Aviation safety investigations & reports

Loss of control involving Robinson R44 helicopter, VH-COK, Jaspers Brush Aerodrome, NSW, 4 February 2012

Investigation number:
Status: Completed
Investigation completed


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What happened

At about 1555 Eastern Daylight-saving Time on 4 February 2012, a Robinson R44 helicopter, registered VH‑COK, lifted off from Jaspers Brush Aerodrome, New South Wales for aerial photography of the launching of a deep sea submarine in nearby Jervis Bay. On board the helicopter were the pilot and a camera operator.

Soon after lifting off the pilot’s door opened and the pilot reached out to close the door. Simultaneously the helicopter abruptly pitched nose-up then steeply nose-down, rolling to the right before the right landing gear skid and main rotor blades struck the ground. A fuel-fed fire started in the vicinity of the fuel tanks and lower mast area prior to the helicopter coming to a stop. Both occupants were fatally injured and the helicopter was destroyed.

What the ATSB found

The Australian Transport Safety Bureau (ATSB) found that the pilot’s door was not properly latched prior to lift off and opened during the turn to depart. In attempting to shut the door the pilot probably let go of the cyclic control from the normal (right) control hand, allowing for an unintended, abrupt nose-up pitch and the helicopter tail hitting the ground. The helicopter nosed over and impacted the ground. A fire began when one of the fuel tanks was breached.

The ATSB identified that the fatal injuries were due to the post-impact fire, as was the case in a number of other R44 accidents. A number of these R44s, including VH‑COK, had not and were not yet required to have been modified in accordance with a manufacturer service bulletin that specified replacement of aluminium fuel tanks with more impact‑resistant bladder‑type fuel tanks. The installation of these tanks decreased the risk of a post‑accident fire. At the time of the accident, these tanks were required to be fitted by 31 December 2014.

What's been done as a result

In response to this and a number of other fatal accidents in other R44 helicopters, the Civil Aviation Safety Authority (CASA) and the ATSB have separately highlighted the benefits of the upgraded bladder-type fuel tank and related modifications to operational and maintenance personnel. In addition, the helicopter manufacturer has progressively reduced the compliance time on service bulletin SB-78 in respect of the installation of the bladder‑type fuel tanks to 30 April 2013. A second bulletin aimed at removing a possible impact‑related ignition source was also issued and the manufacturer is issuing advisory information emphasising the importance of maintaining control of the helicopter during an unexpected event.

Safety message

This accident highlights the importance of ensuring all doors are secured prior to takeoff. That said, the opening of a door in flight will not normally affect the operation of an R44, but the instinctive reaction to immediately deal with such an event can be quite strong. Pilots need to be aware that this reaction may be hard to overcome and in the event of an unexpected situation occurring such as the opening of the door, it is vital that pilots should continue to ‘fly the aircraft’. This includes choosing to land to close the door if necessary. The fitment of bladder-type fuel tanks to R44 helicopters is a worthwhile safety enhancement that could save lives and advice from CASA is that their installation in accordance with the manufacturer’s service bulletin by 30 April 2013 is mandatory.

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Download Preliminary Report
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Alternate: [Download  DOCX: 736KB]

Preliminary report released 9 March 2012

At about 1555 Eastern Daylight-saving Time on 4 February 2012, a Robinson R44 Raven II helicopter, registered VH-COK, lifted off from Jaspers Brush Aerodrome, New South Wales for an aerial filming task at Jervis Bay. On board were the pilot and a camera operator.

Soon after lifting off, the pilot's door opened. The helicopter abruptly pitched nose-up and the tailskid struck the ground. The helicopter then abruptly pitched forward and rolled to the right before the main rotor blades struck the ground. A fuel-fed fire started in the vicinity of the fuel tanks and lower mast area. The fuselage then hit the ground. Both occupants were fatally injured and the helicopter was destroyed.

On 20 December 2010, the manufacturer issued R44 Service Bulletin 78 (SB 78) requiring that R44 helicopters with all-aluminium fuel tanks be retrofitted with bladder-type fuel tanks as soon as practical, but no later than 31 December 2014. At the time of the accident, about 90% of the helicopters originally fitted with all-aluminium fuel tanks, including VH-COK, had not been retrofitted. On 21 February 2012, the manufacturer issued SB 78A that revised the date of compliance to 31 December 2013.

In addition, the manufacturer released SB 82 in respect of the replacement of existing R44 rotor brake switches. The aim of that bulletin was to reduce the chance of the rotor brake switch as a possible ignition source in the event of a fuel leak.

Although the circumstances of this accident are still under investigation, the Australian Transport Safety Bureau has, in the interest of transport safety, issued a Safety Advisory Notice suggesting that operators and owners of R44 helicopters fitted with all-aluminium fuel tanks actively consider replacing those tanks with bladder-type fuel tanks, as detailed in SB 78A as soon as possible. The existence and content of SB 82 is also highlighted.

Download Preliminary Report
[Download  PDF: 308KB]
Alternate: [Download  DOCX: 736KB]
General details
Date: 04 February 2012   Investigation status: Completed  
Time: 1555 ESuT    
Location   (show map): Jaspers Brush Aerodrome   Investigation level: Complex  
State: New South Wales   Occurrence type: Loss of control  
Release date: 03 May 2013   Occurrence class: Operational  
Report status: Final   Occurrence category: Accident  
  Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Robinson Helicopter Co  
Aircraft model R44  
Aircraft registration VH-COK  
Serial number 10421  
Type of operation Private  
Sector Helicopter  
Damage to aircraft Destroyed  
Departure point Jaspers Brush Aero, NSW  
Destination Jervis Bay, NSW  
Last update 14 November 2018