Miami, FL, USA
N2566W
Robinson R22 Beta
The purpose of the flight was to conduct an introductory flight to a potential student. The 6,271 hour certified flight instructor (CFI) demonstrated the preflight inspection step by step following the checklist for the prospective accident student; the inspection included examination of the swash plate assembly for security of the flight control push/pull tubes. No preflight inspection discrepancies were later reported by the accident student. The engine was started, and the flight departed to the west climbing to 500 feet msl, then descended to 300 feet. The student reported that while flying straight and level at 60 knots while he was looking outside, the helicopter banked left and nose down, "... making it impossible for the instructor to control the aircraft." The CFI commented several times "what happened", and attempted to recover from the left and nose down attitude but was unable. 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 student perceived the helicopter impacted the ground first with the left skid. The student did not notice any change in engine sound from the time of takeoff to the moment the helicopter banked left. Postaccident examination of the helicopter revealed the left forward push/pull tube was not connected to the swashplate assembly; the lug was not fractured. The rod-end and securing hardware of the left push/pull tube was not located. The securing hardware which secures the aft push/pull rod to the swashplate assembly was found to be loose; the threads of the bolt did not extend beyond the end of the nut and a palnut was not in position. NTSB examination of the swashplate assembly revealed no elongation of the hole of the left forward lug; linear impressions on the interior surface were consistent with the threads of the bolt. The impressions on the interior surface of the left forward lug were located in the area were the bolt shank is located. Four days before the accident, tracking and balancing of the main rotor was accomplished. The bracket used during the tracking procedure was installed to the left and aft lugs of the swashplate assembly, contrary to the procedure specified in the maintenance manual. The mechanic who performed the work could not recall if he used a new metal self locking nut when reinstalling the push/pull rods. Robinson Helicopter Company personnel reported that "...if either of the forward push/pull tubes were to become disconnected at the lower swashplate, it is assumed that the helicopter would be uncontrollable." Postaccident review of the operator's facility and several helicopters by NTSB and FAA personnel revealed several had the push/pull tubes installed on the incorrect side of the lugs at the swashplate assembly, and the securing hardware was incorrectly installed. Additionally, FAA personnel noted discrepancies with the maintenance records. One of the helicopters which had the push/pull tubes incorrectly installed, had been previously inspected on five separate occasions by one of the mechanics who had performed the last tracking and balancing of the main rotor on the accident helicopter. Installation of the bracket used during the last main rotor tracking and balancing required the removal of the bolts at the left and aft lugs of the swash plate. Proper installation of the bracket requires removal of hardware that secures 2 of 3 flight control push/pull tubes to the swashplate.
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 with] RHC [maintenance manual] R-22 Sections 10.200 to 12.232 [figure] 10.10-[page] 10.29. Tracking adjusted to hover, climb, 50, 70, 80, 90 knots [in accordance with] RHC [maintenance manual] R-22 Section 10-233 [figure] 10-12." There were no further entries in the airframe maintenance records. According to the Director of Maintenance of the operator who signed off the last main rotor tracking and balance procedure, the work was performed by himself and another company mechanic. The DOM witnessed the mechanic performing the work after the equipment was installed, read the instrument once with the accident pilot, and once again with the president of the operator. Any changes and/or adjustments if any, and the removal of the equipment used during the procedure was performed by the other mechanic. The mechanic who installed the equipment used for the main rotor track and balance procedure reported either in writing or verbally that he performed the work under the supervision of the DOM and in accordance with the helicopter maintenance manual. He reportedly installed the bracket used for the main rotor track and balance procedure on the right side of the non-rotating portion of the swash plate assembly. The main rotor tracking and balance procedure began on July 26, 2004, and the helicopter was flown; after which time, he and the DOM made adjustments of balance and tracking in accordance with the maintenance manual. The equipment used for the main rotor track and balance procedure was removed on either July 27th, or July 28th, and the rod end and rod end spherical bearing of the right and aft push/pull tubes were inspected with no discrepancies noted. He further reported the bolts used to secure the push/pull tubes to the right and aft lugs of the non-rotating portion of the swash plate were also inspected with no discrepancies noted. He could not recall if he changed the nuts (P/N MS 21042L4) used to secure the right and aft push/pull tubes; he dry torqued the nuts to 120-inch pounds. He did use new palnuts (P/N B330-13), at the right and aft push/pull tube connections; he torqued them to 11-25 inch pounds. He also applied torque seal to the fasteners in accordance with the maintenance manual. According to a statement by the president and vice president of Helicenter International Corporation, the accident CFI flew the accident helicopter on two flights on the 29th of July; the flights were related to the tracking and balance checks. The mechanic who performed the work was on-board for both flights which lasted a total of approximately 1.5 hours. The helicopter was then flown the following day (July 30th) on 2 separate flights by the president of Helicenter International Corporation to finish the tracking checks. He later reported that during his preflight inspection of the helicopter before both flights, a bracket used for the main rotor tracking and balance procedure was installed at the left side of the non-rotating portion of the swash plate assembly when viewed from the cockpit looking forward. Both flights on that date (July 30th) lasted a total of approximately 2.0 hours. One of the flights was with the mechanic who performed the work on-board, and the other flight was with the DOM on-board. The helicopter was not flown between the last flight by the president of Helicenter International Corporation on the 30th of July, and the accident flight. The accident flight was the first flight since the bracket used during the main rotor track and balance procedure was removed, and the flight control push/pull tubes were required to be properly reinstalled to the non-rotating portion of the swash plate assembly. The operator provided a document which indicated that the hour meter reading at the start of the accident flight (3,176.4) was the same as the hour meter reading recorded in the maintenance records for an entry dated July 27, 2004. As previously reported, the helicopter had been operated approximately 3.5 hours during several maintenance related flights on July 29th and 30th. METEOROLOGICAL INFORMATION A METAR weather observation taken from the Kendall-Tamiami Executive Airport (KTMB) at 0953, or approximately 12 minutes after the accident indicates the wind was from 170 degrees at 6 knots, the visibility was 10 statute miles, few clouds existed at 2,500 feet above ground level (agl), broken clouds existed at 9,000 and 25,000 feet agl, the temperature and dewpoint were 27 and 25 degrees Celsius, respectively, and the altimeter setting was 29.99 inHg. The accident site was located 9.86 nautical miles and 263 degrees from KTMB. COMMUNICATIONS The CFI was not in contact with any air traffic control facility at the time of the accident. WRECKAGE AND IMPACT INFORMATION The helicopter crashed in the Everglades National Park; the wreckage was located at 25 degrees 37.038 minutes North latitude and 080 degrees 35.227 minutes West longitude, or 9.86 nautical miles and 263 magnetic degrees from the center of the Kendall-Tamiami Executive Airport. The NTSB first examined the accident site and wreckage 2 days after the accident; the accident area consisted of open terrain with low vegetation and shallow water. The helicopter was resting on the left side with the longitudinal axis oriented on a magnetic heading of 350 degrees. Sections of the left skid were located along the energy path which was oriented on a magnetic heading of 247 degrees. The cockpit, and engine compartment were consumed by postcrash fire; the gearbox was also consumed by postcrash fire. The tailboom was separated at the end of Bay 1, but located in close proximity to the main wreckage; heat damage was noted to the skin in that area and all five tail boom securing hardware were in place. Tail rotor drive continuity was confirmed from the bevel gear at the gearbox through the tail rotor gearbox to the tail rotor blades; 360 degrees of rotation of the tail rotor blades was noted. Examination of the swash plate assembly revealed push/pull tube assembly (part number (P/N) A121-7), was not connected to the left lug on the forward side of the non rotating portion of the swash plate assembly; the lug was not fractured. The rod end and securing hardware were not located. A section of push/pull tube assembly (P/N A121-7), was connected t
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.
Source: NTSB Aviation Accident Database
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