Aircraft Accident/Incident Report

Miami, Florida 33187
Monday, August 2, 2004 9:36 EDT

NTSB Narrative Summary Released at Completion of Accident

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.

NTSB Probable Cause Narrative

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.

Event Information

Type of Event Accident
Event Date 8/2/2004
Event Day of the Week Monday
Time of Event 936
Event Time Zone Eastern Daylight Time
Event City Miami
Event State FLORIDA
Event Country --
Zipcode of the event site 33187
Event Date Year 2004
Event Date Month 8
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 253702N
Event Location Longitude 0803514W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 953 Eastern Daylight Time
Direction of event from weather observation facility (degrees) 83
Weather Observation Facility ID KTMB
Elevation of weather observation facility 8
Distance of event from weather observation facility (units?) 10
Time Zone of the weather observation EDT
Lighting Conditions Day
Lowest Ceiling Height 9000
Lowest Non-Ceiling Height 2500
Sky/Lowest/Cloud Conditions Few
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 27
Dew Point at event time (in degress fahrenheit) 25
Wind Direction (degrees magnetic) 170
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 6
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.99
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 1
Injury Total Minor 1
Injury Total None --
Injury Total Serious --
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 18824
NTSB Notification Source Miami-Dade Police Department
NTSB Notification Date Aug 2 2004 12:00AM
NTSB Notification Time 1010
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Dec 20 2005 6:27AM
User who most recently changed record NTSB\JOHB
Basic weather conditions Visual Meteorological Cond
FAA District Office Miami, Florida

Aircraft Involved

Aircraft #1

Aircraft Registration Number N2566W
NTSB Number MIA04FA115
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? No
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion Ground
Aircraft Manufacturer's Full Name Robinson
Aircraft Model R22 Beta
Aircraft Series Identifier --
Aircraft Serial Number 0616
Certified Max Gross Weight 1370
Aircraft Category Helicopter
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 2
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Apr 22 2004 12:00AM
Airframe hours since last inspection 69.36
Airframe Hours 3180.16
ELT Installed No
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name Matthew L. Spitzer
Aircraft Owner Street Address 3809 Amyx Ct.
Aircraft Owner City Hayward
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 94542
Operator is an individual? No
Operator Name Helicenter International Corporation
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 14005 S.W. 127th St., Bldg. 120-A #7
Operator City Miami
Operator State FL
Operator Country USA
Operator Zip code 33186
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Instructional
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code KTMB
Departure City Miami
Departure State FL
Departure Country USA
Departure Time 925
Departure Time Zone EDT
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code KTMB
Destination City Miami
Destination State FL
Destination Country USA
Specific Phase of Flight Descent
Report sent to ICAO? No
Evacuation occurred Yes
Date of most recent change to record Oct 4 2005 11:48AM
User who most recently changed record KENJ
Since inspection or accident Time of Accident
Event Location Runway Number and Location --
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --