ROBINSON. MODEL R44 II. SECTION 4. NORMAL PROCEDURES. FAA APPROVED: 21 OCT 4-i. SECTION 4. NORMAL PROCEDURES. CONTENTS. Pooleys Flying and Navigational products and accessories. Checklists | Robinson R44 Raven I & II | NCL | Robinson R44 Raven I & II Checklist. Free Robinson R44 Checklists to Download. The web’s largest collection of checklists.

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It is not the function of the Board to assign fault or determine civil or criminal liability.

‎R44 Raven II on the App Store

View document in PDF. You need a PDF reader to access this file. Find out more on our help page. At about Eastern Standard Time, chhecklist its initial climb, C-FNZO lost engine power and the pilot made a forced landing in a residential neighbourhood in Forestville. Both people on board had minor injuries and were taken to hospital.

The helicopter was substantially damaged. The emergency locator transmitter did not activate following the hard landing. The accident occurred during daylight hours. Two checkilst stopovers were planned: However, it was the Jet A-1 fuel hose. None of the pilots noticed this, and the refueller was asked to refuel the helicopters. Two of the pilots and the passengers went inside the terminal, and the pilot of C-FNZO 2 remained with the r444 while the first helicopter was being refuelled.

However, the pilot then went into the terminal to use the washroom. Upon returning, the refueller was finishing refuelling the auxiliary tank in the pilot’s helicopter.

The 3 helicopters were refuelled in no particular order and each had only 1 tank refuelled. The refueller saw the manufacturer’s placards text boxes 1 and 2 but did not pay any particular attention to them. The refueller was alone when refuelling the aircraft and did not use a ladder. The refueller seemed to be less than adept with the hose, allowing it to come into contact with the surface of the helicopters; but the pilots did not question his knowledge of refuelling R44s.

Shortly thereafter, the refueller joined the pilots and their passengers inside the terminal. One of the passengers signed 2 of the invoices and the third one was signed by one of the pilots. Although the price was lower than expected, neither the passenger nor the pilot noticed that Jet A-1 fuel had been used, as indicated on the invoices.

C-FNZO was the last of the 3 helicopters to take off. During take-off, the fuel gauges were showing less than full. After a few radio exchanges among the 3 helicopters, and at approximately feet above ground level aglthe pilots concluded that the wrong fuel had been used.

C-FNZO experienced reduced power and there were indications that the engine was overheating. Almost immediately, noises were heard from the engine and a significant loss of power occurred. The pilot performed an autorotation 3 and landed on a street in a residential neighbourhood in Forestville.

C-FNZO was substantially damaged due to the force of the impact.

The landing skids collapsed and the tail boom broke at the end ravne the tail assembly, leaving the tail rotor attached by only the tail skid. During the autorotation, the pilot radioed these observations, leading the others to land immediately and thus without incident.

The weather conditions in the flight area exceeded the conditions required for VFR flight, and there is no indication that they played a role in this occurrence. Therefore, the day ended at approximately The pilot was certified and qualified for the flight, in accordance with existing regulations.

The pilot obtained a private helicopter licence in September and had over flying hours on the Robinson R The technical records indicated that the aircraft was certified and maintained in accordance with chcklist regulations. There was no evidence found of any airframe failure or system malfunction during the flight, other than the loss of power associated with the wrong checklish of fuel being added to the tanks.


The R44’s fuel system consists of a main tank on the left and an auxiliary tank on the right. The 2 filler caps are located at the top of the fuselage on each side of daven aircraft. The system is designed so that the engine receives fuel from the main tank. Both tanks are interconnected by a hose. The bottom of the auxiliary tank is higher than the bottom of the main tank and thus, by gravity, the auxiliary tank continuously feeds the main tank. Transparent stickers 4 with black inscriptions were affixed to the aircraft near the filler caps.

The placard for the main ravn Text box 1 indicates the type of fuel required. The placard near the auxiliary tank Text box 2 indicates that, to ensure full fuel, the main tank should be filled first and topped off after the auxiliary tank is filled.

The inspection tasks include checking the amount of fuel by using the fuel gauges and taking a fuel sample. Section 7 of the POH states that fuel rven must be taken from the 3 drains before the first flight of the day and after refuelling. Fuels are distinguished ravej their color.

Pilots do not generally take samples immediately after refuelling. It is considered that the agitation caused by refuelling allows contaminants to disperse and potentially remain in suspension for several minutes.

Therefore a sufficient amount of time ravdn elapse before fuel samples are taken after each refuelling. The Robinson Helicopter Company RHC stated that it does not set a specific amount of time for sampling, and that, after refuelling, pilots must use their judgment to determine what tasks, if applicable, can be omitted from the eaven checklist.

There is no checklist for rapid turn-around.

Transportation Safety Board of Canada – Aviation Investigation Report A11Q

The helicopter was not equipped with a cockpit voice recorder or a flight data recorder; neither is required by regulation. The ELT was not damaged in the accident and did not activate on impact.

The 2 skids collapsed on checklistt side of the fuselage on impact. According to RHCthe R44 landing gear is designed to withstand impact forces without collapsing at a rate of descent of feet per minute. It is almost identical to the R44, but is powered by a turbine engine that r444 Jet A-1 fuel.


Checmlist is a registered aerodrome that has been operated by the town of Forestville sincewhen it was transferred by Transport Canada. Aerodrome amenities and services are available only during the summer months. CYFE was equipped with a divided tank containing 2 types of fuel: The fuel type labelling consisted of just 1 label at each end of the tank and 2 labels over the fuel pump.

Pilots simply have to dial the phone number listed in the CFS and the employee on duty will be paged. The aerodrome employees are volunteer firefighters from the town of Forestville. The refueller in question was checklisf, having started working at the aerodrome in November Most of the refuellings done previously had been for helicopters using Jet A-1 fuel.

The training had been accomplished by another, more experienced employee the instructor.

The refueller’s training consisted of a demonstration and supervision of 5 to 8 refuellings. Since his training, the refueller had done 6 to 8 refuellings unassisted. The training lasted several days and included a final evaluation and a certificate.

Neither the refueller nor the instructor had received this training. One of the evaluation questionnaires consisted of 10 questions directly related to nozzle refuelling. Two examples are shown in text boxes 3 ravsn 4 below. State two 2 main characteristics of the Jet A-1 nozzle:.


You approach an aeroplane that needs to be refuelled and the pilot says, “Full fuel. No information was provided to the employees concerning standard procedures to be followed; iii aircraft refuelling reference manuals, no fuel emergency manuals, and no how to prepare incident reports, either at CYFE or at Forestville city hall. However, the Jet A-1 fuel nozzle used to refuel the ravfn R44s in this occurrence measured 1 inch in diameter, which allowed it to be inserted in the fuel filler opening.

There are over AS aircraft registered in Canada. While there are no fuel-nozzle-dimension standards for aircraft refuelling at Canadian airports, there are airworthiness standards for obtaining type approval and changes to type certificates for normal- utility- aerobatic- and ravven aeroplanes. However, there is no standard for helicopters.

Similar occurrences have taken place in recent years, not only with helicopters, but also with piston-engine aircraft. Barely a month after this accident, a similar occurrence was reported: The Transportation Safety Board inspected other installations from the same fuel supplier.

A number of documents were available to employees as reference tools, including a reference manual entitled Aircraft Service Directory Appendix Awhich lists different types of aircraft and their specific refuelling requirements. Refuellers have access to a chart, including an example: Pilot decision making PDM is a critical aspect of flight safety.

PDM can be defined as a four step sequential loop: Evaluating the available options involves a subjective evaluation of risks based on experience and knowledge. Pilots’ decisions can be influenced by a wide range of factors such as the perception of the situation and their experience.

For example, when a flight is successful, without performing all manufacturer-recommended tasks, pilots may be prone to continue deviating from recommended procedures, therefore increasing their tolerance to risk until they experience negative consequences, which too often are disastrous.

Over time, and with experience of uneventful flights, pilots get accustomed to this modified flight procedure, which no longer offers the established safety margin and thus compromises safety. According to the Rasmussen risk management framework, 7 the real safety limit is usually invisible and people do not know whether the system as a whole is on the brink of disaster or far from it.

A shift in work methods, such as making changes to checklists, can continue and evolve over years without mishap—until the real safety limit is reached and an accident occurs. A Transport Canada advisory circular 8 reminded pilots of the importance of performing a careful pre-flight inspection. The circular recommended that pilots hcecklist the total usable fuel on board before the flight and that they drain the tanks to check the quality and colour of the fuel to ensure that Jet A-1 has not been mixed with AVGAS.

A number of successful defences have been introduced to address the risks associated with refuelling errors. However, as with all mitigated risks, when these defences are not used, the risk of error increases considerably. Because the refueller had prepared the hose while waiting for the aircraft, the pilots were lead to believe that the type of fuel required had been confirmed in the phone call. The refueller did not ask checklisf questions, which reinforced the pilots’ belief in the refueller’s qualifications.