NTSB Factual Report

HISTORY OF FLIGHT

On July 23, 2009, at 2226 eastern daylight time, a Robinson R44 helicopter, N7189W, was substantially damaged when it struck a guy-wire and impacted the ground while in cruise flight near Boonsboro, Maryland. The certificated commercial pilot and three passengers were killed. Night visual meteorological conditions prevailed and no flight plan had been filed for the Title 14 Code of Federal Regulations Part 91 business flight. The flight originated from Hagerstown Regional Airport (HGR), Hagerstown, Maryland, and was en route to Frederick Municipal Airport (FDK), Frederick, Maryland, when the accident occurred.

The helicopter was based at FDK and maintained by Advanced Helicopter Concepts (AHC), an operator of five Robinson R22 helicopters. The helicopter was privately owned by a trustee of Advanced Helicopter Youth Foundation, a non-profit charity founded by the President of AHC.

According to witnesses, on the day of the accident, the helicopter flew from FDK to HGR, to transport a Director of Advanced Helicopter Youth Foundation, and another passenger to a business association meeting. In addition, the pilot was scheduled to give rides in the helicopter, in conjunction with that meeting. The pilot and the third passenger were employees of AHC. The helicopter arrived at HGR at approximately 1812. It was originally scheduled to arrive at 1630, but was delayed due to weather. The pilot then gave rides in the helicopter, until about 2000. The rides consisted of a flight around the traffic pattern and lasted less than 5 minutes each.

After the business meeting and the rides, the pilot and passengers boarded the helicopter; however, it was shut-down shortly thereafter and the occupants returned to the terminal. An airport employee reported that one of the passengers stated that the weather was "pretty bad" and that the pilot thought they would be delayed about 1 hour. At approximately 2100, the pilot called an employee of AHC, to ask about the weather conditions for the return flight to FDK. The employee lived about 4 miles from FDK, near the base of South Mountain, and informed the pilot that the weather conditions were "miserable" with severe thunderstorms in the area. He offered to drive in his car to HGR to return the occupants to FDK; however, the pilot stated they would "wait out" the weather. The pilot called back "sometime between 2200 and 2215," to again ask about the weather conditions. The employee told the pilot that the rain had stopped; however, it was still foggy, and windy with lightning in the area. He again offered to drive to HGR, and the pilot stated that he would wait for the weather conditions to improve. He also mentioned that a wife of one of the passengers owned a minivan, and could pick them up if needed.

It was estimated that the helicopter departed HGR about 2215. The HGR air traffic control tower closed at 2200, and there were no known communications with the helicopter.

A witness, driving east on Interstate 70 (I-70), stated that he observed the helicopter pass over his right side. It was a "dark night," and there was fog present about 50 feet above the roadway surface. The helicopter appeared to fly into "low clouds," turned around, and was heading back toward the west, when it contacted power lines just as his car passed under them. The helicopter impacted the ground and "burst into flames."

Another witness, driving on I-70, reported that the helicopter was flying parallel with the interstate, and "seemed to be getting lower." It then disappeared from view, which was followed by "sparks in the sky." He then observed the helicopter descend toward the roadway.

PERSONNEL INFORMATION

The pilot, age 24, was hired by AHC in January 2009. He held a flight instructor certificate, with ratings for rotorcraft and instrument helicopter. He also held a commercial pilot certificate, with ratings for airplane single-engine land, rotorcraft, instrument airplane, and instrument helicopter.

Review of the pilot's logbooks revealed that as of July 18, 2009, he had accumulated about 645 hours of total flight experience, which included about 440 hours in helicopters. Of the 440 hours, about 20 hours were logged in the same make and model as the accident helicopter, with the remaining time logged in R22 series helicopters. The pilot received a "checkout" in the R44 on December 24, 2008.

In addition, the pilot had logged about 70 and 160 hours during the 30 and 90 days preceding the accident; respectively. The pilot had accumulated about 25 hours of night flight experience, which included about 12 hours at night in helicopters. During the 90 days preceding the accident, the pilot had logged .3 hours of night flight experience.

According to company records, the pilot flew 3.2 hours on the day prior to the accident, and 2.7 hours on July 20, 2010. On the day of the accident, the pilot had one flight scheduled at 1200, which consisted of a 1.9 hour photography flight.

The pilot completed a Robinson Helicopter Company Pilot Safety Course on February 5, 2009.

The pilot's most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on July 13, 2009.

The other AHC employee onboard was hired in 2009, and worked at the "front desk" as an office manager. He held a rotorcraft private pilot certificate, which was issued on March 31, 2009. At that time, he reported about 90 hours of rotorcraft flight experience.

AIRCRAFT INFORMATION

The four-seat, single main rotor, single-engine helicopter, serial number 847, was constructed primarily of metal, and manufactured during September 2000. The primary structure of the fuselage was welded steel tubing and riveted aluminum sheet. The tailcone was a monocoque structure in which aluminum skins carried most of the primary loads. Fiberglass and thermoplastics were used in the secondary structure of the cabin, engine cooling system, and in various other ducts and fairings. The helicopter was powered by a 260-horsepower Lycoming O-540-F1B5 series engine, with a maximum continuous rating of 205-horsepower at 2,718 rpm.

Review of maintenance records revealed that the helicopter had been operated for about 60 hours since its most recent annual inspection, which was performed on March 16, 2009. At the time of the annual inspection, the airframe and engine had been operated for about 1,730 hours since new.

Prior to the accident date, the helicopter was flown from Lexington, South Carolina, to FDK, on July 13, 2009. The pilot of that flight described the flight as "uneventful."

According to the Pilot's Operating Handbook, the helicopter was certified to be operated under visual flight rules flight only.

METEOROLOGICAL INFORMATION

Witnesses at the airport reported that the pilot and AHC employee both checked the weather conditions several times while they were at HGR.

The following weather observations were recorded at HGR, which was located about 13 miles northwest of the accident site, at an elevation of 692 feet mean sea level (msl):

At 2153, wind from 310 degrees at 5 knots; visibility 10 statute miles; few clouds at 2,300 feet, broken clouds at 8,000 feet; temperature 24 degrees Celsius (C), dew point 19 degrees C; altimeter 29.87 inches of mercury (in/hg).

At 2253, wind from 320 degrees at 5 knots; visibility 10 statute miles; sky clear; temperature 23 degrees C, dew point 19 degrees C; altimeter 29.88 in/hg.

The following weather observations were recorded at FDK, which was located about 15 miles southeast of the accident site, at an elevation of 303 feet msl:

At 2210, wind from 130 degrees at 11 knots; visibility 1.5 statute miles, with thunderstorms and heavy intensity rain; broken clouds at 600 and 1,000 feet, overcast clouds at 1,500 feet; temperature 21 degrees C, dew point 20 degrees C; altimeter 29.89 in/hg.

At 2232, wind from 200 degrees at 6 knots; visibility 10 statute miles, with thunderstorms and light intensity rain; scattered clouds at 800 and 8,000 feet; temperature 21 degrees C, dew point 20 degrees C; altimeter 29.88 in/hg.

According to data obtained from the U.S. Naval Observatory, sunset occurred at 2031, and the end of civil twilight was at 2101. The phase of the moon was waxing crescent with 4% of the Moon's visible disk illuminated.

WRECKAGE INFORMATION

The accident site was at an elevation of about 1,130 feet msl, near the top of South Mountain. The helicopter struck and broke an unmarked, steel guy-wire, which extended perpendicular over I-70, near mile marker 37, and was about 70 feet high. According to a power company representative, a 34.5 and a 12-kilovolt power line located below the guy-wire were damaged, with a power interruption noted at 2226.

A ground scar was noted on the center median approximately 30 feet west of the power lines, and the helicopter came to rest on its left side, approximately 42 feet west of the power lines, on a heading of 090 degrees. A postcrash fire consumed the cabin, a majority of the main rotor gearbox housing, and all drive belts.

Examination of the wreckage showed the skids did not exhibit any directional deformation. The left and right toe sections were separated.

Both main rotor blades remained attached to the rotor hub and exhibited impact damage at their respective outboard ends. One blade was bowed upward, contained wrinkling on the upper surface, and was missing about 1 foot of the blade tip. The inboard 5 feet of the second blade was intact; however, the remaining portion of the upper and lower surfaces and leading edges of the blade were separated from the internal honeycomb structure, which was consumed by fire. The outboard two feet of the second blade was separated.

One main rotor pitch change link was disconnected and the upper swash plate connection was fractured, consistent with impact damage. The three push/pull tubes at the swash plate remained connected. The main rotor assembly could not be rotated.

The tail boom was intact. It contained fire damage at its forward end, and impact damage in the vicinity of the damper bearing. The rotor assembly was not damaged and rotated freely. The tail rotor drive shaft was intact until just aft of the damper bearing. The separated ends of the drive shaft contained torsional twisting damage. The tail rotor pitch change control tube was intact through the tail boom.

Due to impact and fire damage, control continuity to the forward cockpit area could not be established.

The helicopter was equipped with a radar altimeter, which was compromise due to the impact and fire damage.

The main and tail rotor gear-box chip detectors were clear of debris.

The engine remained contained in the engine compartment and sustained fire damage. The crankshaft was rotated via the cooling fan and valve-train continuity and thumb compression was attained on all cylinders. Both magnetos remained attached to the engine and sustained fire damage. The right magneto produced spark on all towers when placed on a test bench; however, the sparks became intermittent as the rpm was increased. The left magneto could not be sparked due to fire damage. A subsequent additional examination and disassembly of both magnetos did not reveal any preimpact malfunctions.

All spark plugs were removed and their respective electrodes were intact and displayed "normal" combustion signatures when compared with a spark plug wear chart. A borescope examination of all cylinders did not reveal any abnormalities.

The carburetor remained attached to the engine and was disassembled. Fuel was found in the carburetor bowl. The fuel was light blue in color and absent of visible contamination. A check of the fuel with water finding paste did not reveal the presence of water. The fuel inlet screen was absent of debris.

Examinations of the airframe, engine, and drive systems did not reveal any evidence of preimpact mechanical malfunctions.

MEDICAL AND PATHOLOGICAL INFORMATION

Post mortem examination of the pilot and passengers was conducted on July, 23, 2009, by the Office of the Chief Medical Examiner, Baltimore. Maryland. The examination report for all occupants listed the cause of death as "multiple injuries."

Toxicological testing performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma was negative for drugs and alcohol.

ADDITIONAL INFORMATION

Radar Data

Review of radar data obtained from the FAA revealed a target with a 1200 beacon code which corresponded with the location of the accident helicopter. The last target was recorded at 2226:08, at an altitude of 1,100 feet msl, in the vicinity of the accident site. During the final minute, the target maintained an altitude of about 1,100 feet msl, and a heading between 167 and 188 degrees. During the final 20 seconds, the target's ground speed decreased from 57 knots to 25 knots. In addition, when the helicopter's radar targets were observed on a topographical map, it was noted that the helicopter was flying above rising terrain. During the final 2 minutes of the accident flight, the terrain elevation rose from about 600 feet, to almost 1,200 feet.

Robinson Helicopter Safety Notices

Robinson Helicopter Safety Notice SN-26, issued January 1987 and revised June 1994 stated, in part:

"NIGHT FLIGHT PLUS BAD WEATHER CAN BE DEADLY

Many fatal accidents have occurred at night when the pilot attempted to fly in marginal weather after dark. The fatal accident rate during night flight is many times higher than during daylight hours.

When it is dark, the pilot cannot see wires or the bottom of clouds, nor low hanging scud or fog. Even when he does see it, he is unable to judge its altitude because there is no horizon for reference. He doesn't realize it is there until he has actually flown into it and suddenly loses his outside visual references and his ability to control the attitude of the helicopter. As helicopters are not inherently stable and have very high roll rates, the aircraft will quickly go out of control, resulting in a high velocity crash which is usually fatal…."

Robinson Helicopter Safety Notice SN-16, issued April 1984, and revised June 1994, stated, in part:

"POWER LINES ARE DEADLY

Flying into wires, cables, and other objects is by far the number one cause of fatal accidents in helicopters. Pilots must constantly be on alert for this very real hazard….Always maintain at least 500 feet AGL except during take-off and landing. By always flying above 500 feet AGL, you can virtually eliminate the primary cause of fatal accidents."

NTSB Probable Cause

The pilot’s improper decision to depart on a visual flight rules (VFR) flight at night in adverse weather conditions in close proximity to rising mountainous terrain in a helicopter that was only certified to be operated under VFR and his subsequent failure to maintain adequate clearance with wires.