CEN23FA183 · Robinson R22 Beta
Robinson R22 Beta · Incident: loss of control on ground while standing
Event
- NTSB case
- CEN23FA183
- Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
- Incident
- InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
- Completed
- API-reported fatalities
- 1 · all aircraft and ground
- Ground fatalities
- Unknown
- OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
- General aviation
- WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
- Visual Meteorological Cond
Robinson R22 Beta
- Aircraft type
- Robinson R22
- Category
- Helicopter
- RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
- N40506
- Operator
- Unknown
- Onboard fatalities
- Unknown
- Route
- From not recordedTo not recorded
- Aircraft age
- About 32 years (built 1991)
- Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
- Part 91: General Aviation
- Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
- Standing · engine(s) operating
- Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
- Loss of control on ground
- DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
- Substantial
Cause areas
- Aircraft › Aircraft propeller/rotor
- Personnel issues › Physical
- Personnel issues › Psychological
- Personnel issues › Task performance
Approximate · Coordinates from the NTSB case API, which marks them as estimated or does not say; no uncertainty radius is established.
NTSB narrative
Although there were no witnesses to the crash, it is likely that the non-certificated pilot was conducting an engine ground run when the helicopter inadvertently became airborne. The helicopter impacted the terrain about 70 ft from the concrete pad used during ground operations. After the crash, the collective friction control was found off, which likely resulted in an unintended increase of the collective control to a point where the helicopter became airborne.
The pilot’s logbook contained a student pilot certificate; however, it expired more than 50 years before the crash. A review of the pilot’s logbook did not reveal any flights after he received a 90-day solo endorsement for a single-engine airplane in 1971, nor did it reveal any flights completed in a helicopter. The pilot had served in the US Army but in a non-pilot role.
The pilot purchased the helicopter in March 2016 as an investment and family members could not recall the last time he flew the helicopter. One of the pilot’s daughters reported that he would occasionally bring the helicopter out of the shed to perform an engine run and, on multiple occasions, he forgot to engage the collective friction control, which resulted in unintended movement of the helicopter on the ground while the engine was running.
The 93-year-old pilot’s medical history was significant for impairing physical and mental conditions. There was documentation of a previous stroke and Parkinson’s disease that impacted the strength and function of his left and right upper extremities. During his last hospital admission, about 4 months before the crash, the pilot was diagnosed with moderate senile dementia. The pilot’s postmortem toxicology results detected central nervous system depressant medications, including gabapentin and cyclobenzaprine, both of which can adversely interact with one another and worsen impairment, especially in older adults. The pilot’s baseline ability to operate the helicopter is uncertain. Regardless, it is likely that some combination of the pilot’s various physical and mental conditions and his use of potentially impairing medications contributed to the circumstances of the crash.
Ethanol was detected in blood, but not in vitreous fluid or urine. Other volatiles, n-butanol and n-propanol were also detected. It is likely that some, or all, of the detected ethanol was from postmortem production. Thus, it is unlikely that ethanol contributed to the crash.
Probable cause
The non-certificated pilot’s failure to ensure the collective friction control was adequately engaged during an on-ground engine run, which resulted in the helicopter inadvertently becoming airborne. Contributing to the crash were the pilot’s various physical and mental conditions and his use of potentially impairing medications.
Verbatim NTSB analysis and probable cause from the NTSB dataset
Sources
NTSB record CEN23FA183
- Event ID
- 20230515174530
- Case number
- CEN23FA183
- Dataset
- full-current
- Source SHA-256
- 5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
- Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
- Filled from the NTSB case API where the bulk record had no value: investigation status, coordinates, cause areas. Values present in the bulk record are kept.
- The date is the local date, which is the same as the UTC date the NTSB stores.
- API snapshot SHA-256: fde657ad3309efb6a45ddd83f6ff786accb1724c7f75c981433cec6b5b3525a2; retrieved 2026-09-15T07:59:56.539Z.