Pilot Debrief

ROBINSON HELICOPTER CO R66 near Palmyra, PA — 2021-04-03

Final reportERA21LA171
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Date
2021-04-03
Location
Palmyra, PA, USA
Airport
58N
Aircraft
ROBINSON HELICOPTER CO R66
Registration
N577DD
Category
Helicopter
Highest injury
Serious
Fatalities
0
Phase of flight
Approach

Probable cause

The pilot’s improper judgment to attempt a flight while impaired by medications, which resulted in the helicopter’s abnormal ground contact, loss of control, and collision with terrain.

NTSB narrative

The pilot picked up the helicopter at a maintenance facility, flew it to a private heliport at his residence, where he landed briefly to pick up a package, then flew to his destination airport. Upon arriving in the area of the destination airport, the pilot entered the traffic pattern with an intended landing point of a grassy area just east of the runway. According to the pilot, on touchdown, the helicopter was on a slight downhill slope. He felt a dynamic rollover starting, so he pulled up on the collective control stick and his right foot slipped off the right tail rotor control pedal and got stuck behind it. The helicopter then impacted the ground in a left turn from a low hover. A postaccident examination of the helicopter did not reveal any failures or malfunctions that would have prevented normal operations, and the terrain where the accident occurred was flat. A neighbor who lived near the pilot reported that the pilot “buzzed” his home, flying about 20 ft above his roof when the pilot was landing at his private heliport. The neighbor stated this was uncharacteristic for the pilot and “something wasn’t right with him or the helicopter…given his landing maneuvers.” A witness, who worked at the destination airport stated the helicopter flew toward her office from the runway, coming close to the picnic tables that were near the building where she worked. She stated that the helicopter was “real wobbly,” bounced off the ground, flew up quickly, made a tailspin in the opposite direction away from the office, and crashed. Several witnesses reported seeing the pilot with a pill bottle in his hands following the accident. One of the witnesses reported seeing the pilot with two pills in his hand, but he did not see the pilot take them. One of the witnesses reported seeing the pilot toss the pills into the field, and another witness reported seeing pills falling out of the bottle. A witness who saw the pilot throwing pills on the ground picked up two of the pills and gave them to law enforcement. The pills were later identified as acetaminophen and hydrocodone bitartrate 300mg/7.5mg. Toxicology tests performed on blood and urine samples taken from the pilot at the hospital following the accident identified hydrocodone, acetaminophen, cyclobenzaprine, as well as several other drugs. Vicodin, which the pilot reported using, is a Schedule II controlled substance made from a combination of acetaminophen and hydrocodone. Hydrocodone may impair ones mental or physical abilities to perform activities such as driving a car or operating machinery. The level of hydrocodone in the pilot’s blood when tested was within the range that novice users could expect to have side effects. Cyclobenzaprine is known to cause drowsiness and may also impair mental and/or physical abilities required to perform tasks such as operating machinery or driving a motor vehicle. The level of cyclobenzaprine in the pilot’s blood was within the range that impairing effects are expected. The pilot reported having obstructive sleep apnea and told healthcare providers he used a continuous positive airway pressure device for treatment. However, no information was available concerning his usage in the days before the accident. As a result, whether fatigue from inadequately treated sleep apnea contributed to the pilot’s performance could not be determined. The pilot had effective levels of two potentially impairing medications in his system when the accident occurred. When used in combination, the effects of such medications are greater than when each is used alone, although the exact effects have not been studied. In this case, the pilot’s performance during the flight was not consistent with his level of skill and experience in the helicopter; it is likely effects from his use of a combination of impairing medications contributed to his degraded performance and his inability to safely land the helicopter.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen to avoid landing on a slope or delayed landing due to disorientation.

NTSB coding

Evidence available

  • FDR / data
  • ADS-B / radar
  • Photos
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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