NTSB Factual Report

***This report was modified on April 16, 2015. Please see the docket for this accident to view the original report.***

HISTORY OF FLIGHT

On July 27, 2013, about 1255 mountain daylight time, a Robinson R44 II helicopter, N25WH, was substantially damaged following a loss of control and subsequent impact with terrain near Thompson Falls, Montana. The helicopter was registered to Zoot Helicopter I LLC, of Bozeman, Montana, and operated by Rocky Mountain Rotors, of Belgrade, Montana. The certified commercial pilot received fatal injuries; one passenger sustained serious injuries, and a second passenger suffered minor injuries. Visual meteorological conditions prevailed for the aerial survey flight, which was being conducted in accordance with 14 Code of Federal Regulations Part 91, and no flight plan was filed. The flight departed the Polson Airport (8S1), about 2 hours prior to the time of the accident. The intended destination was Thompson Falls.

According to the passenger who sustained minor injuries, the purpose of the flight was to photo document the condition of cross-country power lines and their supporting wooden structures. The passenger reported that the pilot occupied the right front seat, his associate, who was operating videotaping equipment, occupied the left front seat, and he occupied the left rear seat taking still photographs. The passenger stated that initially everything was going fine, and that they were about 50 feet from the power lines and about 50 feet above them. However, the helicopter started to rotate in a clockwise orientation, about 4 revolutions prior to impact with terrain. He described the impact attitude of the helicopter as being very steep, nose down, and banked to the right. There was no postcrash fire.

About 6 months after the accident, the left-front-seat passenger, who was assigned to operate the onboard video camera, was interviewed via telephone by the National Transportation Safety Board (NTSB) investigator-in-charge (IIC). The passenger stated that prior to the start of the helicopter spinning it was flying straight and level, and the next thing he remembered was the helicopter impacting a tree. He further stated that prior to impact he heard the Low Rotor rpm warning horn, as he had heard several times [during the starting of the helicopter's engine]. The passenger further stated that prior to the start of the spin, he did not recall any adverse wind conditions.

An NTSB Vehicle Recorder Specialist was able to download recorded data from an onboard Sony Handycam HDR CX550 recorder; the unit was equipped with a Global Positioning System (GPS) receiver. The recorder captured the entire accident sequence. The specialist's review of the data revealed the following:

The helicopter was initially observed operating about 8.5 nautical miles west-southwest of Thompson Falls, Montana, along the Montana Secondary Highway 471. About 1248, the helicopter was circling over a power substation at a groundspeed between 40 to 50 knots, at an altitude of about 3,400 feet mean sea level (msl). About 1250, the helicopter departed the substation and began following a line of utility poles northeast bound. About 1251, the helicopter was observed in a left-hand circle around a group of utility poles near a creek at an altitude of 3,226 feet msl. At 1251:38, the helicopter departed back to the northeast and continued to follow utility poles at a speed of 42 knots at an altitude of 3,220 feet msl. The helicopter then entered two more circles to the left at 1252:12, at which time its speed varied between 30 to 40 knots. At 1254:26, the helicopter was re-established on a northeast heading along the utility line at an altitude of 3,162 feet msl and a groundspeed of 39 knots; by 1255:00, the helicopter's groundspeed had decayed to 30 knots. At 1255:02, the helicopter began to yaw to the right as its speed further decayed to 22.6 knots at 1255:04. The helicopter completed a 360-degree spin by 1255:06 and continued to spin to the right. The GPS track continued to deviate for the remainder of the recording, and the groundspeed fluctuated below 22.6 knots until the recorded data terminated. Just before impact, the pilot's feet are shown and the left pedal is deflected forward. The helicopter struck trees about 1255:13, then the recording ended.

PERSONNEL INFORMATION

The pilot, age 35, possessed a commercial pilot certificate with ratings for rotorcraft-helicopter and instrument helicopter. He also held a certified flight instructor certificate with ratings for rotorcraft-helicopter and instrument helicopter. Additionally, the pilot held private pilot privileges for airplane single-engine land.

A review of the pilot's personal logbook, together with records provided by the Federal Aviation Regulation (FAR) Part 135 aeromedical company that he was employed by, revealed that about 1 month prior to the accident the pilot had accumulated a total flying time of 3,299.5 hours, of which 376.9 hours were in the same make and model as the accident helicopter.

Records also revealed that the pilot had completed his most recent Federal Aviation Administration (FAA) flight review in accordance with FAR 61.56 on July 24, 2013. The pilot's most recent second-class FAA airman medical certificate was issued on February 13, 2013, with no limitations noted.

AIRCRAFT INFORMATION

The helicopter was a Robinson R44 II, serial number 10481, manufactured in 2004. The operator reported that the helicopter's maximum gross weight was 2,500 pounds, that it seated four, and that it would have weighed about 2,300 pounds at the time of the accident.

The helicopter was powered by a 245-horsepower Lycoming IO-540-AE1A5 engine. The last annual maintenance inspection was conducted on July 8, 2013, at a total airframe and engine time of 786.2 hours. The helicopter had a total of 799 hours at the time of the accident, as it had operated 13 hours since its last maintenance inspection.

The examination of the maintenance records also revealed that on December 27, 2012, at a total airframe time of 778.9 hours, "Fuel bladder tanks installed. Aircraft returned to service." Additionally, the entry noted that this work "Complied with Robinson Helicopter Company SB-78B, using Robinson Helicopter Kit KI-196-2, IAW kit instruction KI-196-2, Revision "B" dated 10 Jan 2011. Revised Weight and Balance."

METEOROLOGICAL INFORMATION

An NTSB Meteorological Specialist reported that a review of the available weather in the area of where the accident occurred, included the following:

The National Weather Surface (NWS) Surface Analysis Chart for 1200 MDT depicted that a low pressure center was located at the central portion of Montana's border with Canada. A stationary front extended south-southeastward from the low pressure center into north-central Colorado. Another low pressure center was identified along the eastern portion of the Washington/Oregon border.

Many station models in the accident region depicted clear skies, with winds across the region generally 10 knots or less, with direction variable. Temperatures near the accident site were from the mid-70 degrees F to the mid-80 degrees F, with dew points ranging from about 30 degrees F to 60 degrees F.

A composite radar imagery mosaic at 1300 MDT of the accident region from the National Severe Storms Laboratory's National Mosaic and Q2 System did not identify any areas of reflectivity near the accident site.

An Automated Surface Observing System station (ASOS) named KMLP, was located near the Mullan Pass VOR in Mullan Pass, Idaho, about 8 nautical miles (nm) to the southwest of the accident site at an elevation of about 6,000 feet mean sea level (msl). At 1253 MDT, KMLP reported wind variable at 4 knots, visibility of 10 miles or greater, clear skies, temperature 19 degrees C, dew point 2 degrees C, and an altimeter setting of 30.17 inches of mercury.

U.S. Bureau of Land Management/USDA Forest Service Remote Automated Weather System (RAWS) station THAM8, was located about 10 miles to the east-northeast of the accident site at an elevation of about 2,426 feet msl. At 1302, THAM8 reported a temperature of 88 degrees F, a dew point temperature of 47.9 degrees F, relative humidity of 17 percent, and wind from 317 degrees at 7.8 knots with gusts to 17.4 knots. Feedback from the NWS Office in Missoula, Montana, regarding the THAM8 revealed that there was no reason to question wind speeds reported at 1302, and that they appeared to be consistent with the increasing westerly winds reported on the day of the accident at similarly sited (valley) stations.

The NTSB Specialist reported that a Weather Research and Forecasting Model (WRF) simulation was run to estimate wind conditions in the area of the accident site at 1300. WRF simulations of the wind identified sustained wind magnitudes of generally between 2-16 knots through the region, with the wind being from nearly the southwest at the accident site. Wind gust simulations yielded a maximum gust magnitude of close to 20 knots near the accident site.

An Area Forecast Discussion was issued at 0930 MDT by the NWS Forecast Office in Missoula for an area that included the accident location. In part, the discussion revealed that a trough moving through British Columbia would flatten the ridge in Idaho and western Montana, with an increase in winds expected during the afternoon as a westerly pressure gradient developed, with afternoon winds approaching 25 knots at times.

A Red Flag Warning was issued at 0402 by the NWS Forecast Office in Missoula for an area east of the accident location effective at 1200. The warning message advised of west winds of 15 to 20 miles-per-hour (mph) with gusts to 30 mph. The warning indicated that winds would begin to increase around mid-day, and peak in the late afternoon/early evening.

The accident pilot did not receive a DUAT, DUATS or Lockheed Martin Flight Services telephone weather briefing prior to the accident flight. It is not known if the pilot received preflight weather information from another source.

(Refer to the NTSB Group Chairman's Factual Meteorology Report, which is located in the docket for this report.)

WRECKAGE AND IMPACT INFORMATION

On July 28, 2013, representatives from the NTSB, the FAA, Robinson Helicopters, and Lycoming Motors examined the helicopter at the site of the accident. The examination revealed that the helicopter had impacted heavily forested terrain in a steep nose low, right bank attitude, at an elevation of 2,915 feet msl, and subsequently came to rest on its right side, on a measured magnetic heading of 178 degrees. The impact heading could not be determined. All components necessary for flight were accounted for at the accident site. The helicopter was recovered to a secured location for further examination.

On July 30, 2013, under the supervision of the IIC, an examination of the engine and airframe was conducted at the facilities of a local salvage company located in Belgrade, Montana. The results of the examination failed to reveal any anomalies, which would have precluded normal operation with the helicopter. (Refer to the Summary of Aircraft Examination report, which is located in the docket for this accident.)

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy of the pilot was performed at the Montana Division of Forensic Science, Missoula, Montana, on July 29, 2013. The cause of death was listed as "blunt force injuries."

Toxicological testing on the pilot was performed by the FAA Civil Aeromedical Institute's (CAMI) Forensic Toxicology and Accident Research Center at Oklahoma City, Oklahoma. The toxicological tests were negative for alcohol and drugs.

TESTS AND RESEARCH

Examination of Fuel Tanks

On August 29, 2013, under the supervision of an NTSB accident investigator, both the main and auxiliary fuel tanks, along with the instrument cluster, underwent functional testing at the facilities of Robinson Helicopter Company, Torrance, California. The results of the examination revealed the following:

Main Fuel Tank

The main fuel tank, which held a total of 30.5 US gallons, was visually examined. The aluminum skins were dented and/or creased, and the mounting holes were torn away at the edges. Portions of the mounting brackets remained attached to the tank. The tank was temporarily fitted to an exemplar airframe, ensuring proper angles. The instrument cluster was wired to the fuel quantity sending unit, and a warning light was wired to the Low Fuel Warning (LFW) sending unit. With power applied, the Main Fuel Tank Operating Indicator (MFI) read EMPTY, and the LFW light illuminated. Subsequent to 30 gallons of water poured into the tank, the MFI read FULL. When 9.5 gallons was drained, the MFI continued to read FULL. A light tap on the tank resulted in the MFI dropping to just below the 3/4 mark. When the MFI was observed at the 1/2 mark, 14.34 gallons of fuel had been drained, 14.55 gallons remained. When the MFI was at the 1/4 mark, 21.28 gallons had been drained, leaving 7.61 gallons remaining. After draining 24.46 gallons, the LFW light illuminated; 4.43 gallons of fuel remained. When the MFI was at the EMPTY mark and the flow of water stopped, 28.89 gallons had been drained, leaving about 1.11 gallons of unusable liquid in the tank.

Auxiliary Fuel Tank

A visual inspection of the tank, which had a capacity of 17.2 US gallons, revealed that the aluminum skins were dented, which reduced the capacity of the tank, and the mounting holes were torn away at the edges. The tank was temporarily fitted to an exemplar airframe, which insured proper angles. The instrument cluster was wired to a power source and the sending unit. When power was applied, the Auxiliary Fuel Tank Operating Indicator (AFI) read empty. Approximately 17 gallons of water was poured into the tank; the AFI needle read FULL. When the AFI was at the 1/2 mark, 8.80 gallons had been drained, with 8.2 gallons remaining. When the AFI was at the 1/4 mark, 12.91 gallons had been drained, with 4.09 gallons remaining. When the AFI was observed at the EMPTY mark and the flow of water halted, 17 gallons had been drained.

Both fuel quantity sending units, the Low Fuel Sending unit, and both indicators were observed to have functioned within factory specifications.

ADDITIONAL INFORMATION

The FAA Rotorcraft Flying Handbook, publication FAA-H-8030-21, Unanticipated Yaw/Loss of Tail Rotor Effectiveness (LTS), states in part that unanticipated yaw is the occurrence of an uncommanded yaw rate that does not subside of its own accord and, which, if not corrected, can result in the loss of helicopter control. This uncommanded yaw rate is referred to as a loss of tail rotor effectiveness (LTE) and occurs to the right in helicopters with counter-rotating main rotor and to the left in helicopters with a clockwise main rotor rotation. LTE is not related to an equipment or maintenance malfunction and may occur in all single-rotor helicopters at airspeeds less than 30 knots. It is the result of the tail rotor not providing adequate thrust to maintain directional control. The required tail rotor thrust is modified by the effects of the wind. The wind can cause an uncommanded yaw by changing tail rotor effective thrust.

FAA Advisory Circular (AC) 90-95, Unanticipated Right Yaw in Helicopters, dated February 26, 1995 states that the loss of tail rotor effectiveness (LTE) is a critical, low-speed aerodynamic flight characteristic which could result in an uncommanded rapid yaw rate which does not subside of its own accord and, if not corrected, could result in the loss of aircraft control. It also states, "LTE is not related to a maintenance malfunction and may occur in varying degrees in all single main rotor helicopters at airspeeds less than 30 knots."

Paragraph 6 of the AC covered conditions under which LTE may occur. It states:

"Any maneuver which requires the pilot to operate in a high-power, low-airspeed environment with a left crosswind or tailwind creates an environment where unanticipated right yaw may occur."

Paragraph 8 of the AC states:

"OTHER FACTORS...Low Indicated Airspeed. At airspeeds below translational lift, the tail rotor is required to produce nearly 100 percent of t

NTSB Probable Cause

The pilot's failure to maintain helicopter control while operating in conditions conducive to a loss of tail rotor effectiveness.