NTSB Factual Report

HISTORY OF FLIGHT

On November 4, 2001, about 1800 Pacific standard time, a Robinson R-22 Beta helicopter, N7197Y, collided with trees in an avocado grove and terrain near Escondido, California. Farm workers found the wreckage on the morning of November 6, 2001. The pilot/owner was operating the helicopter under the provisions of 14 CFR Part 91. The commercial pilot and the private pilot rated passenger sustained fatal injuries; the helicopter was destroyed. The helicopter was believed to have departed Oceanside Municipal Airport (OKB), Oceanside, California, about 15 minutes prior to the accident. The primary wreckage was located at 33 degrees 11.113 minutes north latitude and 117 degrees 07.621 minutes west longitude. The wreckage was about 100 yards from a landing pad on the pilot's property.

The Federal Aviation Administration (FAA) accident coordinator interviewed witnesses at Oceanside, which was about 10 nautical miles (nm) west of the pilot's home. The witnesses had observed the pilot fly the helicopter at the airport several times on Sunday, November 4.

The pilot's instructor said that they completed an instructional flight in the pilot's Beech Baron. They landed about 1700 on Sunday, November 4, and debriefed the flight. The instructor left the airport about 1730.

Family representatives stated that the pilot did not report to work on Monday. A calendar in the home was set to Sunday. The Sunday newspaper had been opened and was on a table; the Monday newspaper was still in the mailbox. They said that the pilot always approached the pad from the northeast.

PERSONNEL INFORMATION

A review of FAA airman records revealed that the pilot held a commercial pilot certificate with ratings for airplane single engine land, multiengine land, and instrument airplane. The pilot held a private pilot certificate with ratings for rotorcraft-helicopter. The pilot held a second-class medical certificate that was issued on August 23, 2000. It had the limitations that the pilot must wear corrective lenses.

An examination of the pilot's logbook indicated an estimated total flight time of 790 hours. He logged an estimated 55 hours in the last 90 days, and 15 in the last 30 days. He had en estimated 350 hours in this make and model.

A review of FAA airman records revealed that the pilot rated passenger held a private pilot certificate with a rating for rotorcraft-helicopter. The passenger held a third-class medical certificate issued on August 19, 1999. It had the limitations that the pilot shall wear corrective lenses.

An examination of the passenger's logbook indicated that she had an estimated total flight time of 115 hours. She logged an estimated 5 hours in the last 90 days, and 1 in the last 30 days. She had an estimated 115 hours in this make and model; 78 hours were as pilot-in-command.

AIRCRAFT INFORMATION

The helicopter was a Robinson R-22 Beta, serial number 3247. The owner had taken delivery of the helicopter on October 25, 2001. Investigators estimated that the total time on the helicopter was 10 hours.

The airplane's engine was a Textron Lycoming O-360-J2A, serial number L-38160-36A.

METEOROLOGICAL CONDITIONS

Oceanside Airport, elevation 28 feet msl, had an Automated Surface Observation System (ASOS). It recorded weather data for OKB.

At 1714, the ASOS recorded: skies clear; visibility 4 miles, mist; winds 220 degrees at 4 knots; temperature 64 degrees Fahrenheit; dew point 63 degrees Fahrenheit; altimeter 29.97 inHg.

At 1745, the ASOS recorded: skies 1,000 feet broken; visibility 4 miles, mist; winds 240 degrees at 4 knots; temperature 64 degrees Fahrenheit; dew point 63 degrees Fahrenheit; altimeter 29.99 inHg.

At 1756, it recorded: skies 1,000 feet broken; visibility 4 miles, mist; winds 230 degrees at 4 knots; temperature 64 degrees Fahrenheit; dew point 63 degrees Fahrenheit; altimeter 29.99 inHg.

A CFI at OKB noted that he went indoors at 1715 as the accident pilot was preparing the helicopter for departure. The CFI said the visibility was 4 miles with haze and going down.

Carlsbad, California, is 9 nm southwest of the accident site and issued a routine aviation weather report (METAR) at 1714. It stated: skies clear; visibility 4 miles, mist; winds from 320 degrees at 4 knots; temperature 63 degrees Fahrenheit; dew point 59 degrees Fahrenheit; altimeter 29.97 inHg.

The METAR for Carlsbad at 1753 stated: skies 1,000 feet broken; visibility 4 miles, mist; winds from 290 degrees at 3 knots; temperature 63 degrees Fahrenheit; dew point 59 degrees Fahrenheit; altimeter 29.99 inHg.

Ramona, California, 13 nm southeast of the accident site issued a METAR at 1653. It stated: skies 8,500 feet broken; visibility 5 miles, haze; winds from 270 degrees at 6 knots; temperature 63 degrees Fahrenheit; dew point 57 degrees Fahrenheit; altimeter 29.98 inHg.

The METAR for Ramona at 1753 stated: skies, few clouds at 8,000 feet, 9,000 feet broken; visibility 6 miles, haze; winds from 290 degrees at 6 knots; temperature 61 degrees Fahrenheit; dew point 55 degrees Fahrenheit; altimeter 30.00 inHg.

Witnesses who lived near the accident site reported that there was fog and clouds on Sunday evening, November 4. They noted a lightning storm around 1900. They said that the fog became very thick Sunday night, and stayed very thick through Monday morning. Conditions cleared briefly Monday afternoon. The fog returned Monday evening and remained thick through Tuesday morning, November 6.

Safety Board software determined that at 1800 on November 4, the altitude of the moon was -16 degrees. Sunset occurred at 1659, civil twilight occurred at 1724, and nautical twilight occurred at 1753.

Civil twilight is defined to end in the evening when the center of the sun is geometrically 6 degrees below the horizon. This is the limit at which twilight illumination is sufficient, under good weather conditions, to clearly distinguish terrestrial objects. The horizon is clearly defined, and artificial illumination is normally required to carry out normal activities.

Nautical twilight is defined to end in the evening when the center of the sun is geometrically 12 degrees below he horizon. Under good atmospheric conditions and in the absence of other illumination, general outlines of ground objects may be distinguishable. However, detailed outdoor operations are not possible, and the horizon is indistinct.

The Pilot/Controller Glossary of the Airman's Information Manual defines night as the time between the end of evening civil twilight and the beginning of morning civil twilight.

WRECKAGE AND IMPACT INFORMATION

The pilot had an open dirt area on his 20-acre property that he used as a helipad. The National Transportation Safety Board investigator-in-charge (IIC) estimated that the pad was 90 feet wide by 150 feet long with the long axis oriented about 070/250 degrees. The pad was on top of a ridgeline. An instructor pilot familiar with the pad had suggested to the pilot that he enlarge it and add lighting. No lighting existed at the time of the accident.

Investigators from the Safety Board, the FAA, Robinson Helicopters, and Textron Lycoming examined the wreckage at the accident scene. The helicopter came to rest upright in an avocado grove in hilly terrain about 1,600 feet elevation. All references in the following paragraphs are referenced from the first identified point of contact (FIPC), and left or right of the debris path centerline. All major components were in the main wreckage area, which was about 50 feet in diameter. Several small pieces were about 200 feet away in the direction of the debris path.

The FIPC was broken tree branches and two tree trunks about 30 feet away from the broken branches that exhibited smooth diagonal fracture surfaces. The FIPC was about 150 feet from the helipad on a bearing of 180 degrees. A road transited across the debris path about 20 feet from the FIPC. The debris path was along a magnetic bearing of 170 degrees.

About 10 feet past the road was a tree with multiple trunks about 9 inches in diameter. One trunk forked into two braches that had been debarked and exhibited cut marks. A piece of the skid cross member lay at the base of this tree. Another trunk separated and came to rest about 15 feet away near the main wreckage.

The helicopter came to rest about 50 feet from the FIPC. The right side of the cabin bent around a tree and the male victim was in this location. This victim exhibited a mark extending from the right shoulder diagonally down across the chest.

The front left corner of the cockpit had a cylindrical impression about 1-foot deep. Several boulders that were about 3 feet long were on the left side of the helicopter. The broken tree trunk lay parallel to the helicopter, and one end was on the rocks. The female victim was on the left side of the tree trunk. She had a mark that extended from the left shoulder diagonally down and across the chest.

All control rods were accounted for in the main wreckage. All fractures of the control rods were angular and irregularly shaped.

Both the main rotor and tail rotor gearboxes rotated; the flex plates were distorted, but continuous. The tail rotor drive shaft was continuous. The skids separated from the cross tubes, but were within the main debris field.

The pilot's control stick separated at its base; the left stick was undamaged.

Both of the main rotor blades exhibited trailing edge buckling. The manufacturer's representative noted that the blades did not tulip.

MEDICAL AND PATHOLOGICAL INFORMATION

The San Diego County Coroner completed an autopsy on both occupants.

The FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens of the pilot. The results of analysis of the specimens were negative for carbon monoxide, cyanide, and volatiles.

The report contained the following positive results: 72.821 (ug/ml, ug/g) salicylate detected in urine.

TESTS AND RESEARCH

Investigators examined the wreckage at Eastman Aircraft, Corona, California.

Investigators removed the top spark plugs. The spark plug electrodes were circular and gray in color, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. None of the spark plugs exhibited mechanical damage. The right magneto separated into several pieces. The left magneto remained attached, and spark was obtained at all posts when the magneto was manually rotated.

Thumb compression was obtained on all cylinders in firing order, but cylinder No. 3 was weaker than the rest. The Lycoming representative inspected the cylinder with a lighted borescope and observed black deposits on the valve head. Investigators noted that the exhaust was bent and buckled, and they observed a gap between the cylinder and exhaust flange for cylinder No. 3.

Two streams of fuel were observed after actuating the carburetor's accelerator pump. The carburetor and gascolator fuel screens were clean. Bulges were observed in the forward direction on both the main and auxiliary fuel tanks. The fuel selector valve was between the off and on position.

Precision Airmotive Corporation examined the carburetor under the supervision of a Safety Board investigator. The unit had an acceptable flow test result.

Investigators observed rotational scoring on the cooling fan and fan shroud. They also observed rotational scoring on the belt tension actuator. The belt tension actuator fractured at 1.4 inches; the manufacturer's representative said the actuator's normal range is 1.3 to 1.6 inches.

The helicopter did not have an artificial horizon flight instrument installed. The instrument panel had a placard indicating that the pilot must have sufficient illumination to operate by outside light sources. The Pilot Operating Handbook had the limitation that the pilot must maintain orientation at night by lights on the ground or by adequate celestial illumination.

ADDITIONAL INFORMATION

The IIC released the wreckage to the owner's representative.

NTSB Probable Cause

the pilot's failure to maintain an adequate clearance from obstacles while approaching to land at his private helipad. Factors in the accident were night conditions, inadequate illumination of the landing pad, and a likely low visibility condition due to fog.