Aviation Accident Summaries

Aviation Accident Summary ERA09FA497

Jackson, MS, USA

Aircraft #1

N33PX

ROBINSON R44

Analysis

The Federal Aviation Administration (FAA) Flight Standards District Office (FSDO) inspector arranged to conduct a flight as pilot in command (PIC) of the helicopter as part of his participation in the FAA's internal flight currency and proficiency program, informally referred to as the "4040 program." The PIC and the FSDO manager agreed that the flight could also serve as a familiarization flight for a newly-hired, pilot-rated FSDO inspector. Shortly after takeoff, the PIC informed an air traffic controller that he had changed his plans, and he was cleared as requested to a nearby airport. The helicopter was observed to hover, land, and lift off for a circuit of the traffic pattern. It landed again, and began a second circuit. While on the downwind leg, the helicopter entered a descent that had a rate of approximately 2,400 feet per minute and subsequently impacted trees, terrain, and a house in a residential neighborhood. The PIC held multiple certificates and ratings, and the vast majority of his experience was in fixed-wing aircraft. He had about 140 hours of helicopter experience, and about 60 hours in Robinson helicopters. The second pilot held multiple certificates and ratings, and had over 4,000 hours of helicopter flight experience. His most recent helicopter piloting experience was about 9 years prior to the accident. Due to certain flight and operational characteristics, the FAA mandated Robinson-specific training for pilots, via Special Federal Aviation Regulation (SFAR) 73. The accident flight was the second pilot's first flight in a Robinson helicopter, and no records of any Robinson-specific training or endorsements, including those required by SFAR 73, were located for him. The final trajectory of the helicopter was consistent with a main rotor stall that developed when the helicopter was on the downwind leg. Post-accident examination and testing of the helicopter and components, including a full-power run of the engine, did not reveal any evidence of pre-impact failures or malfunctions. The helicopter manufacturer published notices for pilots that stated that main rotor stall due to low rotor rpm could occur rapidly, and at any airspeed, and could make "recovery virtually impossible." Other guidance noted that appropriate pilot response to an impending stall in an airplane was the opposite of the appropriate response for the helicopter, and could result in, or aggravate, rotor stall. The reason for the decay of the main rotor rpm could not be definitively determined.

Factual Information

HISTORY OF FLIGHT On September 1, 2009, about 1425 central daylight time, a Robinson R44 Raven I helicopter, N33PX, was substantially damaged when it struck trees, terrain and a house near Jackson/Hawkins Field (HKS), Jackson, Mississippi. The pilot in command (PIC) was seriously injured, and the second pilot was fatally injured. The combination currency flight for the PIC and familiarization flight for the second pilot was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed. According to recorded air traffic control (ATC) voice and radar information, the helicopter first contacted Jackson Approach about 1404, when it was still on the ground at Flowood Industrial STOLport (MS90), Flowood, Mississippi. The approach controller instructed the helicopter to contact approach once it was airborne, and assigned it a discrete transponder code. Shortly thereafter, the helicopter reported that it was airborne and northbound. The helicopter target was acquired by the ATC radar facility located at Jackson-Evers Airport (JAN), Jackson, Mississippi. The first radar return associated with the helicopter appeared at 1405:55, when the helicopter was at a radar-indicated altitude of 300 feet above mean seal level (msl), and 2,400 feet north of MS90. Shortly after that, the helicopter contacted approach control again, advised that there was a change of plans, and requested to proceed to HKS for practice at "Area 1." "Area 1" was the designation for a helicopter practice area at HKS, which was located in the grassy area to the east of runway 16/34, and to the north of runway 11/29. The radar data ground track showed the helicopter turn from a northerly heading to a south-southwesterly heading, at an altitude of 700 feet msl. When the helicopter was approximately 4 miles southeast of HKS, Jackson Approach informed the helicopter that radar services were terminated, and instructed it to contact HKS air traffic control tower (ATCT). The helicopter contacted HKS ATCT, requested approval for hover practice, and the request was approved by HKS ATCT. The radar ground track showed that the helicopter turned to the northwest and headed for the southeast corner of Area 1. As the helicopter descended towards HKS, it temporarily disappeared below Jackson Approach radar coverage; the last return acquired during this approach was at 1411:20, and an altitude of 400 feet. According to the ATCT local controller, the helicopter practiced hovering for a short time, and then landed in Area 1. The helicopter then requested "right closed traffic" for Area 1, and was cleared "for the option" by the ATCT controller. The helicopter's radar return was re-acquired at 1420:22, at an altitude of 500 feet. The helicopter flew the downwind leg at an altitude of 900 feet msl, and a lateral offset of approximately 3,800 feet to the east of Area 1. The helicopter made another approach to Area 1, and the last radar return for this approach was acquired at 1422:53, with an indicated altitude of 400 feet msl. The local controller reported that the helicopter conducted a "touch and go," and began another circuit of the traffic pattern. The helicopter re-appeared on radar at 1424:08, at an altitude of 600 feet. Radar returns indicated that the helicopter made an immediate right turn for a second downwind leg that was offset approximately 1,700 feet east of Area 1. The local controller again cleared the helicopter for the option. The local controller then communicated with an aircraft waiting to depart runway 34, and when she tried to visually locate the helicopter to ensure traffic separation, she did not see it. She made several calls to the helicopter, but it did not respond. The last three radar returns from the helicopter were at 1424:37.220, 1424:41.840 and 1424:46.550. The radar return altitudes were 1,000, 800, and 600 feet, respectively. The last recorded radar return was located 700 feet northwest of the accident site. Two pilots from the Mississippi Department of Public Safety (DPS) were standing outside a hangar on the west side of HKS, and one of them saw the helicopter make an approach to Area 1. He then watched it taxi to the north, taxi back to the south, and then climb out to the north for a circuit of the traffic pattern. When the helicopter was on the downwind leg approximately due east of his position, the DPS pilot saw it begin "falling rapidly," and he pointed it out to the other DPS pilot. The other DPS pilot, who had flown Robinson helicopters, initially responded that the high descent rate was not unusual for Robinson helicopters, but as he watched it, he agreed that the descent rate did seem high. After the helicopter had descended a few hundred feet, the two DPS pilots observed it enter a right bank of about 15 degrees. Both DPS pilots stated that prior to the bank, the helicopter's pitch attitude was approximately level. Both pilots watched the helicopter disappear behind the treeline to the east. They realized that the helicopter had likely crashed, and in response, began preparing their helicopter for flight. Another witness was walking down his driveway to meet the postman, when his attention was drawn to the helicopter by its noise, which he described as repeated "clup" sounds. The witness saw the helicopter descend rapidly towards him from the north, strike a tree, and enter "into a spin." It then struck a second tree and "fell into the house," disappearing from view behind the house across the street from the witness. The witness crossed the street and went around the right (east) side of the house to the helicopter, where he saw a person in the left front seat. The postman went around the west side of the house to the helicopter, and noticed that there was another person in the helicopter as well. Both witnesses used their mobile telephones to summon assistance. PERSONNEL INFORMATION Both occupants of the helicopter were inspectors from the Jackson, Mississippi, FAA Flight Standards District Office (FSDO). The PIC was seated in the right seat, and the second pilot was seated in the left seat for the flight. Pilot in Command (PIC) According to FAA information, as of the date of the accident, the PIC was employed by the FAA for about 3 years. He held multiple certificates and ratings, including commercial pilot and flight instructor certificates with rotorcraft-helicopter ratings. According to information compiled from the PIC's personal logbook and FAA records, as of the date of the accident, he had approximately 22,000 total hours of flight experience. This included approximately 221 total hours of helicopter experience, which included approximately 6 hours of R22 experience, and 81 hours of R44 experience. The records indicated that 27.9 of those hours were accrued without a check- or safety-pilot on board. The balance of his helicopter experience was primarily in Bell 206 and Schweizer 300 series helicopters. His most recent FAA second-class medical certificate was issued in April 2009. The PIC's logbook indicated that his initial helicopter flight occurred in April, 2006, in an R44. His first recorded solo flight in a helicopter was conducted on November 7, 2007, in a Schweizer 300 helicopter. The PIC successfully completed his flight test for a commercial helicopter certificate on November 15, 2007. At that time he had 99 total hours of helicopter flight experience, including 39 hours of dual, and no solo, flight experience in Robinson helicopters. On January 22, 2008 the PIC successfully completed his flight test for a helicopter instructor rating. At that time he had 138 total hours of helicopter flight experience, including 60 hours of dual, and no solo, flight experience in Robinson helicopters. Both the commercial- and instructor- flight tests were conducted in a Schweizer 300 helicopter. The most recent R44 entries in the PIC's logbook were dated February 5 and February 12, 2009, and both indicated that the flights were conducted in the accident helicopter. The February 5 flight was also the PIC's most recent flight review. According to the Jackson FSDO computerized records of the PIC's flight history, excluding the accident flight, his most recent flight experience in an R44 was on July 23, 2009, and his most recent flight experience in a helicopter was in a Bell 206, which occurred on July 30, 2009. A logbook endorsement dated February 2007 stated that the PIC had completed the awareness training in accordance with paragraphs "(a)(3) under (b)(5)" of Section 2 of Special Federal Aviation Regulation (SFAR) No. 73. A logbook entry dated April 23, 2008 indicated that the PIC completed the Robinson Helicopter Company (RHC) Pilot Safety Course, and this was confirmed by a representative of RHC. The logbook also contained two endorsements dated February 5, 2009. One stated that the PIC met the experience, flight training, and demonstrated ability requirements to "provide instruction on the general subject areas of Section2(a)(3) and the flight training identified in Section 2(b)(5)(iii) in a Robinson R-44 helicopter." That endorsement did not explicitly specify that the paragraph references were from SFAR73. The endorsement was a component of the requirements to enable the PIC to provide flight instruction in the R44. The other logbook endorsement certified that the PIC had "satisfactorily completed the Flight Review required by FAR 61.56 and SFAR73 Section2(a)(3) and the flight training identified in Section 2(c)(2) and (3) in an R44." Both endorsements were signed by the FAA Safety Team (FAAST) team manager, who was a colleague at the Jackson FSDO. Despite the logbook endorsements and FAA certificates which indicated that the PIC was qualified to provide flight instruction in Robinson helicopters, no evidence that the PIC ever provided flight instruction in a Robinson helicopter was able to be located. Subsequent to the accident, the PIC could not recall any specifics regarding the conduct or events of the flight. Second Pilot According to information provided by the FAA, as of the date of the accident, the second pilot was employed by the FAA for about 1 month. The second pilot held multiple certificates and ratings, including airline transport pilot and flight instructor certificates, each with a rotorcraft-helicopter rating. His most recent FAA first-class medical certificate was issued in October 2008. According to information that the second pilot provided on his employment application to the FAA, he had approximately 16,800 total hours of flight experience, including approximately 4,250 hours in helicopters. The second pilot's application stated that he had "over 3,000" hours of flight experience as pilot in command, including "1,000+" hours as flight instructor, and "500 to 1,000" hours as second in command, in US Army military helicopters. The cited helicopter type was the "BH 205," also referred to as the Bell UH-1H "Huey," which was a turbine-powered helicopter with a maximum gross weight of 10,000 pounds. His application also cited "1- 99" hours in "Bell Single Piston-powered" and "100 - 499" hours in "Hughes Single Piston-powered" helicopters. The investigation was unable to locate or review the second pilot's flight logbooks that documented his helicopter experience. The second pilot's most recent helicopter piloting experience was in 2000. The accident flight was his first flight in a Robinson helicopter. No records of any Robinson-specific training or endorsements, including those required by SFAR73, were located. No definitive evidence regarding whether the second pilot did or did not manipulate the controls was discovered. AIRCRAFT INFORMATION According to the manufacturer and the FAA, the helicopter was manufactured and registered to the owner in 2007. It was equipped with a Lycoming O-540 series piston engine. Power transfer from the engine to the rotor system was accomplished via four "vee-belts" that linked the engine (lower) and rotor system (upper) sheaves. The upper sheave was equipped with an overrunning clutch which permitted the sheave to rotate the main and tail rotor shafts, but prevented the reverse. An electric actuator maintained proper vee-belt tension by moving the upper sheave to change its distance from the lower sheave. The actuator was enabled via a clutch switch in the cockpit. The fuel system was gravity-flow. Fuel capacity was 30.6 gallons in the main tank, and 18.3 gallons in the auxiliary tank. The maximum certificated gross weight was 2,400 pounds. The collective control was equipped with a "twist grip" throttle, and an electronic governor system was installed to maintain engine rpm by adjusting the throttle when the collective control was moved. The Pilots Operating Handbook (POH) stated that the governor was "easily overridden by the pilot," was only active above 80 per cent engine rpm, and could be switched on or off via a toggle switch on the end of the right-seat collective control. The POH stated that the governor was designed "to assist the pilot" in controlling engine rpm in the normal operating range, but that it "may not prevent over or under-speed conditions generated by aggressive flight maneuvers." The helicopter was equipped with a single aural warning horn system; the system was designed so that the horn would sound whenever the main rotor rpm decreased to a value of 97 percent or less. The helicopter was also equipped with a low rotor rpm cockpit warning light designed to illuminate at the same rotor rpm threshold. The POH "Starting Engine and Run-Up" checklist in the "Normal Procedures" section required the pilot to verify the proper activation of the warning horn and light prior to every flight. The horn and the light each received their signal on a shared circuit from the Low RPM Warning Unit. The Warning Unit received a signal from one of the two Hall Effect transducers on the input (drive) yoke of the main rotor gearbox, and the other transducer provided a signal to the rotor tachometer. According to the owner of the property-management company that the helicopter was registered to, the helicopter was primarily for his personal and business use, but was also rented to FAA inspectors from the Jackson FSDO for inspectors' currency and proficiency flights. No other persons flew the helicopter. The helicopter was based at MS90, and kept in the owner's hangar there. According to the maintenance records, the most recent annual inspection was completed in January 2009. At that time, the airframe and engine had a total time in service of 198 hours. A pocket notebook that was used by FSDO personnel to record flight times was recovered from the helicopter. It indicated that the hour meter on the helicopter registered 236.8 hours at the start of the accident flight. At the accident site, the hour meter was observed to register 237.1 hours. METEOROLOGICAL INFORMATION The 1353 weather observation at HKS included winds from 330 degrees at 8 knots, 10 miles visibility, few clouds at 4,700 feet, temperature 27 degrees C, dew point 14 degrees C, and an altimeter setting of 30.13 inches of mercury. The 1453 HKS observation reported winds from 320 degrees at 6 knots, 10 miles visibility, few clouds at 4,900 feet, temperature 28 degrees C, dew point 15 degrees C, and an altimeter setting of 30.11 inches of mercury. COMMUNICATIONS Recorded ATC communications indicated that the helicopter was in radio communication with Jackson Approach Control over a period of 3 minutes and 35 seconds, and then with the HKS ATCT over a period of 13 minutes and 55 seconds. The helicopter was tracked by ATC radar, albeit discontinuously, for a total duration of 18 minutes and 51 seconds. AIRPORT INFORMATION According to FAA and commercial information, the elevation of HKS was 270 feet msl. The non-federal ATCT was operated and staffed by a private company, Robinson Aviation, Inc (RVA, not affiliated with RHC). A letter of agreement (LOA) between several private and government entities, but not including the FAA, described the "procedures and responsibilities to promote safe and efficient control of helicopters operating at" HKS. The LOA

Probable Cause and Findings

The pilot's failure to maintain adequate main rotor rpm, for undetermined reasons.

 

Source: NTSB Aviation Accident Database

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