Accident Details
Probable Cause and Findings
The failure of company maintenance personnel to secure the push/pull tube to the left lug of the non-rotating portion of the swashplate assembly following maintenance, and the inability of the pilot to control the helicopter resulting in the in-flight collision with terrain.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On August 2, 2004, about 0936 eastern daylight time, a Robinson R22 Beta helicopter, N2566W, registered to a private individual and leased to Helicenter International Corporation, dba Helicenter International Academy, collided with terrain in Everglades National Park, Miami, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 local, instructional flight from the Kendall-Tamiami Executive Airport, Miami, Florida. The helicopter was destroyed by a postcrash fire and the certified flight instructor (CFI) was fatally injured. The dual student (student) sustained minor injuries. The flight originated about 0925, from the Kendall-Tamiami Executive Airport.
According to a transcription of communications with the Kendall-Tamiami Executive Airport (KTMB) Air Traffic Control Tower (ATCT), an occupant of the helicopter established initial contacted with the facility at 0925:10, which the controller acknowledged. At 0925:17, an occupant then requested "...spot two request whiskey departure." At 0925:20, the controller responded "november six six whiskey proceed as requested on whiskey departure use caution." That transmission was acknowledged by an occupant who used the last 3 of the registration of the helicopter; there were no further recorded transmissions received by the KTMB ATCT from the accident helicopter.
The student reported that the purpose of the flight was for him to become familiar with rotorcraft operations; the flight duration was intended to be approximately 20-30 minutes. Before departure, both fuel tanks were topped off. The CFI demonstrated to him and several other students the preflight inspection of the helicopter step by step using the checklist, which included checking the flight controls. While following the checklist, the CFI pointed out the component on the helicopter. With respect to the hardware that secures the push/pull tubes to the swashplate assembly, the student later reported to the NTSB that the CFI stepped on the frame of the helicopter and visually inspected the hardware and mentioned that it needed to be tight, secure, and safetied. The student did not report any discrepancies that were found during the preflight inspection. The engine was started, and the flight departed to the west climbing to 500 feet mean sea level (msl). The flight continued westbound and after passing a radar ball located near "QEEZY" which is a fan marker and non-directional beacon, he noted the helicopter was descending and brought that to the CFI's attention who reported he was intentionally descending to 300 feet. While flying at that altitude at 60 knots, the CFI maneuvered the helicopter left and right then while flying northbound straight and level at 300 feet while the student was looking outside, the helicopter banked left and nose down, "...making it impossible for the instructor to control the aircraft...." The CFI responded several times with, "what happened", and tried to recover. The student noted that the CFI moved the cyclic control in an attempt to recover but due to his (student's) confusion, could not recall what position he was moving it to. The CFI was unable to recover from the attitude and when the helicopter was close to the ground, he (student) closed his eyes and perceived the helicopter impacted the ground first with the left skid. He wasn't sure of the airspeed and couldn't recall the impact. Following the impact which was later determined to have occurred approximately 11 minutes after the flight departed, the student released his restraint, exited the helicopter, then heard the CFI ask for assistance. He went back to the helicopter, released the CFI's restraint, and pulled him from the wreckage. He then called 911 using the CFI's cell phone; several calls were disconnected; however, rescue units arrived and both were transported to a hospital. The student further reported he did not notice any change in engine sound from the time of takeoff to the moment the helicopter banked left and nose down.
Review of radar data revealed that after takeoff, the flight proceeded in a westerly direction, climbed to 500 feet, turned to a southwesterly direction and descended initially to approximately 400 feet then to 100 feet. A gap in radar returns was noted south of the accident site but the location and time of the subsequent returns were consistent with the performance capability of the helicopter. The radar data further indicates that the helicopter was noted to maneuver for approximately 45 seconds at 100 feet south-southwest of the accident site. The last radar return associated with the helicopter occurred at 0936:09.
PERSONNEL INFORMATION
A review of CFI's Federal Aviation Administration (FAA) airman file pertaining to rotorcraft certificates and ratings revealed he was issued a private pilot certificate with a rotorcraft helicopter rating on January 15, 1982. He obtained a commercial pilot certificate with rotorcraft helicopter rating on March 22, 1982, and on October 30, 1985, obtained his initial flight instructor certificate with rotorcraft-helicopter rating. Since the initial CFI certificate was issued, he has continuously renewed it, with the last renewal occurring on June 3, 2003. He added an airplane single engine rating to his CFI certificate on August 5, 2003, which qualified as a flight review in accordance with 14 CFR Part 61.56. He was the holder of a 2nd class medical certificate issued on April 13, 2004, with the medical restriction, "must wear corrective lenses." He listed a total civilian flight time of 6,300 hours on the application for his last medical certificate. There were no FAA enforcement actions or previous accident/incident records associated with his pilot certificate.
The CFI attended the FAA-Approved Flight Instructor Refresher Clinic at Robinson Helicopter Company, located in Torrance, California, from March 12-15, 2003. The "Instructor/Pilot Evaluation" form dated March 14, 2003, indicates he was rated "above average" in straight autorotations, 180 autorotations, and hovering autorotations. He was also rated "above average" in overall handling and maneuvering with the comment, "smooth & safe." With respect to simulated engine out procedures he was rated "average."
The CFI became employed by Helicenter International Corporation as an independent subcontractor on September 22, 2003. A review of his resume provided by the operator indicates at the time, he had a total rotorcraft flight time of 5,291 hours, of which 5,195 hours were as pilot-in-command. Of the total rotorcraft flight hours, more than 2,000 hours were in Robinson model helicopters. Since employment, the operator reported he had flown a total of 826.9 hours, of which 644.7 hours were in the Robinson R22 model helicopter.
A review of copies of the CFI's pilot logbooks that begin with an entry dated November 26, 2003, to the last entry dated July 31, 2004, revealed he logged a total rotorcraft helicopter time of approximately 6,271 hours, and 5,739.0 hours as a flight instructor. He also logged approximately 6,152 hours as pilot-in-command.
Prior to the accident flight, the student seated in the right seat did not possess any pilot certificate, and had never been in a helicopter. He is a 2nd Lieutenant in the Dominican Republic Army, and was at Helicenter International Corporation to receive flight training.
AIRCRAFT INFORMATION
The helicopter was manufactured in 1986 by Robinson Helicopter Company as a R22 Beta, and designated serial number 0616. A standard airworthiness certificate in the normal category was issued on December 18, 1986.
The helicopter was purchased by the current owner on August 22, 2003, and leased to Helicenter International Corporation for a 1-year period beginning on August 12, 2003. An individual from Helicenter International Corporation flew the helicopter to their facility, and during a review of the maintenance records noted items that needed correction. The helicopter was then flown to a maintenance facility located in Fort Lauderdale, Florida, where extensive maintenance took place between October 2003, and February 2004. The maintenance included in part removal and reinstallation of the swashplate. Additionally, tracking and balancing of the main rotor blades was accomplished. The corrective action associated with the installation of the push/pull tubes to the swashplate assembly does not indicate new metal self locking nuts or palnuts were used. The helicopter was approved for return to service on February 3, 2004, and returned to the operator.
The Director of Maintenance for the facility that performed the extensive maintenance reported metal self locking nuts are reused if there is resistance during installation, and would be replaced if there is no resistance; the palnut is always replaced with a new one. At that time of the extensive maintenance, the helicopter had a total time of 2,810.8 hours.
The first 100-Hour inspection signed off by a mechanic with Helicopter International Corporation occurred on March 6, 2004. At that time, the helicopter total time was 2,910.8 hours. The helicopter then underwent two 100-Hour inspections performed by the same individual with Helicopter International Corporation. The last 100-Hour inspection which was also performed by personnel from Helicopter International Corporation, was signed off on April 22, 2004; the helicopter total time at that time was reported to be 3,110.8 hours. The helicopter had accumulated approximately 69 hours since the last 100-Hour inspection at the time of the accident. An entry in the maintenance records dated July 29, 2004, which was signed off by the director of maintenance (DOM) for the operator indicated, "...performed tracking and balancing to main rotor blades. Adjust to 0.10 IPS 12:00 o'clock [in accordance with] Chadwick 2000 reading. Work done [in accordance ...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# MIA04FA115