CA 12-12b 25 MAY 2010 Page 1 of 15

Section/division Occurrence Investigation Form Number: CA 12-12a

AIRCRAFT INCIDENT REPORT AND EXECUTIVE SUMMARY

Reference: CA18/3/2/1103

Aircraft Registration ZS-MEX Date of Incident 25 December 2014 Time of Incident 1210Z

Type of Aircraft Robinson R44 Raven II (Helicopter) Type of Operation Commercial

Pilot-in-command Licence Type Commercial (CPL) Age 25 Licence Valid Yes

Pilot-in-command Flying Experience

Total Flying Hours

351.6 Hours on Type 82.1

Last point of departure Lebala Game Lodge, Limpopo province

Next point of intended landing Grand Central aerodrome (FAGC), Gauteng province

Location of the incident site with reference to easily defined geographical points (GPS readings if possible) Lebala Game Lodge at GPS co-ordinates determined to be S24 24. 525 E027 49. 258 at the

elevation of 1 520 above mean sea level (AMSL)

Meteorological Information Temperature, 22C: Visibility, 10 km: Wind direction, 360, Dew point, 12C: Cloud base, 3 500 feet above ground level. Number of people on board 1 + 0

No. of people injured 0 No. of people killed 0

Synopsis

On Thursday morning of 25 December 2014, a Robinson R44 Raven II helicopter departed from O R

Tambo international (FAOR) airport on a charter flight with the pilot and a passenger on-board bound

for Lebala Game Lodge in Limpopo. The flight was uneventful and both occupants disembarked and

proceeded towards the reception. The passenger checked in while the pilot enjoyed a cup of coffee

with other guests. The pilot later went back to the helipad and prepared the helicopter for a

repositioning flight. All was normal, and the pilot boarded the helicopter and started the engine. The

engine and fuel flow indications were normal and he advanced the collective lever and lifted off the

helicopter to a height of about two metres AGL before hovering for departure. During the process the

right hand side door of the helicopter opened, and in an attempt to close it, the pilot allowed the

helicopters nose to pitch up resulting in a tail strike. Damage was limited to the lower vertical stabiliser

and the tail rotor guard and the pilot was unharmed. The investigation revealed that the incident was as

a result of the pilots diverted attention while attempting to close the door at low height, causing

inadvertent backward tilting of the cyclic control and resulting in a tail strike.

Probable Cause

Pilots diverted attention contributing to loss of helicopter attitude at low height, resulting in a

tail strike.

IARC Date Release Date

CA 12-12b 25 MAY 2010 Page 2 of 15

Section/division Occurrence Investigation Form Number: CA 12-12a Telephone number: 011-545-1408 E-mail address of originator:

AIRCRAFT INCIDENT REPORT

Name of Owner/Operator : Blue Turtle Technologies (PTY) LTD Manufacturer : Robinson Helicopter Company Model : Robinson R44 Raven II Nationality : South African Registration Marks : ZS-MEX Place : Lebala Game Lodge Date : 25 December 2014 Time : 1210Z All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z). South African Standard Time is UTC plus 2 hours. Purpose of the Investigation: In terms of Regulation 12.03.1 of the Civil Aviation Regulations (1997) this report was compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to establish legal liability. Disclaimer: This report is given without prejudice to the rights of the CAA, which are reserved.

1. FACTUAL INFORMATION: 1.1 History of Flight: 1.1.1 On Thursday morning 25 December 2014, the pilot drove from his home to the

operators facility, Blue Turtle Technologies based at Grand Central (FAGC)

aerodrome to prepare the helicopter for a charter flight to Lebala Game Lodge located

in the Valwater District Municipality, Limpopo. The pilot scrutinised the helicopters

technical documentation and all was properly signed with no outstanding technical

snags. The maintenance crew pulled the helicopter out of hangar to the helipad. The

helicopter was then fuelled to capacity with 100 LL Avgas followed by a thorough pre-

flight inspection by the pilot.

1.1.2 The pilot stated that everything was normal and he boarded the aircraft and secured

himself with the safety harness. He then communicated with the FAGC tower controller

and requested to start and take off to O R Tambo international (FAOR), which was 10

nautical miles (NM) from FAGC. The request was acknowledged and the tower

controller stated that he had a clear view of the apron area and was watching the

helicopter. The helicopter took off and routed south easterly at 90 knots (kt) indicated

airspeed (AIS), where upon a successful landing at FAOR was carried out after 10

minutes.

CA 12-12b 25 MAY 2010 Page 3 of 15

Figure 1: Google Earth map depicting FAGC and FAOR

1.1.3 Within few minutes the passenger availed himself. His 20 kg baggage was loaded onto

the helicopter and he then embarked. The pilot secured the passenger and provided

him with a safety briefing before start-up. The before start checklist was completed and

the engine was started. The engine and fuel flow gauge indications were normal and

the pilot took off after being cleared by FAOR air traffic controller (ATC). The helicopter

took off and headed in a Northerly direction, landing smoothly on the game lodge

helipad. Approximately 1.2 hours later, upon landing, the pilot shut down the engine

and off-loaded the baggage before proceeding to the lodge reception. At the reception,

the passenger checked in and the pilot was offered a cup of coffee.

1.1.4 The pilot later went back to the helipad and prepared the helicopter for a repositioning

flight to FAGC. All was normal and he boarded the helicopter and started the engine.

The engine and fuel flow indications were normal and he advanced the collective lever,

lifting off the helicopter to a height of about 2 m AGL before hovering for departure. He

then tilted the cyclic forward and the helicopter started to gain forward momentum.

During this time, the right hand side door (pilot door) opened. The pilot reported that he

struggled to close the door with his right hand. The helicopter pitched up, yawed to the

left and then drifted to the right. According to the pilot, weather was fine but everything

happened so quickly and he didnt notice any damage happening. He then gave more

power and climbed to approximately 50 ft where he was able to close the door.

CA 12-12b 25 MAY 2010 Page 4 of 15

1.1.5 The helicopter then proceeded to FAGC at 6 000 ft, 90 kt indicated airspeed. The

landing at FAGC was uneventful. Before shutdown, the main tank fuel gauge indicated

quarter full, and the auxiliary was between quarter full and empty. After flight inspection

revealed a damaged lower vertical stabiliser and the tail rotor guard. No injury was

reported. The operators aircraft responsible person was notified and the matter was

reported to the aircraft accident and incident investigation (AIID). The flight was

conducted under the provisions of Part 127 of the Civil Aviation Regulations of 1997,

as amended and the operator was in possession of a valid air operating certificate

(AOC) No CA/N14OD, which permitted the helicopters use for charter flights.

1.1.6 The incident happened in day light at GPS co-ordinates determined to be S24

24.525 E027 49.258 at an elevation of 1 520 feet AMSL. Figure 1 show Lebala

Game Lodge where the incident occurred.

Figure 2: Lebala Game Lodge and the helipad on a Google Earth map

1.2 Injuries to Persons:

Injuries Pilot Crew Pass. Other

Fatal - - - -

CA 12-12b 25 MAY 2010 Page 5 of 15

Serious - - - -

Minor - - - -

None 1 - - -

1.1 Damage to Aircraft:

1.1.1 Damage was limited to the lower vertical stabiliser and the tail rotor guard.

Figure 3: The helicopter in the hangar

A damaged lower vertical stabiliser and the tail rotor guard

CA 12-12b 25 MAY 2010 Page 6 of 15

Figure 4: Closer view of the lower vertical stabiliser 1.2 Other Damage: 1.2.1 None. 1.5 Personnel Information:

Nationality South African Gender Male Age 25

Licence Number 0272237702 Licence Type Commercial (CPL)

Licence valid Yes Type Endorsed

Yes

Ratings Night and Instrument ratings

Medical Expiry Date 13 May 2015

Restrictions None

Previous Incidents Nil

CA 12-12b 25 MAY 2010 Page 7 of 15

Flying experience:

Total Hours 351.6

Total Past 90 Days 56.5

Total on Type Past 90 Days 52.2

Total on Type 82.1

*NOTE: The investigation into South African civil aviation authority (SA CAA)

maintenance pilots file revealed no enforcement actions, rating failure, or retest

history. The pilot licence was valid and he was rated on Robinson helicopter series.

1.6 Aircraft Information: 1.6.1 Description:

The Robinson R44 is a single-engine four-seater light utility helicopter constructed

primarily of metal and equipped with skid-type landing gear. The helicopter is powered

by an IO540 six-cylinder horizontally opposed fuel-injected engine with angled valve

head and tuned induction capable of producing 300 horsepower. The engine is

controlled by an electronic governor, also manufactured by Robinson Aircraft

Company. Fuel is fed by gravity, with an electric prime pump. Should the engine

inadvertently shut down, the loss of oil pressure turns the pump off, preventing the

engine from flooding during a restart. The output shaft powers both the cooling fan and

the drive belt sheave. The cooling fan provides air to cylinder heads and oil coolers,

and also serves for gearbox cooling and cabin heating. The main rotor system is a two-

blade underslung teetering hinge.

The all-metal stainless steel blades are connected to the hub by two sealed Teflon-

coated coning hinges. The pitch change bearings are wet and enclosed by a neoprene

boot at the blade root. The main gearbox contains a single-stage splash-lubricated

gear set and is driven by a V-belt sheave that lies directly above the engine sheave.

The sprag one-way drive clutch is contained within the upper sheave and can easily be

checked for operation by the pilot during pre-flight inspection. An automatic clutch

actuator raises the upper sheave when the pilot engages the clutch, and a tensioner

automatically stops the engagement when the correct tension is achieved. It also

automatically adjusts tension in flight. The tail rotor drive does not have any hanger

bearings; it drives a splash-lubricated gearbox.

CA 12-12b 25 MAY 2010 Page 8 of 15

The two metal tail rotor blades are attached to a teetering hub with a fixed coning

angle, and use elastomeric teetering bearings and Teflon pitch-change bearings. The

hydraulic system consist of a pump, three servos, a reservoir and lines boosting the

main rotor flight control while eliminating cyclic and collective feedback forces. At the

same time the flight controls maintain a direct mechanical link, allowing full control

should the hydraulics fail. The pump is driven by the main gearbox, operating at a

relatively low pressure of 450 to 500 pressure per square inch (psi). The pilot can turn

the hydraulics off, although electrical power is required to do so, providing a fail-safe

system. The 28-volt DC electrical system powers a single bus bar and includes an

alternator, voltage controller, and 24-volt battery. Standard lighting on the R44

helicopter includes strobe, navigation, panel and map lights. The warning lights are

extensive, and the low rotor warning also includes a horn activated at 97 per cent rpm.

Another standard feature is the four-place voice activated intercom system. The

helicopter has a press-to-talk (PTT) switch in the pistol grip on the cyclic control, which

is activated by the index or key finger. See Figure 5.

Figure 5: Robinson R44 Raven II cyclic

The hydraulic switch is located on the front of the cyclic stick. All the equipment has

been installed for easy accessibility for the observer or pilot in day or night operations,

including independent audio controls, map lights and a pouch for binoculars.

Removable left seat pedals and collective control may be installed to allow a rated co-

pilot to control the helicopter using the centre cyclic control. Figure 6 shows the

exterior of the incident helicopter.

ON/OFF hydraulic toggle switch

Press to talk (PTT) switch on a T-bar cyclic

CA 12-12b 25 MAY 2010 Page 9 of 15

Figure 6: Robinson R44 Raven II helicopter

Airframe:

Type Robinson R44 Raven II

Serial Number 11896

Manufacturer Robinson Helicopter Company

Service ceiling 14 000 ft

Maximum take-off weight 2 500 lb

Empty weight 1 495 lb

Date of Manufacture 2007

Total Airframe Hours (At time of incident) 4 165.7

Last MPI (Hours & Date) 3 052.6 20 October 2014

Total Hours Flown 1.113

Certificate of Airworthiness (Issue Date) 25 September 2007

Certificate of Airworthiness (Expiry Date) 24 September 2015

Airworthiness Directives and Service Bulletins

Complied with

C of R (Issue Date) (Present owner) 13 May 2009

Fuel used Avgas LL 100

Operating Categories Standard Part 127

CA 12-12b 25 MAY 2010 Page 10 of 15

Engine:

Type Lycoming IO-540-AE1A5

Serial Number L-32263-48E

Hours since New 1 988.0

Hours since Overhaul 488

1.7 Meteorological Information: 1.7.1 Weather information as obtained from the pilots questionnaire:

Wind direction 360 Wind speed 12 knots Visibility 10 km

Temperature 22C Cloud cover Few Cloud base 3 500 ft

Dew point 12C

1.8 Aids to Navigation: 1.8.1 The helicopter was fitted with standard navigation equipment as approved at the time

of certification.

1.9 Communications: 1.9.1 No difficulties with communications were known or reported prior to the incident. In

addition, no malfunction on any of the equipment was reported at the time of the

incident.

1.10 Aerodrome Information:

1.10.1 The incident occurred outside airport boundaries.

1.11 Flight Recorders: 1.11.1 The helicopter was not fitted with a flight data recorder (FDR) or a cockpit voice

recorder (CVR), neither was it required in terms of the South African Civil Regulations

to be fitted to this helicopter type.

CA 12-12b 25 MAY 2010 Page 11 of 15

1.12 Wreckage and Impact Information: 1.12.1 Examination of the helicopter, revealed evidence consistent with the helicopter tail

having contacted the ground surface with light force. There was no other damage

found on the tail boom. The flight control system was examined and no anomalies

were found.

1.13 Medical and Pathological Information: 1.13.1 Not applicable. 1.14 Fire: 1.14.1 No pre or post impact fire was reported. 1.15 Survival Aspects: 1.15.1 The incident was considered survivable.

1.16 Tests and Research: 1.12.2 The operation of the cyclic and collective controls confirmed that the control systems

from the pilot inputs to the hydraulic servos were correctly connected and capable of

functioning appropriately. All the helicopter doors were examined and found to be

latching without difficulties. The investigation had concluded that the pilot had

inadvertently applied back pressure on the cyclic control, as he was attempting to

close the door, allowing the abrupt nose-up pitch attitude resulting in a tail strike. This

incident highlights the importance of ensuring all doors are secured prior to take-off.

Having said that, the opening of a door in flight will not normally affect the operation of

the R44 helicopter, yet the inherent reaction to immediately deal with such an event

can be quite strong. This reaction may be hard to overcome and in the event of an

unexpected situation like on this occurrence, it is vital that pilots should continue to fly

the helicopter.

1.17 Organisational and Management Information: 1.17.1 This was a commercial flight.

1.17.2 The aircraft maintenance organisation (AMO) that performed the last inspection on the

helicopter was in possession of a valid AMO approval certificate No 27.

CA 12-12b 25 MAY 2010 Page 12 of 15

1.18 Additional Information:

1.18.1 None.

1.19 Useful or Effective Investigation Techniques: 1.19.1 None. 2. ANALYSIS:

2.1 The available information revealed that fine weather conditions prevailed in the area at

the time of the occurrence. Therefore the weather was considered not to have any

bearing on the incident. The pilot was the holder of a valid commercial helicopter pilots

license and was proficient to perform the task at hand. Available information indicated

that the pilot had flown a total of 351.6 hours preceding the accident, of which all of

those hours were on the Robinson helicopter series.

2.2 The mishap occurred after the right hand side door (pilot door) went open on departure

from Lebala Game Lodge on a repositioning flight to FAGC. The investigation

concluded that the mishap was as a result of the pilot diverted attention from the

operation of the helicopter at low height and his inadvertent backward tilting of the

cyclic control while attempting to close the door resulting in a tail strike. In addition, his

inadequate before start check, specifically his failure to properly latch/close the door,

suggests that he was somewhat in hurry to return to FAGC. The incident could have

been avoided should the pilot had considered to land the helicopter after the door went

open and properly closing it before returning to FAGC.

3. CONCLUSION: 3.1 Findings: 3.1.1 The pilot was a holder of a valid commercial pilots licence and had the helicopter type

endorsed in his logbook.

3.1.2 The pilots medical certificate was valid without restrictions.

3.1.3 Fine weather conditions prevailed at the time and were not considered to have had

bearing on the occurrence.

3.1.4 The AMO that performed the last inspection on the helicopter prior to the occurrence

was in possession of a valid AMO approval certificate No 27.

3.1.5 The operation of the cyclic and collective controls confirmed that the control systems

from the pilot inputs to the hydraulic servos were correctly connected and capable of

functioning appropriately.

CA 12-12b 25 MAY 2010 Page 13 of 15

3.1.6 All the helicopter doors were examined and found to be latching without difficulties.

3.1.7 The helicopter was in possession of a valid certificate of airworthiness at the time of

the incident.

3.1.8 The incident was regarded as survivable.

3.1 Probable Cause/s:

3.1.1 Pilots diverted attention contributing to loss of the helicopter attitude at low height,

resulting in a tail strike.

3.2 Contributing factor/s: 3.2.1 Poor airmanship. 4. SAFETY RECOMMENDATIONS: 4.1 None.

5. Appendices: 5.1 Robinson R44 operating limitations and the pilots checklist.

CA 12-12b 25 MAY 2010 Page 14 of 15

CA 12-12b 25 MAY 2010 Page 15 of 15