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ASN Wikibase Occurrence # 45025
Last updated: 22 November 2019
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Date:06-NOV-2003
Time:15:28 PST
Type:Silhouette image of generic R44 model; specific model in this crash may look slightly different
Robinson R44 Raven I
Owner/operator:Robinson Helicopter Company
Registration: N442RH
C/n / msn: 0002
Fatalities:Fatalities: 2 / Occupants: 2
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Location:Zamperini Field, Torrance, California -   United States of America
Phase: Take off
Nature:Training
Departure airport:Zamperini Field, Torrance, California (TOA/KTOA)
Destination airport:
Narrative:
On November 6, 2003, at 15:28 PST (Pacific Standard Time), a Robinson R22 Beta II, N206TV, and a Robinson R44, N442RH, collided in midair while in the traffic pattern at Zamperini Field, Torrance, California. Pacific Coast Helicopters was operating the R22 under the provisions of 14 CFR Part 91. Robinson Helicopter Company was operating the R44 under the provisions of 14 CFR Part 91. The solo student pilot in the R22 sustained serious injuries. The certified flight instructor (CFI) and the private pilot undergoing instruction (PUI) in the R44 sustained fatal injuries.

Both helicopters were destroyed; a post crash fire partially consumed the R44. The R22 departed on a local instructional flight about 14:42 PST. The R44 departed on a local instructional flight about 14:49 PST. Visual meteorological conditions prevailed, and no flight plans had been filed. The R22 came to rest between runways 29R and 29L; approximate global positioning system (GPS) coordinates of the primary wreckage were 33 degrees 48.275 minutes north latitude, and 118 degrees 20.536 minutes west longitude. The R44 came to rest on the departure end of runway 29L; approximate global positioning system (GPS) coordinates of the primary wreckage were 33 degrees 48.277 minutes north latitude and 118 degrees 20.584 minutes west longitude.

The instructor for the solo student had been watching him during his flight. The student flew the R22 from its parking area between taxiways D and E to a helipad north of runway 29R. The student practised on the helipad, and then completed several touch-and-go landings to the helipad. He requested a return to his parking area. Upon hearing this request, the instructor turned the volume of his radio down, and turned away to talk to a bystander.

One witness reported that the R44 was speeding up and increasing in altitude as it took off straight ahead on runway 29L. He first observed the R22 when it was over runway 29R, or slightly north of it. The R22 was starting to descend as it was transiting across the left runway to the southwest, and appeared to be heading toward its landing area.

Other witnesses pointed out that the R22 was above the R44. The R44 seemed to increase its climb rate just before the collision. The two helicopters collided about 50 feet in the air over runway 29L. The R22 spun left several times before it contacted the ground.

A National Transportation Safety Board specialist interviewed the controllers, and obtained recorded radar data. He prepared a factual report, and pertinent parts follow.

Because of technical difficulties with the recordings of the ATC voice channels, times in this report prior to 15:23.02 PST are based on draft transcripts provided early in the investigation. Times after that are valid times.

The R22 pilot first called the LC1 controller at 14:42 PST requesting to fly from the Pacific Coast Helicopters parking area to the North Pad. He did not indicate that he was a student pilot; the controller did not think that he was a student, because his radio technique was good. He flew to the North Pad, which is a helicopter-only practice landing point that is at midfield on the north side of runway 29R.

Pilots operating at the North Pad typically fly right closed traffic patterns at 600 feet msl. They are required to keep their pattern within the lateral confines of the runway 29R displaced thresholds. They are required to contact the LC1 controller for each circuit around the pattern, or if they wish to extend their pattern beyond the 29R threshold limits.

The R44 pilot contacted the LC1 controller at 14:49 PST, and requested a northeast departure from the "antennae site," which is at the intersection of the ramp area and taxiway G. The LC1 controller cleared him for takeoff from runway 29R, and the pilot departed the airport area to the northeast. The R44 pilot returned at 15:05 PST; he reported 6 miles north of the airport, and requested to operate on the North Pad. The controller advised him that the pad was in use (by the R22), and asked the pilot if he wanted to use the runway instead. The pilot accepted, and the controller instructed him to report a 2-mile right base entry. At 15:07 PST, the controller provided a traffic advisory of a departing helicopter, cleared him for the option on runway 29R, and told him to enter right closed traffic. The pilot continued routine traffic pattern operations until 15:25 PST, including landings on runway 29L.

At 15:23.14 PST, the R22 pilot requested a North Pad takeoff and landing at PCH parking. PCH parking referred to the parking area used by Pacific Coast Helicopters. It is west of the tower, on the ramp between taxiways D and E. The controller instructed him to hold, and the pilot acknowledged holding. At 15:24.33 PST, the controller advised him that he could proceed in right traffic to the North Pad after a Cessna passed off his left. At 15:24.56 PST, the R22 pilot transmitted, " takeoff and land PCH parking." At 15:24.59 PST, the LC1 controller responded, "Helicopter six tango victor fly westbound." Between 15:25.18 PST and 15:25.52 PST, there was some confusion caused by the pilot of a departing helicopter (29M) who incorrectly used the call sign 2RH when requesting departure from the ramp area. The controller resolved the confusion.

At 15:26.01 PST, the controller cleared the pilot of the R44 to, "make your base your discretion two niner left cleared for the option", and at 15:26.15 PST, in the same transmission, continued, "helicopter six tango victor make a right turn to the downwind." At 15:26.19 PST, the R22 pilot acknowledged, but only with his call sign. At 15:26.32 PST, the controller again cleared the R44 for the option on runway 29L, and the pilot acknowledged.

At 15:26.59 PST, the controller advised the pilot of the R22, "ah you're gonna cross midfield as soon as I get a chance." At 15:27.17 PST, the controller instructed the R22 pilot to, "turn right," and the pilot acknowledged with his call sign. At 15:27.49 PST, the controller transmitted, "Helicopter six tango victor runway two niner right cleared to land." At 15:27.53 PST, the R22 pilot acknowledged with his call sign. At 15:27.54 PST, the controller transmitted, "turn right helicopter six tango victor runway two niner right cleared to land." There was no communication from the R22 pilot. At 15:28.12 PST, the LC1 controller advised the R44 pilot, "robinson two romeo hotel caution for the helo oh."

A review of recorded radar data showed a target that turned off the right downwind leg, crossed runway 29R, and approached runway 29L in the immediate area of the accident. The last target for this track was at 15:28.10 PST, approximately 2 seconds before the collision. A plot of this track on a street map indicated that it was perpendicular to the runways at 15:27.49 PST, and the target was between Lomita Boulevard and Skypark Drive. At 15:27.54 PST, this target was still approaching Skypark Drive and north of runway 29R. After crossing Skypark about 5 seconds later, the target appeared to turn toward the southwest, and the last two targets were approaching runway 29L at a shallow angle. Another target turned from right downwind to base to final for runway 29L. Its last target appeared at 15:27.15 PST; its track lined up with runway 29L, and was westbound abeam the approach end of runway 29R.

Probable Cause: the student pilot in the R22's failure to comply with an ATC clearance. Registration N442RH was cancelled by the FAA on April 1 2010. A subsequent court case awarded a settlement of $4,500.000 USD: on September 25, 2008 it was reported "US District Judge Florence-Marie Cooper ruled that tower controllers Edward Weber and Cynthia Issa made a series of incorrect and negligent decisions that led to the crash, which killed pilots Robert Bailey and Brett Boyd onboard a Robinson R44." (see links #5, #6, and #7)

Sources:

1. NTSB Accident Number: LAX04FA037B at https://www.ntsb.gov/_layouts/ntsb.aviation/brief2.aspx?ev_id=20031119X01921&ntsbno=LAX04FA037A&akey=1
2. FAA register: http://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?omni=Home-N-Number&nNumberTxt=442RH
3. http://www.griffin-helicopters.co.uk/accidentdetails.aspx?accidentkey=1528
4. https://www.dailybreeze.com/2008/05/07/judge-clears-pilots-in-03-crash/
5. http://www.aero-news.net/index.cfm?do=main.textpost&id=51bc388e-53cc-4204-9973-db1a839dab46
6. https://www.aviationpros.com/press_release/10403344/faa-to-pay-45-million-in-torrance-helicopter-crash-settlement
7. https://www.dailybulletin.com/2008/09/24/faa-settles-in-torrance-crash/
8. http://articles.latimes.com/2008/may/07/local/me-torrance7
9. https://www.pprune.org/rotorheads/108108-r-22-r-44-midair-over-torrance.html


Revision history:

Date/timeContributorUpdates
28-Oct-2008 00:45 ASN archive Added
02-Sep-2016 22:29 Dr.John Smith Updated [Time, Location, Departure airport, Source, Narrative]
21-Dec-2016 19:24 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
08-Dec-2017 20:22 ASN Update Bot Updated [Total occupants, Departure airport, Source, Narrative]
17-Oct-2018 23:50 Dr.John Smith Updated [Time, Aircraft type, Total occupants, Departure airport, Source, Narrative]

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