Loss of control and collision with

terrain involving Robinson

R44 II, registration VH-HOB
near Clare, South Australia, on 22 December 2020

ATSB Transport Safety Report

Aviation Occurrence Investigation (Defined)
AO-2020-064
Final – 8 December 2022
Cover photo: Operator, used with permission

Released in accordance with section 25 of the Transport Safety Investigation Act 2003

Publishing information
Published by: Australian Transport Safety Bureau
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Office: 12 Moore Street, Canberra, ACT 2601
Telephone: 1800 020 616, from overseas +61 2 6257 2463
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Email: [email protected]
Website: www.atsb.gov.au

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Addendum

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Executive summary
What happened
On 22 December 2020, the pilot of a Robinson R44 II helicopter was conducting aerial agricultural
spray operations on a property about 13 km south-east of Clare Valley Aerodrome, South
Australia. After completing numerous spraying runs throughout the morning, the pilot started a
gentle descending turn to the landing site to replenish with chemical product when a loud bang
emanated from the rear of the helicopter. The pilot reported that the helicopter descended rapidly,
and the flight controls appeared to be jammed. The helicopter collided heavily with the loading
vehicle, coming to rest on its side. The pilot and ground crewman were uninjured, and the
helicopter was substantially damaged.

What the ATSB found

The ATSB found that the forward yoke of the helicopter’s clutch shaft had failed due to an
undetected fatigue crack that originated from an indent in one of the arms of the yoke. This
resulted in loss of drive to the main and tail rotor systems. The unrestrained clutch shaft caused
the displacement of the hydraulic reservoir and the loss of fluid. The loss of hydraulic fluid
removed hydraulic power assistance to the flight control servos leading to increased control stick
forces to operate the helicopter.
The pilot experienced difficulties in controlling the helicopter and executed an emergency descent
from a low height without hydraulic power assistance and no tail rotor control. The pilot was
presented with a compound emergency for which no training had been provided and for which
they had no prior experience.
The ATSB found that the helicopter manufacturer’s maintenance instructions requiring verification
that no cracks, corrosion or fretting were present on the yoke, lacked specific instructions on the
method to be employed. The visual inspection that was employed increased the risk that a crack
in the yoke arm may not be detected.

What has been done as a result

The helicopter manufacturer, the Robinson Helicopter Company, introduced new maintenance
inspection requirements for the clutch shaft forward yoke at the 2,200/2,400-hourly inspection for
the R44 helicopter. This included replacement of yokes of earlier revision status (A through G) and
for later revision (H and subsequent), the option of replacement, or a more detailed examination
that included a magnetic particle inspection. This update was included in the R44 maintenance
manual in August 2022. The manufacturer also changed the paint colour of the yokes at the
forward flex coupling from dark grey to white. This was to enhance the visibility of fretting dust
during inspections, in the event of loose hardware.
Following the accident, the ATSB issued a Safety Advisory Notice, AO-2020-064-SAN-014
advising operators of R44 helicopters that based on the preliminary finding of fatigue cracking, to
look for the presence of corrosion, fretting or cracking, which may not be visually obvious during
all inspections of the clutch shaft yoke.
The Civil Aviation Safety Authority issued an Airworthiness Bulletin, AWB 63-010 advising industry
of the failure of the yoke based on the ATSB investigation preliminary finding. It advised pilots and
maintenance personnel to exercise vigilance for any signs of deterioration in the helicopter drive
train components. This was further supported by the release of similar bulletins by the European
Union Aviation Safety Agency and the US Federal Aviation Administration.

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Safety message
This occurrence highlighted how non-life limited components such as a drive train yoke may still
develop defects and fail in-flight. Aircraft owners and maintenance personnel are reminded of the
importance of applying inspection and maintenance criteria specified in the aircraft manufacturer’s
publications. Should maintenance information be lacking or unclear, the manufacturer or
authorised representative should be contacted for appropriate, additional information.
The occurrence also serves as a reminder to pilots and maintenance personnel that when
conducting inspections to be prepared for the unexpected, and to remain vigilant for defects in
parts with an established history of reliability.

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Contents
Executive summary................................................................................................................iii
The occurrence ........................................................................................................................1
Context ......................................................................................................................................3
Pilot information 3
Aircraft information 3
Meteorological information 3
Wreckage information 4
R44 rotor drive system 5
R44 II hydraulic system 6
Yoke examination 7
Manufacturer’s clutch shaft forward yoke inspections 11
Maintenance practices 12
Helicopter emergency procedures 12
Recorded data 13
Related occurrences 15
Safety analysis ...................................................................................................................... 16
Yoke failure and separation 16
Yoke inspections 16
Maintenance instructions for critical item 16
Helicopter control 17
Multiple emergencies 18
Findings ................................................................................................................................. 19
Contributing factors 19
Other (key) finding 19
Safety issues and actions ................................................................................................... 20
Proactive safety action taken by the Robinson Helicopter Company 21
Safety action not associated with an identified safety issue 21
Safety advisory notice to operators of R44 helicopters 21
Additional safety action taken by CASA 21
Additional safety action taken by European Union Aviation Safety Agency (EASA) 22
Additional safety action taken by Federal Aviation Administration (FAA) 22
General details ...................................................................................................................... 23
Glossary ................................................................................................................................. 24
Sources and submissions .................................................................................................. 25
Australian Transport Safety Bureau .................................................................................. 26

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 ATSB – AO-2020-064

The occurrence
On the morning of 22 December 2020, the pilot of a Robinson Helicopter Company R44 II,
registered VH-HOB, prepared the helicopter for aerial agricultural spray operations to be
conducted on a property located about 13 km to the south-east of Clare Valley Aerodrome, South
Australia. The pilot completed the daily inspection and departed the Clare Valley hangar at 0652
Central Daylight-saving Time 1 for the short flight to the loading zone, from where operations would
be based.
The pilot arrived at the loading zone at 0700 and departed at 0702 with the property owner on
board to conduct a short survey flight of the area to be sprayed, returning to the loading zone at
0708. Following the arrival of the ground crewman, the helicopter was loaded with chemical
product, and at 0728 the pilot departed and conducted a series of spraying runs.
Numerous spraying runs were completed during the morning between 0728 and 0920 with the
pilot returning to the loading zone periodically to replenish with chemical product and to refuel the
helicopter. The pilot reported that the operation proceeded smoothly, and the long spray runs with
minimal obstacles made for ideal spraying conditions.
During the final descent to the loading zone at about 0926, the pilot momentarily increased
altitude to gain a better view of a light shower approaching from the south-west, and to assess its
potential impact on further spraying operations. The pilot slowed the helicopter, and once satisfied
that the shower did not pose a threat, started a gentle, right descending turn at 0926:20 towards
the ground loading vehicle with the intent to land alongside as on previous occasions (Figure 1).
Figure 1: VH-HOB flight path showing return to loading zone and descent and inset
providing accident location

Source: Google and DGPS data, annotated by the ATSB

About 10 seconds into the turn, at 0926:30, a loud bang from the rear of the helicopter was heard,
followed by vibrations from the rotor systems. The ground crewman recalled looking up and
seeing that the tail rotor had stopped turning. The pilot reported that the cockpit flight controls
appeared to have jammed and of not being able to move the tail rotor pedals. The helicopter’s rate

1
Central Daylight Time (CDT): Coordinated Universal Time (UTC) +10.5 hours
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 ATSB – AO-2020-064

of descent increased to 550 ft/min and as reported by the pilot, its movement towards the ground
loading vehicle was generally unaffected by the pilot’s attempts at control inputs. The helicopter’s
flight path continued until its landing gear impacted the vehicle’s roof, which resulted in it rolling
onto its right side and colliding with terrain at 0926:46.
The pilot was not injured in the collision and was assisted from the helicopter wreckage by the
ground crewman. There was no post-impact fire, and the helicopter was substantially damaged.

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 ATSB – AO-2020-064

Context
Pilot information
The pilot of VH-HOB held a Commercial Pilot Licence (Helicopter) and a Private Pilot Licence
(Aeroplane), both issued in March 2015. The pilot held class ratings included single engine
helicopters and helicopter low-level rating. From 2017, the pilot also held an aerial application
rating for helicopter operations.
The pilot completed an aerial application proficiency check for single engine helicopters and a
night Visual Flight Rules (Helicopter) flight review for Robinson R44 helicopters on 23 July 2020.
Both were valid until 31 July 2021.
The pilot held a Class 2 Aviation Medical Certificate issued by the Civil Aviation Safety Authority
(CASA), without medical restrictions, which was valid until 23 January 2023.
The pilot’s logbook indicated that at the time of the accident, the pilot had a total flying experience
of about 6,521 hours. Of these, about 1,337 hours were in the Robinson R44 helicopter and
1,018 hours conducting aerial application work. The pilot had flown about 105 hours on type in the
previous 90 days, and about 54 hours on type in the previous 30 days.

Aircraft information
VH-HOB was a Robinson Helicopter Company R44 II helicopter that was manufactured in the
United States in 2005 with serial number 10801. It was first registered in Australia in 2005.
The R44 II is a single-engine, light utility and training helicopter with a semi-rigid, two-bladed main
rotor, a two-bladed tail rotor and skid type landing gear. It had an enclosed cabin with two rows of
side-by-side seating for a pilot and three passengers.
The helicopter was powered by a Textron Lycoming IO-540-AE1A5, 6-cylinder, fuel-injected piston
engine and was fitted with hydraulic servo-actuators providing hydraulic power assistance to the
main rotor, flight control system.
VH-HOB was configured for aerial application work that included a belly-mounted storage tank
and laterally mounted spray booms for chemical product dispersal.
The helicopter’s current maintenance release was issued on 20 October 2020, about 92 flight
hours prior to the accident. It was valid for 12 months or 100 hours, whichever occurred sooner. At
the time of the accident, VH-HOB had accumulated about 4,579 hours, total time-in-service. There
were no open defects recorded on the maintenance release and no outstanding or overdue
maintenance was noted.
Maintenance records also showed that about 188 flight hours prior to the accident, at an aircraft
time-in-service of 4,391.0 hours, an airframe 2,200-hour/12-year inspection was completed.

Meteorological information
The forecast meteorological conditions for Clare Valley Aerodrome (13 km north-west of the
accident site) area, indicated winds from the south-south-west at 19 kt and a temperature of
12 ⁰C. Visibility was forecast to be greater than 5 km with isolated showers of rain and broken
cloud above 1,200 ft.
The METAR 2 for Clare Valley township issued at 0930 recorded wind from the south-west at 7 kt
and a temperature of 14 ⁰C. This was consistent with witness in the accident area who reported
that some cloud was present with isolated showers to the south.

2
METAR: a routine aerodrome weather report issued at routine times, hourly or half-hourly
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 ATSB – AO-2020-064

Wreckage information
The ATSB did not attend the accident site and based assessment of the helicopter on imagery
and reports supplied by the operator, maintenance personnel, interview records and witness
account.
The helicopter presented as relatively intact with the tailboom broken aft of its forward mount
point. The operator’s examination identified that one of the arms of the clutch shaft forward yoke
had fractured resulting in loss of drive to the main and tail rotor systems. The tubular steel
structure surrounding the shaft was damaged by the rotation of the unrestrained clutch shaft. The
hydraulic reservoir was also found displaced from its mounting base and was located within the
wreckage (Figure 2).
Figure 2: VH-HOB following the collision with inset showing clutch shaft with upper drive
sheaves and displaced hydraulic reservoir

Source: Supplied, annotated by the ATSB

Following the accident, attending maintenance personnel reported they conducted a functional
check of the flight control system and found the cyclic 3 and collective 4 controls had full and free
movement. However, one of the tail rotor control tubes exhibited bending damage that was likely
the result of contact with the unrestrained clutch shaft.
Both the pilot and the ground crewman reported that the engine stopped operating shortly before
the collision. Images showed that a cutting action of the unrestrained clutch shaft forward yoke
(see R44 rotor drive system below) penetrated the engine upper firewall and damaged the engine

3
Cyclic: a primary helicopter flight control that is similar to an aircraft control column. Cyclic input tilts the main rotor disc,
varying the attitude of the helicopter and hence the lateral direction.
4
Collective: a primary helicopter flight control that simultaneously affects the pitch of all blades of a lifting rotor. Collective
input is the main control for vertical velocity.
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 ATSB – AO-2020-064

fuel system flow divider located on the engine below. The yoke perforated the flow divider top
housing, which likely interrupted fuel flow to the engine, resulting in engine stoppage.
Both of the fuel tanks were found intact and there was little external distortion of the auxiliary tank
following the impact with the ground.
At interview, the ground crewman commented that the helicopter was observed to approach at a
low rate of descent, and had it not struck the vehicle, the landing would likely have resulted in
significantly less damage to the helicopter.

R44 rotor drive system

The clutch shaft forward yoke assembly is part of the R44 rotor drive system. The R44 pilot’s
operating handbook provided the following description of the main and tail rotor drive system and
is illustrated in Figure 3.
A vee-belt sheave is bolted directly to the engine output shaft. Vee-belts transmit power to the upper
sheave which has an overrunning clutch contained in its hub. The inner shaft of the clutch transmits
power forward to the main rotor and aft to the tail rotor. Flexible couplings are located at the main
gearbox input and at each end of the long tail rotor drive shaft.

Figure 3: R44 drive train with inset showing clutch shaft forward yoke and flex plate
providing input power to the main and tail rotor gearboxes

Source: Robinson Helicopter Company R44 maintenance manual, annotated by the ATSB

Images provided by maintenance personnel showed that during the accident sequence, the
vee-belts had dislodged from the upper sheave.
A manual, cable operated rotor brake was mounted on the aft end of the main gearbox and when
applied via the pull handle in the cabin ceiling, friction pads of the braking mechanism would
contact the main gearbox input yoke to stop the rotor system. Images showed that the actuating

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 ATSB – AO-2020-064

cable was displaced from its guide pulley and was disconnected from the braking mechanism
(Figure 4).
Figure 4: Rotor brake mechanism minus actuating cable attached and trapped wire
material around the main gearbox input yoke shaft

Source: Maintenance organisation, annotated by the ATSB

The action of separating the cable from the braking mechanism likely caused the rotor brake to be
momentarily actuated, and while considered minimal, may have affected the speed of the main
rotor system.

R44 II hydraulic system

The R44 II hydraulic system consists of a pump mounted to the main rotor gearbox, a servo at
each of the control tubes connecting the cockpit controls to the swashplate, a reservoir assembly,
hydraulic fluid and interconnecting flexible hoses (Figure 5). Should a loss of hydraulic pressure
occur, the servos contain an irreversible feature to reduce main rotor feedback forces to the pilot’s
controls. However, in the absence of hydraulic pressure, the manufacturer advised that the cyclic
control system is harder to move in the fore-and-aft and lateral planes, while the collective control
can be easily lowered, but becomes harder to raise.

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 ATSB – AO-2020-064

Following the accident, the hydraulic system was provided to the ATSB for further examination.
Without hydraulic pressure applied, examination of each servo showed that the irreversible feature
was functional. The forces required to move each servo were noted to be slightly higher in
comparison to new servos but were considered acceptable.
The hydraulic reservoir had separated from the hydraulic manifold mounted to the tubular frame
likely from the clutch shaft striking the manifold (mounting location circled, Figure 5). This resulted
in significant loss of hydraulic fluid. The ATSB’s examination of the hydraulic reservoir revealed
multiple impact marks attributed to striking, or being struck repeatedly by a rotating component,
likely the main gearbox input yoke.
Figure 5: Hydraulic system and main gearbox installation from VH-HOB

Source: Maintenance organisation, annotated by ATSB

Yoke examination
The clutch shaft with the fractured yoke arm, the forward flex plate and the attaching hardware
were provided to the ATSB for detailed examination (Figure 6). A portion of the flex plate that
remained connected to the yoke and the separated section of the arm was also provided for
examination.
The yoke presented with one arm intact, to which a portion of the forward flex plate and its
attaching hardware were present. The opposite arm had fractured at the bolt hole that secured the
arm to flex plate.
The surfaces of the yoke presented with scoring marks and indentations to the painted surfaces.
Mechanical impact damage and gouging was also present with smearing damage to the arm
fracture surfaces obscuring some of the original fracture features.

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 ATSB – AO-2020-064

Figure 6: Fractured forward yoke arm with inset showing clutch shaft assembly and flex
plate

Source: ATSB

A detailed visual inspection of the yoke arms using an optical microscope and a magnetic particle
inspection of the yoke surfaces and bolt hole regions, did not identify additional cracks.
Red-coloured corrosion products were observed on the forward face of the yoke where it
contacted the bonded stainless-steel washer from of the forward flex plate (Figure 7). Fretting
damage was present on the aft face that was in contact with the attaching hardware. Microscopic
examination of the red-coloured product identified it to have been produced from general
corrosion/oxidation of the underlying steel surface. There were no indications of pitting corrosion.

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 ATSB – AO-2020-064

Figure 7: Fractured yoke arm and separated section front and rear surface condition

Source: ATSB

Visual examination of the fracture surfaces on either side of the bolt hole showed evidence of
fatigue fracture. The fracture surface showed concentric beach marks indicative of a progressive
crack mechanism, which radiated outwards from the likely origin at the inner bolt hole surface on
the front face of the yoke (Figure 8). The fatigue crack had propagated from the front to the aft
face, and initially obscured from view by the presence of the attaching hardware.
Crack propagation continued across a substantial portion of the cross section (about 98% of
fracture # 1 and about 80% of fracture #2), with a visible portion on the rear face of about 6 mm
before final overstress fracture and separation occurred.

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 ATSB – AO-2020-064

Figure 8: Separated yoke tip with fracture features identified

Source: ATSB

A scanning electron microscope (SEM) was used to further qualify the fracture surfaces at high
magnifications. The SEM examination confirmed:
• many hundreds of crack progression bands were observed, which indicated crack growth
occurred as a result of high-cycle fatigue 5
• surface damage (an indent) approximately 0.10 mm in depth at the fatigue crack origin of
fracture #1 had likely influenced the initiation of cracking within the yoke arm at the point of
fracture
• a clear boundary on the fracture surface existed between the region of corrosion and the
region that was not corroded (Figure 9).

5
Failure mechanism associated with high frequency vibration, flexing or rotation of machinery, typically at a rate of many
times per second.
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 ATSB – AO-2020-064

Figure 9: Fracture surface of separated section showing corrosion boundary with inset
showing crack surface discoloration

Source: ATSB

Metallurgical, chemical and dimensional analysis established that the yoke conformed to the
manufacturer’s specification for material type, hardness, and physical dimensions.
Overall corrosion protection had been specified by the manufacturer that was for the yoke to be
cadmium-plated, primed and then painted. These corrosion protection schemes were confirmed
during metallurgical examination of the yoke.

Manufacturer’s clutch shaft forward yoke inspections

The manufacturer’s instructions for continuing airworthiness of the clutch shaft forward yoke (part
number C907) were contained in the Robinson R44 II pilot’s operating handbook (POH) and the
aircraft maintenance manual. The following was noted:
• At each daily or pre-flight inspection, the yoke flanges 6 (yoke arms) were to be checked. No
cracks were permitted.
• At each 100-hour or annual airframe inspection, the yoke was to be checked for condition and
to verify no cracks, corrosion or fretting was present. The yoke was also to be checked for
security and operating clearance.
• At each 2,200-hour inspection, a 100-hour or annual inspection is also conducted, and the
yoke was to be checked for condition. Additionally, the aircraft maintenance manual provided a
list of components that were to be replaced with new or overhauled exchanged parts when

6
Yoke flanges or arms: interchangeable terms used by the manufacturer to describe the connecting surfaces of the yoke
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 ATSB – AO-2020-064

they had accumulated 2,200/2,400-hours time-in-service. There was no requirement for the
yoke to be replaced with a new or overhauled part once those hours had accumulated.
Other than for unscheduled maintenance, the yoke was only separated from the forward flex plate
(see Figure 3 insert) when parts were replaced at their assigned 2,200/2,400-hour service interval.
The yoke was treated as an ‘on-condition’ item and was not assigned an operating time-in-service,
fatigue, or calendar life-limit.
Maintenance personnel reported that when installed, the yoke can be viewed on a daily inspection
via an access panel located on the right side of the helicopter. During the 100-hour or annual
inspection, the yoke can also be inspected from above when the upper panel between the fuel
tanks was removed. It was noted that cracking on the front face of the yoke arm would not be
visible during these inspections as there was no requirement to remove the yoke from the flex
plate.
The aircraft maintenance manual specified a range of examination methods for the detection of
defects and identified specific parts that warranted examination above that provided by visual
inspection means. Higher levels of examination for nominated parts included the use of a suitably
powered magnifying glass, and fluorescent penetrant and magnetic particle inspection processes.
However, the yoke was not included in the nominated parts list.

Maintenance practices
The pilot reported that on the day of the accident, a pre-flight inspection was completed, and no
defects were noted. Maintenance personnel also reported that no defects associated with the
forward yoke were noted during the 100-hour inspection that was conducted 92 hours prior to the
accident.
During the most recent 2,200-hour inspection, the helicopter’s main rotor gearbox was refitted,
and the three flex plates of the rotor system drive train were replaced with new items.
Records showed that the engine-to-gearbox clutch shaft assembly had been replaced about
701 hours prior to the 2,200-hour inspection with the forward yoke transferred to the replacement
shaft. This may have provided another opportunity for detailed inspection of all yoke surfaces.
Maintenance personnel involved in the 2,200-hour inspection reported that at the time of replacing
the flex plates, following separation from the forward flex plate, the yoke surfaces were visually
examined for defects and the yoke was determined to be serviceable.
The manufacturer advised that yokes were commonly removed from service due to the presence
of corrosion or fretting damage, but not due to cracks. When forward yokes were returned to the
manufacturer as part of the clutch shaft for overhaul, the surface finish was removed, and a
magnetic particle inspection for defects would be completed prior to release to service.

Helicopter emergency procedures

Hydraulic system normal and emergency procedures
The R44 II POH advised pilots that for training purposes, a hydraulic system failure may be
simulated by switching the hydraulic system off by using the cyclic-mounted hydraulic switch. With
hydraulics switched off, controlling the helicopter in a hover may be difficult due to control system
feedback forces.
The handbook also advised pilots to expect control stiffness and feedback when conducting
hydraulic systems checks or pre-take off control checks with the hydraulic system switched off.
The handbook described the symptoms for a hydraulic system failure as indicated by heavy or stiff
cyclic and collective controls, and loss of hydraulic fluid may cause intermittent and/or vibrating
feedback in the controls. Should that occur, the POH stated that control of the helicopter would be
normal except for the increase in stick forces. Additionally, if hydraulic power was not restored
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 ATSB – AO-2020-064

after verifying that the hydraulic switch is in the ‘ON’ position, the pilot is to switch hydraulics to
‘OFF’ and to land as soon as practical.

Engine power loss or loss of tail rotor function

In the event of an engine or drive system failure, the POH advised pilots to immediately lower the
collective lever and enter autorotation 7 while observing airspeed requirements. Pilots were also
instructed to enter an autorotation if loss of tail rotor thrust in forward flight occurs.
An autorotation is typically conducted at a specified forward airspeed and rotor RPM at which a
power-off glide is most efficient. Autorotation airspeed and RPM is different for each helicopter
type and is characterised as a controlled descent. The flight controls are used to manoeuvre the
helicopter during the autorotation, through to completion of the landing sequence.
Although the tail rotor is used to counteract the yawing effect of the main rotor at low speed, a loss
of tail rotor control or drive to the tail rotor, is manageable provided adequate airspeed is
maintained, as directional stability is provided by the helicopter’s vertical and/or dorsal fin.
Pilots are trained to perform autorotational descents, and autorotational capability is a certification
requirement for helicopters.
At interview, the pilot reported that simulated engine failures, tail rotor system malfunctions and
hydraulic failures were practised during training and flight reviews. However, they were trained
and assessed as independent emergencies and were never conducted simultaneously as a
compound emergency.

Recorded data
VH-HOB was not equipped with a flight data or cockpit voice recorder, nor was it required to be.
Differential GPS 8 flight path data from the on-board SatLoc Bantam 9 aerial application tracking
device was provided to the ATSB.
Speed and position data from the SatLoc device was used in the analysis of the helicopter’s
movements in the final 3 minutes of flight (Table 1).

7
Autorotation, also known as an autorotational descent, is a power off manoeuvre in which the engine is disengaged
from the main rotor system and the rotor blades are driven solely by the upward flow of air through the main rotor.
8
Differential GPS: an enhancement to global navigation satellite system (GNSS) systems. A differential GPS base
station broadcasts a correction signal that allows differential GPS devices to provide sub-metre positional accuracy
relative to the base. If the position of the base is precisely known, this allows for high absolute positional accuracy.
9
SatLoc Bantam: a proprietary aerial application guidance system utilising differential GPS signals.
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 ATSB – AO-2020-064

Table 1: Key events involving VH-HOB during the final minutes of flight with approximate
values of flight behaviour
Time VH-HOB movements Height above Ground Rate of Rate of track
ground level speed descent change
(ft) (kt) (ROD) (fpm)
(⁰ per minute)

0924:06 Pilot returning to loading zone, 250 19

slows prior climbing flight from
about 160 to 40 fpm.

0924:08 Pilot commences descent to 20 60

loading zone

0925:44 Bottom of descent 62 21 0

0925:46 Pilot initiates a climb, rate of 64 20

climb about 60 fpm

0926:18 Approaching top of climb, pilot 124 5

slows rate of climb to about 20
fpm

0926:20 Helicopter on descent 122 5 60

0926:28 Bang heard (estimated time of 104 4 200 475

noise)

0926:30 Descent 94 5 335 416

0926:36 Descent – maximum ROD 43 8 550 207

0926:38 Descent 30 10 413 232

0926:40 Descent 18 10 314 133

0926:42 Descent 10 11 236 74

0926:44 Descent 5 10 160 11

0926:46 Helicopter collides with 9 160

vehicle/terrain

From 09:26:40 to collision at 09:26:46, the aircraft track varied by about 4 degrees. In the last two
seconds of flight, the track varied by less than one degree, and aligned the helicopter’s movement
with the position of the stationary ground vehicle (Figure 10).

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 ATSB – AO-2020-064

Figure 10: VH-HOB flight path showing landing approach with momentary climb and
descent towards ground vehicle

Source: Google, annotated by the ATSB

Related occurrences
This accident involving the clutch shaft forward yoke (part number C907) was the first occurrence
to be investigated by the ATSB that involved an in-flight failure of a yoke on a helicopter model in
the Robinson range.
Robinson advised of no other reports of fatigue cracks associated with forward yokes. Searches of
the CASA, the US Federal Aviation Administration (FAA) and New Zealand Civil Aviation Authority
(CAA) Service Difficulty Report databases did not reveal other documented cases of fatigue
related cracking.
There was one similar R44 occurrence, involving loss of drive to the main and tail rotor due to
weld failure of the forward yoke. The incident occurred during cruise flight in which the pilot heard
a bang and experienced a loss of tail rotor effectiveness due to the failure of a weld joint in the
forward yoke.
As a result of this incident, an airworthiness directive was issued by the FAA in August 1999 (FAA
Priority Letter Airworthiness Directive AD 99-17-17), requiring the replacement of certain yoke
assemblies in R44 helicopters before further flight. The manufacturer identified manufacturing lots
associated with the failed yoke and retired the affected yokes from service. If uncorrected, the
FAA advised that the condition could result in failure of the yoke assembly, loss of main and tail
rotor drive, and subsequent loss of control of the helicopter. In October 1999, CASA issued
AD/R44/13 in support of FAA action.

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 ATSB – AO-2020-064

Safety analysis
The collision with terrain involving Robinson R44 II VH-HOB, about 13 km south-east of Clare
Valley Aerodrome, South Australia, was the result of the loss of drive to the main and tail rotor
systems due to fracture of the clutch shaft forward yoke. This analysis will focus on the failure of
the yoke, the emergency descent, and the subsequent collision with terrain. The analysis will also
consider maintenance information for the continued airworthiness of the yoke and management of
in-flight emergencies.

Yoke failure and separation

The yoke failed as a result of fatigue crack propagation that initiated on the forward face of the
yoke arm coincident with the bolt hole. On one side, the crack had initiated from a mechanical
surface defect. The fatigue cracking was assessed to have propagated slowly as evidenced by the
many hundreds of crack progression bands, with failure of the yoke arm occurring when minimal
intact cross-sectional area remained.
A distinctly corroded region was identified on the forward-most surface of the yoke. A similarly
corroded/stained region was identified on the fracture surface. The corroded regions were
underneath where the bonded washer from the forward flex plate would normally be clamped. The
varying nature of the corrosion within the fatigue crack and the demarcation between the various
regions suggested that the crack had existed during an overhaul cycle of the component.
Following the fracture of the yoke, the clutch shaft became disconnected from the main gearbox
creating misalignment of the upper and lower sheaves and displacement of the vee-belts. This
resulted in a loss of drive from the engine to both the main and tail rotor systems. The loss of drive
committed the pilot to find a suitable place to land the helicopter while conducting an emergency
descent without tail rotor control.

Yoke inspections
The manufacturer’s in-service requirements for yoke serviceability specified that the yoke be
inspected for cracks, fretting or corrosion at specific intervals that included the daily inspection, at
scheduled time in service intervals and during the 2,200-hour inspection.
The drive train was inspected on the morning of the accident flight and at the previous scheduled
inspection, and no defects were found. However, with the yoke connected to the forward flex
plate, there was no opportunity to visually detect the crack on the forward face during the daily and
100-hour inspections. Once the crack had progressed to the rear surface of the yoke arm, it would
have been difficult to see, given that the crack was estimated to be about 6 mm in length, and the
area would have needed to have been sufficiently clean.
The only opportunity for detecting a crack initiating on the front face of the yoke would be when all
yoke surfaces were exposed and not obscured by the presence of the flex plate and attaching
hardware. This would be at the 2,200-hour inspections, or at unscheduled clutch shaft or flex plate
removal. The last time the yoke was separated from the forward flex plate was at the recent
2,200-hour inspection, about two months and 188 flight hours prior to the accident.
The presence of corrosion deposits in part of the cracked region indicated that the crack was likely
present at that inspection. Once the yoke arm was re-installed, the forward face was obscured by
the flex plate and the crack would not have been visible during the subsequent routine
inspections.

Maintenance instructions for critical item

The forward yoke was not assigned a service life by the manufacturer so its continuation in
service was dependent on it meeting specific inspection criteria to determine on-going
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serviceability. The maintenance instructions for continued airworthiness specified that the yoke be
inspected for condition, and maintenance personnel were required to verify that no cracks,
corrosion or fretting was present. No specific method on how to accomplish this was provided in
the manufacturer’s documentation, and as such, a visual inspection would be acceptable.
Defects related to corrosion and fretting damage are likely detected by the un-aided eye, but crack
identification may be not as obvious. At the 2,200-hour inspection, the yoke was separated from
the forward flex plate and the visual inspection method that was used to detect cracks that existed
on the helicopter’s forward yoke, was unsuccessful.
The methods used to verify the absence of cracks varied between this maintenance organisation
and the aircraft manufacturer. When yokes were returned to the manufacturer as part of the clutch
shaft assembly, the yokes were subject to magnetic particle inspection, which would have a
greater chance of identifying a crack than visual inspection alone. This suggested that the
inspection instruction was open to interpretation and was not consistently applied.
On this occasion, the failure of the yoke led to a loss of drive to both the main and tail rotor
systems. The failure of this critical item further resulted in a secondary failure of the hydraulic
system under the action of the unrestrained clutch shaft. This presented the pilot with a compound
emergency resulting in an emergency descent and subsequent collision with the ground vehicle
and terrain.
The reliability of the yoke and lack of history of removal from service due to cracking, likely
influenced the use of visual inspection methods and reduced the expectation for a crack to be
present. However, that further reduced the probability of detecting the crack when all the yoke
surfaces are available for inspection.

Helicopter control
The pilot reported that when the yoke fractured the helicopter was configured for a gentle descent
and turn towards the loading vehicle. However, the consequential failures that followed the failure
of the yoke, which included a loss of tail rotor drive, resulted in degraded directional control. The
pilot also reported that the cyclic and collective controls felt like they were jammed.
The significant bending of the tail rotor pitch control tube following impact by the intermediate flex
coupling/clutch shaft aft yoke, likely restricted the movement of the tail rotor pedals, adding to the
sense of difficulty in controlling the helicopter.
Post-accident examination of the collective and cyclic control systems found that they moved
freely within their travel range. The loss of hydraulic power assistance would have increased the
cyclic and collective feedback forces required by the pilot to control the helicopter. An unexpected
increase in the control forces while flying with a normal relaxed grip on the cyclic and collective
might have led the pilot to perceive the controls were jammed.
The multiple impact marks that presented on the hydraulic reservoir body indicated that the
reservoir had become dislodged in flight rather than when the helicopter collided with terrain. The
ATSB considered the possibility that the displaced hydraulic reservoir impeded the movement of
the hydraulic servos or their control system, or that in the attempt to position the helicopter away
from the ground vehicle, the flight controls were moved to their mechanical stops, which prevented
further movement. However, based on the evidence available, neither of these possibilities could
be confirmed.
The pilot’s usual practice was to land beside the loading vehicle to enable replenishment of
chemical product and had configured the helicopter accordingly. Analysis of the flight path
following the initial turn towards the ground support vehicle, revealed that the helicopter’s rate of
descent repeatedly changed, as did the rate of turn as it approached the vehicle. This suggested
that the helicopter was likely responding to some pilot control inputs and therefore some control of

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the helicopter was likely available. However, it was insufficient for the pilot to avoid a collision with
the loading vehicle.

Multiple emergencies
The pilot reported that during their initial training and subsequent flight reviews, there was a
requirement to demonstrate competency in performing autorotational descents and flying and
landing the helicopter without hydraulic power assistance. However, there was no requirement to
conduct compound major emergencies, such as the loss of tail rotor control coupled with a loss of
hydraulic power assistance.
The hydraulic pump is driven by the helicopter’s main gearbox, so the hydraulic system is
expected to continue providing hydraulic power during autorotation training. Consequently, this
accident presented the pilot with a scenario for which they had no prior experience. It also
occurred at a low height and low forward speed, which provided the pilot with very little time to
diagnose the situation and manage the emergency landing.

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Findings
ATSB investigation report findings focus on safety factors (that is, events and conditions that
increase risk). Safety factors include ‘contributing factors’ and ‘other factors that increased risk’
(that is, factors that did not meet the definition of a contributing factor for this occurrence but
were still considered important to include in the report for the purpose of increasing awareness
and enhancing safety). In addition, ‘other findings’ may be included to provide important
information about topics other than safety factors.
Safety issues are highlighted in bold to emphasise their importance. A safety issue is a
safety factor that (a) can reasonably be regarded as having the potential to adversely affect the
safety of future operations, and (b) is a characteristic of an organisation or a system, rather than
a characteristic of a specific individual, or characteristic of an operating environment at a
specific point in time.
These findings should not be read as apportioning blame or liability to any particular
organisation or individual.

From the evidence available, the following findings are made with respect to the loss of control
and collision with terrain involving Robinson R44, VH-HOB, near Clare, South Australia, on 22
December 2020.

Contributing factors
• Fatigue cracks in the clutch shaft forward yoke progressed until the yoke fractured during
operation, which led to a loss of drive to the main rotor system that necessitated an emergency
descent.
• During the emergency descent from a height of about 100 feet, the pilot experienced difficulties
in controlling the helicopter and was unable to avoid colliding with the ground vehicle, which
increased the severity of the collision with terrain.
• Although it was very likely that a crack was present when the clutch shaft yoke was last
disassembled from the forward flex plate, it was not detected during inspection. Once
assembled, the crack, which had formed on the forward face of the yoke arm, was obscured by
the presence of the flex plate.
• Although the helicopter manufacturer’s instructions for continuation in service for the
clutch shaft forward yoke specified that the condition of the yoke was to be inspected to
verify that no cracks, corrosion, or fretting was present, it did not provide specific
instructions for the method to be employed. The visual inspection that was employed
increased the risk that a crack in that area may not be detected [Safety issue].

Other (key) finding

• The emergency descent was performed without hydraulic power assistance to the main rotor
control systems and without drive to the tail rotor. That required the pilot to manage
simultaneous emergencies that were not concurrently presented during training sessions and
for which they had no prior experience.

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 ATSB – AO-2020-064

Safety issues and actions

Central to the ATSB’s investigation of transport safety matters is the early identification of safety
issues. The ATSB expects relevant organisations will address all safety issues an investigation
identifies.
Depending on the level of risk of a safety issue, the extent of corrective action taken by the
relevant organisation(s), or the desirability of directing a broad safety message to the aviation
industry, the ATSB may issue a formal safety recommendation or safety advisory notice as part
of the final report.
All of the directly involved parties are invited to provide submissions to this draft report. As part
of that process, each organisation is asked to communicate what safety actions, if any, they
have carried out or are planning to carry out in relation to each safety issue relevant to their
organisation.
The initial public version of these safety issues and actions will be provided separately on the
ATSB website on release of the final investigation report, to facilitate monitoring by interested
parties. Where relevant, the safety issues and actions will be updated on the ATSB website
after the release of the final report as further information about safety action comes to hand.

Critical item
Safety issue description
Although the helicopter manufacturer’s instructions for continuation in service for the clutch shaft
forward yoke specified that the condition of the yoke was to be inspected to verify that no cracks,
corrosion, or fretting was present, it did not provide specific instructions for the method to be
employed. The visual inspection that was employed increased the risk that a crack in that area
may not be detected.

Issue number: AO-2020-064-SI-01

Issue owner: Robinson Helicopter Company

Transport function: Aviation: Maintenance

Current issue status: Closed – Adequately addressed
Issue status The ATSB is satisfied that the amendments to the aircraft maintenance manual will result
justification: in yokes being removed from service before cracks on the forward face progress to
failure. As such, the ATSB considered that the safety issue had been adequately
addressed.

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 ATSB – AO-2020-064

Proactive safety action taken by the Robinson Helicopter Company

Action number: AO-2020-064-PSA-04
Action organisation: Robinson Helicopter Company

Action Date: August 2022

Action status: Closed

On advice from the FAA, the helicopter manufacturer conducted a risk assessment that resulted in
no need for immediate airworthiness action but did recommend long term airworthiness action.
The helicopter manufacturer advised the ATSB that as a result, they would be introducing new
requirements for the clutch shaft forward yoke at the 2,200/2,400-hour inspection. This included
replacement of yokes with earlier revisions (A through G), or the option of replacement or a more
detailed inspection, including a magnetic particle inspection, for later revisions. This update was
included in the R44 maintenance manual in August 2022.
The helicopter manufacturer also advised that as a result of the contributing safety issue, they
initiated additional safety action by revising the paint colour of the yokes at the forward flex
coupling from dark grey to white. The colour change was to enhance the visibility of fretting dust
during inspections in the event of loose hardware.

Safety action not associated with an identified safety issue

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant
organisations may proactively initiate safety action in order to reduce their safety risk. All of the
directly involved parties are invited to provide submissions to this draft report. As part of that
process, each organisation is asked to communicate what safety actions, if any, they have
carried out to reduce the risk associated with this type of occurrences in the future. The ATSB
has so far been advised of the following proactive safety action in response to this occurrence.

Safety advisory notice to operators of R44 helicopters

SAN number: AO-2020-064-SAN-014
SAN release date: 5 November 2021

The ATSB advises operators of R44 helicopters to note the preliminary finding of this accident and
to look for the presence of corrosion, fretting or cracking, which may not be visually obvious,
during all inspections of the clutch shaft yoke. Any identified defects should be notified to both the
ATSB and the Civil Aviation Safety Authority.

Additional safety action taken by CASA

CASA issued Airworthiness Bulletin AWB 63-010 Issue 1 to inform owners, registered operators,
maintenance organisations and Licensed Aircraft Maintenance Engineers of a failure in a
Robinson R44 drive train component (the yoke) that was found by the ATSB during investigation
AO-2020-064 and that the ATSB has issued a Safety Notice AO-2020-064-SAN-014 to highlight
the component failure.
A revision to the AWB (Issue 2) was issued by the CASA on 23 September 2021. Further to
original references that signs of loose fasteners, corrosion or discolouration warrant further
investigation, Issue 2 advised that further investigation may require the use of specialised
inspection methods such as non-destructive testing (NDT). The manufacturer's maintenance data
should be consulted and if lacking sufficient detail for the required inspection or method/s, then the
manufacturer is to be contacted for the appropriate inspection data, or if a specialised inspection is
required, then the inspection data will need to be generated and approved under civil aviation
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legislation. Further, any specialised inspections will need to be conducted using approved data by
an appropriately authorised person.

Additional safety action taken by European Union Aviation Safety Agency

(EASA)
Following the release of CASA AWB 63-010 Issue 1 dated 21 June 2021, EASA issued Safety
Information Bulletin No. 2021-13 on 29 June 2021 advising owners and operators that EASA
concurs with the AWB's recommendations and to ensure that owners and operators are aware of
the recommendations.

Additional safety action taken by Federal Aviation Administration (FAA)

Following receipt of a report of a failed C907 yoke in the R44 main rotor drive system, the FAA
issued a Special Airworthiness Information Bulletin (SAIB: AIR-22-08) to remind owners and
operators of any Robinson R44 rotorcraft of the importance of adhering to existing inspection
procedures in the applicable operating handbooks and maintenance manuals.

The SAIB advised of the presence of a fatigue crack near the bolt hole of the arm of the C907
yoke, and that an initial metallurgical examination found corrosion products and fretting damage
on the surface near the fatigue crack. The yoke failure may have been caused by corrosion and/or
improper hardware torque. Further, inadequate inspection and maintenance of all driveshaft yokes
may result in undetected wear and/or corrosion that could lead to yoke failure and loss of main
and tail rotor drive.

The FAA recommended that owners and operators of R22 and R44 series rotorcraft follow
Robinson's published pre-flight inspection and periodic maintenance criteria regarding main and
tail rotor driveshaft yokes in order to prevent future failures.

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General details
Occurrence details
Date and time: 22 December 2020, 0927 CDT
Occurrence class: Accident
Occurrence categories: Loss of control, Collision with terrain, Flight controls
Location: Clare Valley (ALA), South Australia, 135° T 13Km
Latitude: 33º 45.702' S Longitude: 138º 42.996' E

Aircraft details
Manufacturer and model: Robinson Helicopter Company R44 II
Registration: VH-HOB
Operator: County Helicopters Pty Ltd
Serial number: 10801
Type of operation: Aerial Work-Aerial Agriculture – (Aerial Work)
Activity: General aviation–Aerial work-Agricultural spreading / spraying
Departure: Clare Valley
Destination: Clare Valley
Persons on board: Crew – 1 Passengers – 0
Injuries: Crew – 0 Passengers – 0
Aircraft damage: Substantial

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 ATSB – AO-2020-064

Glossary
AD Airworthiness Directive
ATSB Australian Transport Safety Bureau
AWB Airworthiness bulletin
CASA Civil Aviation Safety Authority
DGPS Differential Global Positioning System
EASA European Union Aviation Safety Agency
FAA Federal Aviation Administration
CAA Civil Aviation Authority
GPS Global Positioning System
METAR Meteorological Terminal Air Report
POH Pilot Operating Handbook
RHC Robinson Helicopter Company
SAN Safety Advisory Notice
SDR Service Difficulty Report
TAF Terminal Aerodrome Forecast

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 ATSB – AO-2020-064

Sources and submissions

Sources of information
The sources of information during the investigation included the:
• accident witnesses
• aircraft manufacturer
• Bureau of Meteorology
• Civil Aviation Safety Authority
• maintenance organisations for VH-HOB
• County Helicopters Pty Ltd
• photographs and videos taken on the day of the accident
• pilot of the accident flight
• recorded data from the DGPS unit on the aircraft.

References
Federal Aviation Administration (2019), Helicopter Flying Handbook, U.S. Department of
Transportation, FAA-H-8083-21B

Submissions
Under section 26 of the Transport Safety Investigation Act 2003, the ATSB may provide a draft
report, on a confidential basis, to any person whom the ATSB considers appropriate. That section
allows a person receiving a draft report to make submissions to the ATSB about the draft report.
A draft of this report was provided to the following directly involved parties:
• aircraft manufacturer
• Civil Aviation Safety Authority
• County Helicopters Pty Ltd
• pilot of the accident flight
• maintenance organisations for VH-HOB.
Submissions were received from:
• aircraft manufacturer
• Civil Aviation Safety Authority
The submissions were reviewed and, where considered appropriate, the text of the report was
amended accordingly.

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 ATSB – AO-2020-064

Australian Transport Safety Bureau

About the ATSB
The ATSB is an independent Commonwealth Government statutory agency. It is governed by a
Commission and is entirely separate from transport regulators, policy makers and service
providers.
The ATSB’s purpose is to improve the safety of, and public confidence in, aviation, rail and
marine transport through:
• independent investigation of transport accidents and other safety occurrences
• safety data recording, analysis and research
• fostering safety awareness, knowledge and action.
The ATSB is responsible for investigating accidents and other transport safety matters involving
civil aviation, marine and rail operations in Australia, as well as participating in overseas
investigations involving Australian-registered aircraft and ships. It prioritises investigations that
have the potential to deliver the greatest public benefit through improvements to transport
safety.
The ATSB performs its functions in accordance with the provisions of the Transport Safety
Investigation Act 2003 and Regulations and, where applicable, international agreements.

Purpose of safety investigations

The objective of a safety investigation is to enhance transport safety. This is done through:
• identifying safety issues and facilitating safety action to address those issues
• providing information about occurrences and their associated safety factors to facilitate
learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability.
At the same time, an investigation report must include factual material of sufficient weight to
support the analysis and findings. At all times the ATSB endeavours to balance the use of
material that could imply adverse comment with the need to properly explain what happened,
and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of
taking administrative, regulatory or criminal action.

Terminology
An explanation of terminology used in ATSB investigation reports is available on the ATSB
website. This includes terms such as occurrence, contributing factor, other factor that increased
risk, and safety issue.

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