Pilot Debrief

ROBINSON R44 near Miami, FL — 2013-04-03

Final reportERA13FA186
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Date
2013-04-03
Location
Miami, FL, USA
Airport
TMB
Aircraft
ROBINSON R44
Registration
N3101H
Category
Helicopter
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The mechanic's failure to properly secure the pitch link hardware of one main rotor blade to the rotating swash plate, which resulted in the pitch link separating in flight and the pilot's subsequent loss of control. Contributing to the accident was the pilot’s/owner's pressure on the mechanic to return the helicopter to revenue service.

Contributing factors

Contributing to the accident was the pilot's/owner's pressure on the mechanic to return the helicopter to revenue service.

NTSB narrative

The pilot, who also owned the helicopter company, hired a mechanic to change the main rotor blades on the helicopter. The main rotor blade change also required several adjustments to the pitch change rods on the rotor system followed by test flights. The accident flight was the second maintenance flight of the day and occurred about 1 hour of operation after the main rotor blade replacement. Witnesses observed the helicopter flying and heard a loud "pop" sound followed by components separating from the helicopter. They then observed the tail section separate from the helicopter and the helicopter crash to the ground. Witness statements and wreckage documentation were consistent with a main rotor blade rotating upward during the accident flight, which was followed by a tail strike and the helicopter rolling inverted. Subsequently, the mast bumped and the helicopter descended uncontrolled to the ground. A witness, who had flown the helicopter numerous times, stated that he observed the mechanic make adjustments to the pitch change rods on the rotor system during the maintenance procedure. He also stated that the mechanic told him that the owner of the helicopter was upset and that the helicopter manufacturer installed refurbished spindles onto the new blades. The owner's frustration likely distracted the mechanic and/or applied pressure for the mechanic to return the helicopter to service and revenue operations as soon as possible. On-scene examination of the wreckage revealed that the pitch-link-to-swash-plate connection for one of the main rotor blades was missing. The pitch link and horn were found about 90 feet away. Metallurgical examination of the main rotor system revealed that the attaching hardware for the pitch-link-to-swash-plate connection was most likely not secured properly and separated after about 1 hour of flight following the maintenance. All other failures were consistent with overstress and no preexisting cracking was noted. No other anomalies with the helicopter structure, systems, or engine were found.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Proper installation and inspection of rotor blades and spindles could have prevented failure.

NTSB coding

Evidence available

  • Photos
  • 20 docket documents
View NTSB final reportView NTSB docket

Docket documents20

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