helicopter came to rest. The instructor reported that the engine was still running after impact, but at sporadic speeds. The instructor reported that due to atmospheric conditions, they were using carburetor heat, with the control pulled out to about 1/4 of its limit. The accident site was surrounded by low-lying cedar trees, within rolling hills located at an elevation of 6,385 ft mean sea level (msl). According to the flight instructor, this was a common location used for stage checks. The helicopterwas recovered from the accident site and an examination was performed by a Federal Aviation Administration inspector, with no anomalies noted. The engine had accrued 2,386.7 hours since overhaul and before the accident, both it and the airframe had been scheduled for an overhaul in the weeks to follow. The helicopter was shipped to the overhaul facility for assessment. During the subsequent engine disassembly, the facility reported that the No. 1 cylinder intake valve head appeared discolored, and that a notch was found in both the valve head and its corresponding seat. The overhaul facility was not able to provide further details including photographic evidence of the failure. The pilot provided his performance calculations for the accident flight. Based on the helicopter weight, environmental conditions, the use of carburetor heat, along with the flight school standard operating procedure which included a 500 ft buffer, he calculated the out-of-ground-effect hover ceiling to be 6,400 ft. The calculations appeared to match the data in the performance section of the helicopter’s Pilot’s Operating Handbook.

Aircraft

Registration
N297SU
Reported as
Robinson Helicopter R44 (Cadet)
Category
Helicopter
Serial number
30017
Built
2017
Airframe hours
4,746
Engine
Lycoming O-540-F1B5, 210 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Registered owner
Southern Utah University
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · September 19, 2022 · 90.6 hours before
Departed
CDC · Cedar City, UT
Equipment
Satellite tracking device, Electronic multifunction display

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Student pilot
Age
19
Injuries
None
Certificate
Student
Medical
Class 2, Without waivers/limitations
Seat
Right
Restraint
3-point
Flight hours
46 total · 46 in this make and model · 2 as pilot in command · 25 in the last 90 days · 9 in the last 30 days
Role
Flight instructor
Age
24
Injuries
None
Certificates
Flight instructor, Commercial
Instrument ratings
Helicopter
Medical
Class 1, Without waivers/limitations
Last flight review
July 23, 2021
Seat
Left
Restraint
3-point
Flight hours
980 total · 960 in this make and model · 920 as pilot in command · 162 in the last 90 days · 68 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
130° at 8 knots
Visibility
10 statute miles
Lowest ceiling
8,000 ft broken
Temperature
64 °F, dew point 54 °F
Altimeter
30.09 inHg
Observed at
KCDC, 7 nm away
METAR
METAR KCDC 301853Z AUTO 13008KT 10SM SCT060 BKN080 BKN090 18/12 A3009 RMK AO2 RAE43 SLP133 P0000 T01830122=

Docket · 7

The files NTSB released with the investigation on September 11, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.9 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.