Redlands, CA, USA
N1225D
Robinson R22 Beta
The helicopter crashed vertically in a city street during an autorotation following a loss of engine power. The pilot was on his second logged flight since obtaining his rotorcraft rating and was on a solo cross-country flight when witnesses reported hearing the engine miss-fire and then quit. The witnesses saw the helicopter's main rotor blades coning up and then stop rotation completely. The helicopter fell straight down to a city street below. The magneto switch was found in the off position with no sign of impact damage to the switch or key. An evaluation of the crash dynamics, the force vectors involved, and the structural deformation of the helicopter could not explain the magneto switch position. Witnesses to the accident said the magneto switch was not turned off by anyone after the accident. Examination of the engine and helicopter systems found no anomalies that would have prevented their normal operation. The engine roughness heard by the witnesses coupled with the magneto switch position may indicate that the pilot was attempting to diagnose an engine roughness by selectively turning off one magneto at a time and in the process, he may have inadvertently selected the both off position. The pilot was in the right seat and manipulation of the magneto switch would have required him to take his hand off the collective, which could have resulted in a delay in reacting to the loss of engine power. Toxicology reports on the pilot showed that chlorpheniramine was detected in blood at a level several times higher than the level expected with a typical maximum single over-the-counter dose of the medication. Chlorpheniramine is an over-the-counter sedating antihistamine commonly used for cold and allergy symptoms and is present in many over-the-counter multisymptom preparations. In typical doses, the medication has measurable adverse effects on performance of complex cognitive and motor tasks. It is likely that the pilot's performance and judgment were impaired by chlorpheniramine. The Federal Aviation Administration instructs Aviation Medical Examiners that, "any airman who is undergoing continuous treatment with... sedating antihistaminic...drugs... must be deferred certification..."
HISTORY OF FLIGHT On December 15, 2003, at 0958 Pacific standard time, a Robinson R22 Beta helicopter, N1225D, crashed into a city street near Redlands, California, following a loss of engine power. Supersonic Aviation, Inc., was operating the helicopter under the provisions of 14 CFR Part 91. The commercial pilot, the sole occupant, sustained fatal injuries; the helicopter was destroyed. The personal cross-country flight departed San Bernardino International Airport (SBD), San Bernardino, California, about 0940, with a planned stop at the French Valley Airport (F70), Temecula, California, before returning to SBD. Day visual meteorological conditions prevailed, and no flight plan had been filed. The primary wreckage was at 34 degrees 04.13 minutes north latitude and 117 degrees 13.58 minutes west longitude. Witnesses reported that the accident helicopter was flying about 2 miles south of SBD, when they heard the engine start to miss-fire and then quit. The helicopter turned to the west and appeared to be attempting an autorotation to the street below. At 200 to 300 feet above ground level (agl) they observed the rotors coning up and then stop rotation completely. The helicopter fell straight down coming to rest on the city street below. There was no post impact fire. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the pilot had a private pilot certificate for rotorcraft, and a commercial pilot certificate with ratings for single and multiengine land airplanes. He also held an instrument airplane rating. The pilot was issued a third-class medical certificate on May 8, 2001. It had no limitations or waivers. The pilot had received his private helicopter rating on July 31, 2003. He had not logged any rotorcraft flight time since he completed a company helicopter checkout on December 13, 2003. An examination of the pilot's rotorcraft logbook indicated a total rotorcraft flight time of 53 hours. He logged 0.7 hours in the last 90 days, and 0.7 in the last 30 days. All of the pilot's rotorcraft experience was obtained in the accident helicopter make and model. The accident flight was the pilot's second logged rotorcraft flight since obtaining his rotorcraft rating. AIRCRAFT INFORMATION The helicopter was a Robinson R22 Beta, serial number 3295. A review of the helicopter's maintenance records revealed a total airframe time of 765.0 hours at the last 100-hour inspection. An annual inspection was completed on February 2, 2003. The Hobbs hour meter read 370.1 at the last annual inspection. The Hobbs hour meter read 806.7 at the accident scene. The helicopter had a Textron Lycoming O-360-J2A engine, serial number L-38391-36A. Total time on the engine at the last 100-hour inspection was 765.0 hours. Fueling records established that the helicopter was last fueled at SBD on December 15, 2003, at 0937, with the addition of 22.12 gallons of 100 low-lead aviation fuel. Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the helicopter prior to departure. METEOROLOGICAL INFORMATION The closest official weather observation station was March AFB Riverside, CA (RIV), which was located 6.5 nautical miles (nm) south of the accident site. The elevation of the weather observation station was 1,535 feet msl. A routine aviation weather report (METAR) for RIV was issued at 0956. It stated: skies 22,000 feet broken; visibility 50 statue miles; winds from 060 degrees at 4 knots; temperature 57 degrees Fahrenheit; dew point 33 degrees Fahrenheit; altimeter 30.26 inches of Hg. WRECKAGE AND IMPACT INFORMATION Investigators from the National Transporation Safety Board, the FAA, and Robinson Helicopter Company examined the wreckage at the accident scene. The accident site was on Lugonia Avenue, west of California Avenue in the city of Redlands. Lugonia Avenue was in a predominately rural area with open farming fields on both sides of the street. The street was measured at 55 feet wide with two lanes for westbound traffic and one lane for eastbound traffic. The wreckage was in the number 1 and number 2 lanes of the westbound lanes of Lugonia Avenue. The debris field was contained in an area of approximately 85 feet from the main wreckage. The Safety Board investigator-in-charge (IIC) found the magneto switch in the off position, and the ignition key was completely inserted into the lock with no apparent damage to the key. Interviews with the responding parties confirmed that the switch was in the off position when they arrived on scene. The helicopter was oriented along a magnetic bearing of 190 degrees. All of the flight control components to the helicopter were located in the main wreckage. Both fuel tanks were breeched during the accident sequence. Both fuel tanks exhibited hydraulic bulging. The fuel selector valve was in the on position. The helicopter wreckage was recovered and transported for further examination. MEDICAL AND PATHOLOGICAL INFORMATION The San Bernardino County Coroner completed an autopsy on the pilot. The FAA Bioaeronautical Sciences Research Laboratory, Okalahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide, cyanide, and volatiles. The report contained the following results for tested drugs: 0.04 (ug/ml,ug/g) chlorpheniramine detected in blood, and chlorpheniramine was detected in liver. TESTS AND RESEARCH Investigators examined the wreckage at Eastman Aircraft, Corona, California, on December 16, 2003. Investigators removed the bottom spark plugs. All spark plugs were clean with no mechanical deformation. The spark plug electrodes were gray in color, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. A borescope inspection of the engine revealed no mechanical deformation on the valves, cylinder walls, or cylinder heads. Investigators were not able to manually rotate the crankshaft due to extensive impact damage. Investigators rotated the magnetos by use of a bench tester, and both magnetos produced spark at all posts. The oil sump screen was clean and open. The oil screen filter was clean. The bulbs in the warning light panel were examined for filament stretching. The Low Rotor rpm, Low Fuel, Tail Rotor Chip, Starter On, Main Rotor Chip, Main Rotor Chip, Main Rotor Temp, and Clutch all displayed tight coils. The Alternator and Oil Pressure - Engine had stretched coils. The Robinson R22B pilot operating handbook section 3 page 3-10 states: The low rotor horn and caution light are disabled when collective is full down. ADDITIONAL INFORMATION The IIC released the wreckage to the owner's representative on January 5, 2004.
a loss of engine power due to the pilot inadvertently turning off the magnetos and his failure to initiate an autorotation and to maintain main rotor rpm. A factor in the accident was the pilot's use of an over-the-counter medication that impaired his judgment and/or performance.
Source: NTSB Aviation Accident Database
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