Encinitas, CA, USA
N8049V
Robinson R-22 Beta
During a daytime solo cross-country flight the student pilot, en route to his private pilot certification examination, became spatially disoriented and inadvertently descended into the ocean while maneuvering to avoid inclement weather. The student's certified flight instructor (CFI) was not present at the airport on the day of the accident flight. The CFI reported that on the previous day he had authorized his student to fly from San Diego to Long Beach, where the examination was to take place. On the day of the accident the student pilot received a weather briefing about 2 hours prior to his departure. He was advised, in part, that instrument meteorological conditions existed and were forecast along a portion of his planned route of flight, and that the conditions were forecast to improve. Thereafter, the student telephoned his flight instructor and discussed the briefing, but (according to the student's CFI) he did not advise the CFI that the weather conditions were, in certain locations, below the limits established for his flying or that instrument weather conditions existed. Without independently verifying the weather forecast, the CFI authorized the flight, and the student took off at his planned departure time on a northerly course paralleling the coastline. After about 9 minutes of flight, at 1009:03, the student pilot stated to a local air traffic controller "I'm in a little trouble" and "I'm gonna start climbing to get out of clouds." The northbound student pilot commenced a left turn while flying northbound over the ocean. This positioned the helicopter farther off shore. During the turn the student pilot said to the controller, at 1009:45, "I need to get out of the clouds visibility is really bad out here." At 1009:50, the controller said "if you would like to go (inland) to the I-5 (interstate freeway) and follow north that's approved." The pilot responded with his last recorded transmission and stated at 1010:00, "Roger I'm gonna start climbing." Recorded radar indicates that the pilot climbed from 200 to 600 feet, whereupon the radar track ended upon completion of a left 360-degree turn. The helicopter wreckage was located 0.3 miles from its last radar location, and about 0.5 miles offshore. An Federal Aviation Administration (FAA) aviation safety inspector was located near the shoreline. He reported observing fog along the coast and said the visibility was about 1/8-mile. The student's CFI subsequently acknowledged to the Safety Board investigator that he had not independently ascertained the weather, but had relied upon what the student told him in authorizing the flight. The CFI reported that, had he known the actual weather conditions, he would not have authorized the flight. The FAA requires, before a CFI authorizes a student's solo cross-country flight, that the CFI has reviewed the current and forecast weather conditions and has determined that the flight can be completed under visual flight rules.
HISTORY OF FLIGHT On August 25, 2003, about 1010 Pacific daylight time, a Robinson R-22 Beta, N8049V, descended into the Pacific Ocean and sank about 0.7 nautical miles west-southwest of Encinitas, California. The helicopter was destroyed, and the student pilot was fatally injured. Instrument meteorological conditions prevailed in the vicinity of the accident site. A visual flight rules flight plan was filed, and activated, by the pilot. According to the pilot's certified flight instructor (CFI), the purpose of the solo cross-country instructional flight was for the student to fly from San Diego to Long Beach, California. Upon arriving in Long Beach, the student was scheduled for an examination to acquire certification as a private pilot. The student pilot rented the helicopter from Shier Aviation Corporation, which owned and operated it under the provisions of 14 CFR Part 91. The flight originated from the Montgomery Field in San Diego, about 1000. A review of Federal Aviation Administration (FAA) recorded radar data for aircraft departing Montgomery Field about 1000 on a northerly course paralleling the coastline was undertaken. Several tracks were observed. One of the tracks identified by the Civil Air Patrol (CAP) was consistent with the accident helicopter's flight planned northerly course. This track was the only one that terminated in the vicinity of the accident site. Further examination of the radar data indicates that at 1009:14, the accident helicopter was at 400 feet (as indicated by the helicopter's Mode C transponder), and had commenced a left turn. At 1009:32, the track for this helicopter indicated that it had descended to 200 feet. At 1009:46, the helicopter had climbed to 500 feet, and had turned to a southerly course. At 1010:04, the helicopter was at 600 feet on an easterly course. The last recorded position was at 1010:13, and the helicopter was on a north-northeasterly course at 600 feet. This track terminated at 1010:13, with the last radar hit at 600 feet. At the time of the last radar hit, the helicopter had made a left 360-degree turn (in the vicinity of the accident site), and it was about 33 degrees 02.163 minutes north latitude by 117 degrees 17.901 minutes west longitude. About 1 minute before the helicopter commenced the aforementioned left, 360-degree turn, the pilot contacted the Palomar Air Traffic Control Tower. The pilot requested permission to transition through Palomar's airspace in a northerly direction. The Palomar local controller stated "northbound transition approved say altitude." The pilot responded "I'm a little low probably about one hundred feet." At 1009:03, the pilot stated "I'm in a little trouble I'm gonna climb way above these clouds out here." The controller responded to the pilot and twice asked if he needed assistance. At 1009:24, the pilot stated "hang on a sec." At 1009:33, he stated "I'm gonna start climbing to get out of clouds." At 1009:35, the local controller stated "I have no traffic outbound any altitude is fine are you at four hundred feet?" The pilot responded at 1009:45, "affirmative I need to get out of clouds visibility is really bad out here." At 1009:50, the local controller said "if you would like to go (inland) to the I-5 (interstate freeway) and follow north that's approved." The pilot's last transmission was at 1010:00. At this time he stated to the local controller, "roger I'm gonna start climbing." No witnesses were located as having observed the accident. On September 9, 2003, the helicopter and pilot were located about 0.5 miles west of the shoreline, at an approximate depth of 70 feet below sea level. PERSONNEL INFORMATION Student Pilot. The pilot held a combined student pilot and third-class aviation medical certificate. The certificate was issued in September 2002, without limitations. The student's CFI had endorsed the certificate for solo flying R22's, and for solo cross-country flights in Rotorcraft. The CFI also provided all logbook endorsements. A review of the pilot's personal flight record logbook revealed he commenced primary flight training in April 2002. His first flight was in the accident helicopter. Thereafter, the pilot flew R22's (mostly the accident R22) until his last logged flight on August 21, 2003. By the accident date, the pilot had logged 80.6 hours (total time) and 31.4 hours (pilot-in-command time). All of this flight time, with the exception of about 1.5 hours, was acquired flying the R22. The pilot's logbook did not indicate that the student had flown any other make or model of aircraft other than the aforementioned 1.5 hours, which were in a R44 and a Bell 206. The student's primary CFI reported that his student did not have any experience flying under instrument flight conditions. He reported that the FAA does not require instrument flight training in rotorcraft for primary flight students. The National Transportation Safety Board investigator found no evidence in the student's flight training logbook of the student having received any actual or simulated instrument flight training. With the above 1.5-hour exception, all flight training had been in the R22, and the primary student's flight instructor had provided over 90 percent of the instructional lesson. Certified Flight Instructor. The CFI held a commercial pilot certificate with a rotorcraft-helicopter rating. He was also rated to fly single engine airplanes with private pilot privileges. The CFI reported that his total flight time was approximately 2,200 hours. Of this time, he has flown helicopters about 2,000 hours, and airplanes about 200 hours. The CFI reported that he has been a flight instructor for about 4 years. Since June 2000, he has worked as a full-time flight instructor for Corporate Helicopters, a division of Shier Aviation Corporation. The CFI has taught about two dozen students to fly helicopters. All his students have passed their certification flight tests on their first attempt. AIRCRAFT INFORMATION A review of the helicopter's maintenance logbooks revealed that the owner-operator maintained its helicopter on an annual/100-hour inspection program. The last annual and 100-hour inspections were performed on October 30, 2002, and August 5, 2003, respectively. The operator reported that there were no outstanding squawks on the helicopter. By the accident date, the helicopter's total airframe time was approximately 4,103 hours. The engine's total time was about 7,714 hours. The helicopter was certificated for flight under visual meteorological conditions. It was not equipped with an artificial horizon. METEOROLOGICAL INFORMATION At 0753, on August 25, 2003, the accident pilot telephoned the FAA San Diego Automated Flight Service Station (FSS) and requested a standard visual flight rules (VFR) weather briefing for a "student cross-country flight." The pilot stated that he would be flying from Montgomery to the Long Beach Airport on a flight that would take 1:20 hours. Also, he was planning to depart Montgomery about 1000. In pertinent part, the FSS briefer advised the pilot that an AIRMET for occasional IFR conditions existed over sections of the coast. According to the briefer, presently at Montgomery Field (elevation 427 feet mean sea level (msl)) there were scattered clouds at 600 feet above ground level (agl), and the visibility was 6 miles with mist. Farther up the coast, at Palomar (elevation 331 feet msl), there was an overcast ceiling at 400 feet agl. A few miles farther north, at Oceanside (elevation 28 feet msl), an overcast ceiling at 500 feet agl existed. The FSS briefer stated that the weather "should not be a factor" at your proposed 1000 departure time. He stated "they're forecasting ceilings one thousand broken tops two thousand visibilities three to five miles with mist." The pilot responded by stating "okay I should be able to make it up there if I leave about ten o'clock I think I'll be able to dodge the bulk of that ah you know that marine layer type fog up there." In the pilot's flight plan he advised the FSS briefer that he intended to fly at 1,500 feet and "take the coast route and from Montgomery up through Del Mar all the way up the coast en route to Long Beach." The FAA reported finding no evidence that the pilot recontacted FSS personnel to obtain an updated briefing prior to his departure. The closest aviation weather reporting facility to the accident site was located at McClellan-Palomar Airport (CRQ). At 0953, CRQ reported the following weather: Wind variable at 6 knots; few clouds at 800 feet agl; temperature/dew point 21/18 degrees Celsius. About 0730 and 1030, an FAA aviation safety inspector observed the weather conditions over the coast. The inspector reported that, at 0730, he had been standing near the beach (about 7 miles north of the accident site). The inspector stated that he observed "heavy fog along the coast," and the visibility was 1/8-mile horizontally. About 1030, the FAA inspector was driving northbound on I-5 (about 3 miles southeast of the accident site). He reported observing "very heavy fog along the coastline in the vicinity of Cardiff State Beach. The fog was isolated to the coast line." The estimated visibility was less than 1/8-mile in the fog-affected areas. (Cardiff State Beach is about 2 miles southeast of the accident site.) WRECKAGE AND IMPACT INFORMATION On September 9, 2003, the helicopter pilot and wreckage were located in the Pacific Ocean, about 0.5 nautical miles west-southwest (247 degrees, magnetic) from the shoreline nearest the city of Encinitas. The depth of the water in which the wreckage had sunk was about 70 feet. Recovery personnel reported the wreckage was located about 33 degrees 02.101 minutes north latitude by 117 degrees 18.299 minutes west longitude. This location is about 0.3 nm and 248 degrees from where it was last recorded on radar. San Diego County Sheriff personnel photo-documented the submerged wreckage with still photographs and videotape. The Safety Board investigator reviewed the pictures and videotape. In summary, the wreckage was found in one principal location. The helicopter's cockpit, main and tail rotor assemblies, mast, engine, and the tail boom were attached to the fuselage. The majority of the helicopter wreckage was recovered. MEDICAL AND PATHOLOGICAL INFORMATION The student's CFI indicated to the Safety Board investigator that he believed the student was in good health. He did not exhibit evidence of physical impairments. An autopsy was performed on the decedent by the San Diego County Coroner's Office. The FAA's Civil Aeromedical Institute, Bioaeronautical Sciences Research Laboratory, performed toxicology tests on blood and urine specimens from the pilot. Ethanol and propanol were detected in blood, tissue, and urine specimens. Acetaldehyde was detected in blood and tissue specimens. The laboratory's manager opined that the ethanol found in this case was from postmortem ethanol formation, and not from the ingestion of ethanol. TESTS AND RESEARCH The recovered wreckage was examined by Safety Board investigators and participant personnel, and in summary, the following was noted: Both fuel caps were found seated. The gascolator bowl and screen were not located. The engine's throttle and carburetor heat controls were functional. No evidence of preimpact separation was observed with the mixture control. Circumferential scoring was apparent on the upper belt sheave, on the cooling fan outer edges, and in arcs inside the cooling fan scroll. The drive belts were intact. The sprag clutch locked and free-wheeled. The main rotor gear box contained oil. Both elastomeric teeter stops were found in place. Both spindle "tusks" were intact. The droop stop attachment bolt and both droop stops were intact. The main rotor blades exhibited trailing edge compressive buckling and did not appear coned upward. The tail rotor drive shaft bearing was free to rotate, and the tail rotor drive shaft was intact. The tail rotor gearbox contained oil and was free to rotate. Several of the flight controls were found disconnected. In all cases the breaks appeared in impact-damaged areas of the deformed fuselage. The landing gear skids and struts were intact and remained attached to the airframe. The bottom of the cockpit appeared hydraulically crushed in an upward and aft direction, as evidenced by accordion-like folds in skin panels and underlying deformation to structure. Robinson participants opined that no evidence of preimpact failures were evident. Flight Instructor Conduct and Responsibilities. The CFI stated that the minimum weather conditions in which the student was authorized to fly, as written in the student's logbook, was 5 miles visibility. Also, if a ceiling existed, its base could not be lower than 1,200 feet agl. The CFI reported to the Safety Board investigator that on August 24, 2003, he had endorsed the accident student's logbook indicating that he was authorized to fly from the Montgomery Field to the Long Beach Airport in order to take an examination for certification as a private pilot. The CFI stated that he was in Oregon on the 25th. Therefore, he dated the logbook showing the 25th. The CFI stated that prior to the student's flight, he spoke with his student via telephone to fulfill his regulatory responsibilities of overseeing the student's cross-country flight. The CFI acknowledged that he did not request that any other instructor at the company cover for him during his absence. According to the CFI, the following (summarized) events occurred on morning of the 25th: (1) The student telephoned the FSS and obtained a weather briefing, and then the student telephoned the CFI; (2) The student advised the CFI what he had learned during his briefing; and (3) The student did not inform the CFI that the weather conditions along his planned route of flight were, in certain locations, below the previously established limits for his flying. The CFI indicated that neither before nor after the telephone conversation with his student did he ascertain for himself what the weather conditions were for his student's flight. The CFI reported that he relied on his student's understanding of the information that he had received from the FSS in providing his flight authorization. The CFI reported that if he had (actually) known what the weather conditions were, he would not have authorized the flight. The CFI stated that he had the capability to personally review the applicable weather conditions, but he did not do so, relying instead upon what his student told him the weather conditions were. FAA Regulations for Solo Cross-country Flight, 14 CFR Part 61.93(d)(1) and (2). The FAA places requirements on flight instructors regarding their authorizing students to perform solo cross-country flights. According to the FAA, an instructor may not permit a student pilot to conduct a solo cross-country flight unless that instructor has: (1) Determined that the student's cross-country planning is correct for the flight; and (2) Reviewed the current and forecast weather conditions and determined that the flight can be completed under VFR. ADDITIONAL INFORMATION The recovered helicopter wreckage was released to its registered owner on September 11, 2003.
The student pilot's spatial disorientation and inadvertent descent into the ocean while maneuvering to avoid inclement weather. Also causal was the flight instructor's inadequate supervision due to his improper approval of his student's preflight preparation and failure to ensure that the flight could be performed under visual flight rules. Contributing factors were the low cloud condition, and the student's improper weather evaluation and preflight planning.
Source: NTSB Aviation Accident Database
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