NTSB Factual Report

HISTORY OF FLIGHT

On January 22, 2008, at 1234 eastern standard time, (unless otherwise noted, all times are based on a 24 hour clock) a Robinson R44, N18HB, registered to Alex Mill Developments Inc., collided with the ground while maneuvering over runway 27 at the Dade-Collier Training and Transition Airport, in the vicinity of Ochopee, Florida. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 with no flight plan filed. Visual meteorological conditions prevailed and the helicopter received substantial damage. The airline transport rated pilot, and private pilot passenger were fatally injured. The flight departed Dade-Collier Training and Transition Airport on January 22, 2008, at 1233.

A witness who was working at the Dade-Collier Training and Transition Airport, mowing the grass, stated the helicopter had been practicing takeoffs and landings between 20 minutes to 1 hour. He observed the helicopter at a hover above the grass; north and parallel to the taxiway, short of the runway 27 hold line. The helicopter went up very fast to an altitude of about 200 feet and made a right turn above runway 27 in a nose down attitude. The tail of the helicopter turned 45 degrees to the left side of the runway. The helicopter made a roll to the left and became inverted. The rotor blades stopped and the helicopter continued the roll to the left until it became right side up and descended in a nose down, left turn colliding with the ground and catching fire, followed by an explosion.

The daughter of the registered owner stated the airline transport pilot had been giving her father flight instruction in rotary wing aircraft, and the daughter of the airline transport pilot confirmed her statement.

PERSONNEL INFORMATION

The airline transport pilot, age 64, located in the left front seat, held a foreign based commercial pilot certificate issued on October 24, 1980, with ratings for airplane single engine land and airplane single engine sea. The certificate was issued on basis of and valid only when accompanied by his Canadian pilot license. In addition, the pilot was issued an airline transport pilot certificate on June 27, 2003, with ratings for airplane multiengine land, commercial pilot, rotorcraft helicopter, and private pilot with ratings for airplane single engine land, and airplane single engine sea. The pilot held a Cessna 525S type rating with the limitation, "This certificate is subject to pilot-in-command limitation for Cessna 525S." The pilot did not have a flight instructor certificate. The pilot held a first class medical certificate issued on April 24, 2007, with no medical restrictions. The pilot indicated on his application for the first class medical certificate that he had 13,000 total flight hours. Review of the Pilot History Form dated August 11, 2007, for insurance on the accident helicopter revealed the pilot indicated his last flight review was on July 30, 2007. According to a helicopter flight instructor, the pilot completed a helicopter flight review in the R44 on August 17, 2007, along with 1.5 hours of ground instruction and 2.3 hours of flight instruction. The pilot indicated he had 660 rotary wing hours, of which 585 hours were in the Robinson R22 and 15 hours were in the R44. The pilot's logbook was not located. Review of training records obtained from Robinson Helicopter Company revealed the pilot attended a Flight Instructor Safety and Refresher Clinic from November 9, 2003 through November 13, 2003. The flight instructor providing instruction to the pilot listed the following comments on flight maneuvers that were conducted during the training:

MANEUVERS PROFICIENY COMMENTS

Low RPM Recovery Average None

Settling With Power Below Average Slow Recognition

Straight Autos Below Average To Fast

180 Autos Below Average Fast

Hovering Autos Average None

Simulated Engine Out Average None

Overall Handling and maneuvering Average None

Attitude Average None

Knowledge Average None

The flight instructor wrote the following general comment. "Hi time airplane pilot still thinks airplane." The pilot was issued a Robinson Helicopter Company Pilot Safety Course Certificate of Completion on November 13, 2003.

The pilot rated passenger, age 74, located in the right front seat, held a private pilot certificate issued on January 31, 1983, with ratings for airplane single engine land, and airplane single engine sea. The certificate was issued on basis of and valid only when accompanied by his Canadian pilot license. The pilot did not hold a rotorcraft helicopter rating. The pilot's Federal Aviation Administration (FAA) medical certificate was denied on June 18, 2007, due to the pilot's failure to provide additional medical information requested by the FAA Aerospace Medical Certification Division. Transport Canada granted a medical certificate to the pilot on July 27, 2006. The pilot's daughter stated her father had bypass surgery in 2004 or 2005. The pilot reported on his application for the medical certificate that he had accumulated 6,650 total flight hours. The pilot rated passenger's logbook was not located. The pilot's total time in the R44 and his last flight review was not determined. Review of the Pilot History Form dated August 11, 2007, for insurance on the accident helicopter revealed the pilot indicated his last flight review was in June 2006. The pilot indicated the date of his last FAA medical was in July 2007. The pilot indicated he had between 50 to 100 hours of helicopter flight time, of which 15 hours were in the R44 with a Robinson Chilean Chief flight instructor, 15 hours in an R22 with the deceased airline transport pilot, 10 additional hours in an R44 with "S. Diaz" in Santiago, Chile, and 65 hours in the Robinson R44 Astro. In addition, the pilot indicated he had an instrument rating.

AIRCRAFT INFORMATION

The Robinson R44 is a four place, single main rotor, single engine helicopter constructed primarily of metal and equipped with a skid type landing gear, serial number 0634 manufactured on July 21, 1999. A Lycoming O-540-F1B5, 260 hp engine, powered the helicopter. Review of the logbooks revealed the helicopter was transported to Europe on July 21, 1999, and had 7.3 total hours. The helicopter returned to the United States on June 2, 2005 and had 2,115 hours. A United States Standard Airworthiness Certificate was issued in the normal category on June 3, 2005. The engine was overhauled on May 24, 2007, and the engine was zero timed. The engine was reinstalled on the helicopter during the 2,200-hour overhaul and an annual inspection was conducted on June 21, 2007. The helicopter had a total of 2,180 hours at the last annual inspection. The previous owner of the helicopter stated it had been flown between 90 to 95 hours since the last annual inspection. The helicopter was topped off at Banyan Air Service, Fort Lauderdale, Florida, on January 22, 2008; with 34.8 gallons of 100 low lead fuel at 11:12 AM.

METEOROLOGICAL INFORMATION

The 1253 surface weather observation at Miami International Airport, Miami, Florida, located 33 nautical miles southeast of the crash site was: wind 080-degrees at 15 knots, visibility 10 miles, 2,100 broken, 13,000 overcast, temperature 26 degrees Celsius, dew point temperature 18 degrees Celsius, and altimeter 30.21.

AIRPORT INFORMATION

Dade-Collier Training and Transition Airport is located at a field elevation of 13 feet. Runway 27 is 10,499 feet long and 150 feet wide. The taxiway at the hold short line for runway 27 is on a heading of 155 degrees magnetic. The airline transport pilot obtained a Dade-Collier Training and Transition Airport Aircraft Use Permit issued effective August 28, 2007, through August 28, 2008.

WRECKAGE AND IMPACT INFORMATION

The helicopter wreckage was located 10 feet left of runway 27 on a heading of 210 degrees magnetic. Examination of the crash site revealed the helicopter collided with the ground in a nose up left skid low attitude on a heading of 250 degrees magnetic on runway 27. The landing gear separated and the bottom of the engine assembly collided with the runway. The red main rotor blade and tail rotor gearbox collided with the runway and separated. A red lens cover was present adjacent to the engine ground scar along with yellow and black paint transfer from the airframe. The helicopter continued forward 33 feet and came to rest on its left side. Oil staining from the engine oil sump and the tail rotor gearbox was present on the runway in the vicinity of the crash debris line. The crash debris line extended 50 feet.

Examination of the airframe and flight control system components revealed no evidence of a preimpact mechanical malfunction. A post crash fire consumed the cabin structure. The pilot's and co-pilot's left anti torque pedals were full forward and the right anti torque pedals were full aft. The co-pilot's left anti torque pedal footrest was bent downward. The co-pilot's cyclic grip was consumed by fire. The pilot's cyclic grip was damaged at mid point and fire damaged. The collective friction hardware was positioned at .9 inches below the full up position, which equates to 72 percent of travel. The co-pilot's removable collective stick, cyclic and anti torque pedals were installed. The interconnected throttle was in the closed position.

The red main rotor blade remained attached to the main rotor hub and was fire damaged. The red main rotor blade separated five feet outboard of the main rotor hub, was coned upward, and the leading edge was bent aft 6 feet inboard of the main rotor blade tip. Red paint transfer was present on the lower surface of the red main rotor blade at the blade tip from contact with the "Danger" decal on the tail boom assembly. The blue main rotor blade remained attached to the main rotor hub and was fire damaged extending 6 feet outboard from the main rotor hub. No scarring was present on the leading edge of the blue main rotor blade.

Examination of the main gearbox, forward flex coupler, overrunning clutch, intermediate flex coupler, tail rotor drive shaft, aft flex coupler, main gearbox and tail rotor gear box chip detectors revealed no evidence of a pre crash mechanical failure or malfunction. The belt tension actuator measured 1 inch between the scissor mounts. The lower actuator support bearing rotated smoothly when turned by hand. The upper actuator support bearing received fire damage and would not rotate by hand. All four drive belts were fire damaged.

The tail cone assembly remained attached to the upper airframe and was separated 12 feet aft of the forward tail cone mount. The lower vertical stabilizer of the empennage was damaged and the tailskid separated from the lower stabilizer. The tail rotor gearbox was separated from the input-mounting flange and the tail rotor gearbox output shaft was rotated by hand. The tail rotor blade assembly remained attached to the tail rotor gearbox. The target and non-target tail rotor blades were torn from the tail rotor blade leading edge. Scarring was present on the outboard skin of both tail rotor blades, and scarring was present on the outboard face of the tail rotor hub.

Examination of the recovered engine assembly and accessories revealed no anomalies.

MEDICAL AND PATHOLOGICAL INFORMATION

The District 20 Medical Examiner, Naples, Florida, conducted postmortem examination of the airline transport pilot, on January 24, 2008. The cause of death was "blunt force injuries and fire." The Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma performed postmortem toxicology of specimens from the pilot. The studies were negative for carbon monoxide, cyanide, ethanol, basic, acidic, and neutral drugs.

The Collier County Medical Examiner conducted postmortem examination of the private pilot, on January 23, 2008. The cause of death was "blunt force injuries and fire." The Medical Examiner stated the pilot had bypass grafting times 5 on August 16, 2005. The Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma performed postmortem toxicology of specimens from the pilot. The studies were negative for carbon monoxide, cyanide, and ethanol. An undetermined amount of metoprolol and triamterene was detected in the blood and urine.

TEST AND RESEARCH

Review of the Robinson R44 Pilot's Operating Handbook, Safety Notice SN-24, Low RPM Rotor Stall Can Be Fatal states, "Rotor stall due to low RPM causes a very high percentage of helicopter accidents, both fatal and non-fatal. Rotor stall can occur at any airspeed and when it does, the rotor stops producing the lift required to support the helicopter and the aircraft literally falls out of the sky. Rotor stall also occurs at higher altitudes and when it happen at heights above 40 or 50 feet AGL it is most likely to be fatal. As the RPM of the rotor gets lower, the angle of attack of the rotor blades must be higher to generate the lift required to support the weight of the helicopter. Even if the collective is not raised by the pilot to provide the higher blade angle, the helicopter will start to descend until the upward movement of air to the rotor provides the necessary increase in blade angle of attack. The increased drag on the blades act like a huge rotor brake causing the rotor rpm to rapidly decrease, further increasing the rotor stall. As the helicopter begins to fall, the upward rushing air continues to increase the angle of attack on the slowly rotating blades, making recovery virtually impossible, even with full down collective."

Review Safety Notice SN-10, Fatal Accidents Caused By Low RPM Rotor Stall states, "A primary cause of fatal accidents in light helicopters is failure to maintain rotor RPM. To avoid this every pilot must have his reflexes conditioned so he will instantly add throttle and lower collective to maintain RPM in any emergency. Power available from the engine is directly proportional to RPM. If the RPM drops 10 percent, there is 10 percent less power. With less power, the helicopter will start to settle, and if the collective is raised to stop it from settling, the RPM will be pulled down even lower, causing the ship to settle even faster. If the pilot not only fails to lower collective, but instead pulls up on the collective to keep the ship from going down, the rotor will stall almost immediately. When it stalls, the blades will either "blow back" and cut off the tail cone or it will just stop flying, allowing the helicopter to fall at an extreme rate. In either case, the resulting crash is likely to be a fatal. No matter what causes the low rotor RPM, the pilot must first roll on throttle and lower the collective simultaneously to recover RPM before investigating the problem. It must be a conditioned reflex. In forward flight, applying aft cyclic to bleed off airspeed will also help recover lost RPM."

Review of Safety Notice SN-29, Airplane Pilot's High Risk When Flying Helicopters states, "The ingrained reactions of an experienced airplane pilot can be deadly when flying a helicopter. The airplane pilot may fly the helicopter well when doing normal maneuvers under ordinary conditions when there is time to think about the proper control response. But when required to react suddenly under unexpected circumstances, he may revert to his airplane reactions and commit a fatal error. Under those conditions, his hands and feet move purely by reaction without conscious thought. Those reactions may well be based on his greater experience, i.e.' the reactions developed flying airplanes....

To stay alive in the helicopter, the experienced airplane pilot must devote considerable time and effort to developing safe helicopter reactions. The helicopter reactions must be stronger and take precedence over the pilot's airplane reactions because everything happens faster in a helicopter. The pilot does not have time to realize he made the wrong move, think about it, and then correct it. It's too late; the rotor has already stalled or a blade has already struck the airframe and there is no chance of recovery."

NTSB Probable Cause

The pilot's failure to maintain aircraft control while maneuvering. Contributing to the accident were a tailwind condition and the pilot's inadequate in-flight planning/decision.