NTSB Factual Report

HISTORY OF FLIGHT

On June 25, 2003, about 0830 central daylight time, a Robinson R44 II helicopter, N7512P, operated by Berg Aviation Inc., was destroyed when it impacted terrain near Coleta, Illinois. The business flight was operating under 14 CFR Part 91. Visual meteorological conditions prevailed at the time of the accident. No flight plan was on file. The pilot and two passengers were fatally injured. The flight originated from a private airfield near Mukwonago, Wisconsin, about 0730, and was en route to Kansas City, Missouri, when it impacted terrain.

A witness saw a helicopter heading in a southwestly direction. She stated:

As I watched the copter lost [altitude]. I thought perhaps it was

getting below our light cloud cover. The copter continued to loose

altitude. I heard no surge of power. The copter didn't seem to

have maneuvering difficulty. It still continued to lose altitude. I

noticed the propeller losing speed. The copter appeared to lose

half of its [altitude] very quickly. Before the copter actually went

down, the blades appeared to stop rotation and then I counted 2

blades. I didn't hear any noise on impact. Nor did I see smoke or

flames.

Another witness stated:

... At about 8:30 AM I was standing outside of home heard a plane

having trouble coming from [the northeast] heading [southwest]

motor seemed to be having trouble. Motor never stopped but took a

nose dive in to field. Return to house [and] had [my] wife call 911.

The Whiteside County Sheriff's Department report showed that a 911 call was received at 0832. The helicopter was found in a cornfield at 41 degrees 54.501minutes North latitude and 89 degrees 48.207 minutes West longitude.

PERSONNEL INFORMATION

The pilot held a student pilot certificate. The back of that certificate showed a flight instructor's endorsement, dated March 15, 2003, to solo a Robinson R44. The certificate stated in bold lettering, "Passenger-Carrying Prohibited." He held a Federal Aviation Administration (FAA) second-class medical certificate issued on March 13, 2003, with no limitations. At the time of that medical, he reported 60 hours total flight time to date and 60 hours in the six months prior to that examination. The medical application asked, "Do you currently use any medication (Prescription or Nonprescription)?" The pilot indicated "No."

AIRCRAFT INFORMATION

The accident helicopter, N7512P, serial number 10046, was a Robinson R44 II, Raven, four-place, two-bladed, single main rotor, single-engine helicopter, with a spring and yield skid type landing gear. The primary structure of its fuselage was welded steel tubing and riveted aluminum sheet. The tailcone was a monocoque structure consisting of an aluminum skin. A Lycoming IO-540-AE1A5, serial number L-28594-48A, engine rated at 205 horsepower, powered the helicopter. The helicopter had a five-minute takeoff rating of 245 horsepower. The helicopter contained a standard airworthiness certificate dated February 4, 2003, and a temporary registration certificate dated March 7, 2003.

METEOROLOGICAL INFORMATION

At 0835, the Whiteside County Airport-Joseph H. Bittorf Field, located 13.2 nautical miles and 151 true degrees from the accident site, recorded weather was: Wind 200 degrees at 6 knots; visibility 8 statute miles; sky condition clear; temperature 27 degrees C; dew point 18 degrees C; altimeter 29.98 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

An on-scene investigation was conducted. The helicopter was found resting on its left side. The helicopter's heading was about 78 degrees magnetic. The left side of the helicopter cabin was crushed inward. The rotor blades remained attached to the rotor head. The rear landing skid crosstube was detached from fuselage and was found about 21 feet south of the fuselage. The muffler was detached from the engine and was found about 26 feet south of the fuselage. The tail cone was separated aft of the squirrel cage blower. The detached tail cone was found about 23 feet southwest of the fuselage. The left hand side's fuel cap was found lying on the ground about three feet from its filler neck. A semicircular area of vegetation between 15 and 40 feet southwest of the fuselage exhibited blight. The Hobbs meter read 95.8 hours.

The engine was rotated by hand and it produced a thumb compression at five of its six cylinders. The cylinder that did not produce a thumb compression sustained impact damage. The magnetos were removed. One magneto was able to produce spark at all leads when it was rotated by hand. The other magneto sustained impact damage and was retained for further examination. The mechanical fuel pump ejected a blue liquid when manipulated by hand. The electric fuel pump pumped a liquid when an electric current was applied. The fuel distribution valve contained a liquid consistent with avgas. The fuel servo contained a blue liquid and a sample of it was retained for testing. Both fuel tanks were ruptured. Engine control continuity was established from the cockpit to the engine. Flight control continuity was traced from the cockpit to the main and tail rotor blades. The main and tail rotor gearboxes fully rotated when turned by hand. No pre-impact anomalies were detected with the helicopter or its engine.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the Whiteside County Coroner's Office.

The FAA Civil Aeromedical Institute (CAMI) prepared a Final Forensic Toxicology Accident Report. The report stated:

0.377 (ug/ml, ug/g) AMPHETAMINE detected in Blood

10.479 (ug/ml, ug/g) AMPHETAMINE detected in Urine

0.626 (ug/mL, ug/g) FLUOXETINE detected in Blood

FLUOXETINE present in Urine

NORFLUOXETINE present in Blood

NORFLUOXETINE present in URINE

TESTS AND RESEARCH

The magnetos, fuel distribution valve, distribution lines, fuel injectors, and fuel servo were taken to RLB Accessories, Addison, Illinois, for testing on July 2, 2003. The left magneto rotated at various speeds and produced spark at all leads. The magneto retard operated as designed. The p-lead operated as designed. The right magneto had a bent shaft. The right magneto rotated at various speeds and produced spark at all leads. The p-lead operated as designed. The tachometer points operated as designed.

The fuel servo had a bent mixture control shaft. The shaft was stiff and moved fully from idle cut off to wide-open throttle position. The idle cut off was able to stop the fuel flow when the mixture control shaft was manually pushed into its normal position. No other anomalies were detected on the servo. The servo met service limits during the flowmeter testing. The test specification sheet and data collected during testing are appended to the docket material associated with this investigation.

The fuel distribution valve operated correctly. Fuel injectors delivered an equal flow of test liquid as observed and collected in containers.

The hydraulic system was sent to its manufacturer for testing and a NTSB air safety investigator oversaw the testing. The examination and testing revealed that the servos sustained impact damage and that they did not meet production specifications. The testing showed that the servos' cylinders did move in both directions with hydraulic pressure applied and that the cylinders could be moved without hydraulic pressure. The hydraulic pump was test run and it met production specifications. The manufacturer's accident report is appended to the docket material associated with this investigation.

The engine was sent to its manufacturer for disassembly, examination, and documentation. The examination, to include Service Bulletin 388B valve checks, revealed no pre-impact anomalies. The manufacturer's report on the disassembly is appended to the docket material associated with this investigation.

The retained blue liquid sample was sent to the DuPage County Crime Laboratory, Wheaton, Illinois, for analysis. The analysis revealed "the presence of aviation gasoline." That analysis is appended to the docket material associated with this investigation.

A FAA inspector collected a fuel sample from the pilot's refueling storage tank. The United States Air Force Reserve unit at Milwaukee, Wisconsin, forwarded the fuel sample to the Aerospace Fuels Laboratory at Wright Patterson AFB, Ohio. The laboratory tested the fuel and their report stated that the sample met the specifications of 100LL. The laboratory's report on the fuel is appended to the docket material associated with this investigation.

ADDITIONAL INFORMATION

FAA regulations stated:

61.53 Prohibition on operations during medical deficiency.

(a) Operations that require a medical certificate. Except as

provided for in paragraph (b) of this section, a person who

holds a current medical certificate issued under part 67 of

this chapter shall not act as pilot in command, or in any

other capacity as a required pilot flight crewmember, while

that person:

(1) Knows or has reason to know of any medical condition

that would make the person unable to meet the requirements

for the medical certificate necessary for the pilot operation; or

(2) Is taking medication or receiving other treatment for a

medical condition that results in the person being unable to

meet the requirements for the medical certificate necessary for

the pilot operation.

91.17 Alcohol or drugs.

(a) No person may act or attempt to act as a crewmember of a civil

aircraft -

...

(3) While using any drug that affects the person's faculties in any

way contrary to safety; or

Fluoxetine is a prescription antidepressant also indicated for the use of obsessive-compulsive disorder and bulimia nervosa (an eating disorder) and often known by the trade name Prozac. Norfluoxetine is a metabolite of fluoxetine. Amphetamine is a stimulant, often known informally as"speed." It may be prescribed for conditions including narcolepsy, obesity, and attention deficit and hyperactivity disorder, but it is often a drug of abuse and has a high incidence of addiction.

The parties to the investigation included Robinson Helicopter Company, Textron Lycoming, and the FAA.

The aircraft wreckage was released to a representative of the helicopter's owner.

NTSB Probable Cause

The pilot not maintaining main rotor RPM during cruise flight. The factor in the two passenger's fatal injuries was the pilot not following directives concerning the prohibition of carrying passengers while a student pilot. Other factors were the pilot's use of inappropriate medication/drugs, and the impairment of the pilot by amphetamine.