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NTSB Final Report: Orlando, FL

 

Location:

Orlando, FL

Accident Number:

ERA17LA163

Date & Time:

04/20/20171030 EDT

Registration:

N899GB

Aircraft:

ROBINSON R44

Aircraft Damage:

Substantial

Defining Event:

 

Injuries:

3 None

Flight Conducted Under:

Part 91: General Aviation - Executive/Corporate - Sightseeing

Analysis
The commercial pilot was conducting a local sightseeing flight in a helicopter with two passengers onboard. He reported that, while he was flying southbound and descending from 1,000 to 600 ft, he heard a "pop" sound and noted a corresponding right yaw, followed by vibration and engine roughness. The pilot looked at the instruments, and the main rotor tachometer was indicating that the rpm had dropped to "0" and that the engine tachometer was indicating between 60% and 70%. The pilot immediately initiated an autorotation to a median, and the helicopter landed hard. The helicopter began rolling forward, and in response, the pilot applied aft cyclic control input, which was contrary to the instructions in the Pilot's Operating Handbook, which contained a caution in the emergency procedures section related to power failures that stated to "not apply aft cyclic during touchdown…to prevent possible blade strike to the" tailboom. The pilot's improper control input resulted in the main rotor blades contacting and substantially damaging the tailboom.

Postaccident examination of the engine and the tail rotor drive system revealed no evidence of any preimpact mechanical failures or malfunctions that would have precluded normal operation. The engine was test-run, and it started and operated normally. One of the two main rotor tachometer indication system magnet assemblies was separated and not recovered. According to helicopter manufacturer personnel, with only one magnet assembly installed, the main rotor tachometer rpm would indicate about 50% of the actual rotor rpm. Therefore, the main rotor tachometer rpm indication was likely erroneous due to the separation of a magnet assembly from the rotor rpm sensor. The pilot's perception that the main rotor tachometer had decreased to "0" was likely in response to his seeing the needle near the lowest number on the scale. The reason for one of the magnet assemblies' separation could not be determined because it was not located.

Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:

A partial failure of the helicopter's engine tachometer due to the separation of one of the magnet assemblies and engine roughness, which precipitated the pilot's initiation of an off-airport autorotation, during which he applied improper aft cyclic flight control input, which was contrary to the Pilot's Operating Handbook. The reason for the reported engine roughness could not be determined during postaccident examination and engine test-runs.

Findings

Aircraft

Indep instrument (clock, etc) - Failure (Cause)

Personnel issues

Use of equip/system - Pilot (Factor)

Use of policy/procedure - Pilot of other aircraft (Factor)


Factual Information
On April 20, 2017, about 1030 eastern daylight time, a Robinson R44 II, N899GB, was substantially damaged during an autorotative landing near Orlando, Florida. The commercial pilot and two passengers were not injured. Visual meteorological conditions prevailed at the time, and no flight plan was filed for the local flight that originated about 5 minutes earlier from Air Orlando Heliport (2FD7), Orlando, Florida. The revenue sightseeing flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91.

During the 1st flight of the day while returning to 2FD7, the pilot stated that he was flying southbound and descending out of 1,000 feet, when at 600 feet, he heard and felt a loud "pop" that was accompanied by a yaw to the right, shaking and vibration, with engine roughness. At that time the rotor tachometer had, "dropped to zero", while the engine tachometer was "at about 60-70%." He immediately entered an autorotative descent to a median between two roads, but did not recall his airspeed during the maneuver, and landed, "…a little hard…." After touchdown the helicopter began to roll forward, which he attempted to correct with aft cyclic input. Once the helicopter was stable on the ground, he secured the engine, and then evacuated the passengers after the main rotor had stopped.

Postaccident examination of the helicopter revealed the aft section of the tailboom was partially detached from the helicopter, and the leading edge of the main rotor blades exhibited slight damage. In the area of the tailboom separation point, the tail rotor drive shaft was fractured and the tail rotor push-pull tube assembly was deformed. Further examination of the tailboom revealed the arm associated with the damper assembly was bent about 90° and fractured. The damper remained connected to the support which was torn and deformed. No deformation was noted internally to structural members adjacent to the damper area. No other damage to the tail rotor drive system was noted. Examination of the engine compartment revealed one magnet assembly part number (P/N) B570-1 associated with the main rotor tachometer indicating system was separated from the Yoke Assembly, P/N C908-1, and was not recovered. The other magnet assembly remained secured to the yoke assembly. The yoke assembly was not damaged, but there was evidence of slight damage to 1 sender assembly, consistent with the magnet assembly separation. The lowest numeric marking on the dual tachometer associated with the main rotor is 50, with 2 graduated lines beneath.

The engine was removed from the helicopter and taken to a repair facility where it was examined and then placed on a test stand and operated twice. The first and second engine runs lasted 15 and 25 minutes, respectively with no discrepancies noted. The engine was operated a third time, and about 10 minutes into the engine run, the left magneto failed the magneto check. The defective magneto was removed, and a replacement magneto was installed. The engine was started and operated normally.

Robinson Helicopter Company personnel reported there have been instances of a magnet separating from a magnet assembly which prompted issuance of Service Bulletin (SB) 86; however, they report there have not been any previous instances of the magnet assembly separating from the yoke assembly.

According to the Pilot's Operating Handbook, a caution in the emergency procedures section related to power failure specifies to not apply aft cyclic during touchdown or ground slide to prevent possible blade strike to the tailcone.

According to the maintenance manual, the sensor for the main rotor tachometer is an electronic Hall Effect device which senses passage of two magnets attached to main rotor gearbox input yoke assembly. Robinson personnel reported that with only 1 magnet installed, the main rotor tachometer rpm would indicate about 50% of the actual rotor rpm.


 


Administrative Information

Investigator In Charge (IIC):

Timothy W Monville

Adopted Date:

06/25/2019

Additional Participating Persons:

Cheryl King; FAA/FSDO; Orlando, FL

Publish Date:

06/25/2019

Note:

The NTSB did not travel to the scene of this accident.

Investigation Docket:

http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=95040

History of Flight

Enroute-descent

Miscellaneous/other

Emergency descent

Off-field or emergency landing

Landing-flare/touchdown

Hard landing

 

 

Pilot Information

Certificate:

Commercial

Age:

36, Male

Airplane Rating(s):

None

Seat Occupied:

Front

Other Aircraft Rating(s):

Helicopter

Restraint Used:

Unknown

Instrument Rating(s):

None

Second Pilot Present:

No

Instructor Rating(s):

None

Toxicology Performed:

No

Medical Certification:

Class 2 With Waivers/Limitations

Last FAA Medical Exam:

05/04/2016

Occupational Pilot:

Yes

Last Flight Review or Equivalent:

03/30/2016

Flight Time:

1315 hours (Total, all aircraft), 1093 hours (Total, this make and model), 1243 hours (Pilot In Command, all aircraft), 202 hours (Last 90 days, all aircraft), 109 hours (Last 30 days, all aircraft), 6 hours (Last 24 hours, all aircraft)

 

 

Aircraft and Owner/Operator Information

Aircraft Make:

ROBINSON

Registration:

N899GB

Model/Series:

R44 II

Aircraft Category:

Helicopter

Year of Manufacture:

2006

Amateur Built:

No

Airworthiness Certificate:

Normal

Serial Number:

11190

Landing Gear Type:

Skid;

Seats:

4

Date/Type of Last Inspection:

03/17/2017, 100 Hour

Certified Max Gross Wt.:

2500 lbs

Time Since Last Inspection:

40 Hours

Engines:

1 Reciprocating

Airframe Total Time:

1142.9 Hours at time of accident

Engine Manufacturer:

LYCOMING

ELT:

Not installed

Engine Model/Series:

IO-540-AE1A5

Registered Owner:

AERO SPECIALTY FINANCE LLC

Rated Power:

260 hp

Operator:

Air Florida Helicopter Charters, Inc.

Operating Certificate(s) Held:

None

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Visual Conditions

Condition of Light:

Day

Observation Facility, Elevation:

MCO, 96 ft msl

Distance from Accident Site:

8 Nautical Miles

Observation Time:

1053 EDT

Direction from Accident Site:

50°

Lowest Cloud Condition:

Scattered / 3700 ft agl

Visibility

10 Miles

Lowest Ceiling:

Broken / 30000 ft agl

Visibility (RVR):

 

Wind Speed/Gusts:

10 knots / 17 knots

Turbulence Type Forecast/Actual:

None

Wind Direction:

100°

Turbulence Severity Forecast/Actual:

Unknown

Altimeter Setting:

30.17 inches Hg

Temperature/Dew Point:

27°C / 16°C

Precipitation and Obscuration:

No Obscuration; No Precipitation

Departure Point:

Orlando, FL (2DF7)

Type of Flight Plan Filed:

None

Destination:

Orlando, FL (2DF7)

Type of Clearance:

None

Departure Time:

1025 EDT

Type of Airspace:

Class G

 

 

Wreckage and Impact Information

Crew Injuries:

1 None

Aircraft Damage:

Substantial

Passenger Injuries:

2 None

Aircraft Fire:

None

Ground Injuries:

N/A

Aircraft Explosion:

None

Total Injuries:

3 None

Latitude, Longitude:

28.450000, -81.470556 (est)

 





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Created 140 days ago
by jhadmin

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