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Aviation safety reports, made easier to study

NTSB Reports is an independent research and search tool for public aviation accident and incident records. It brings NTSB aviation reports, structured fields, docket files, extracted figures, photos, videos, and update history into one searchable interface.

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March 17, 1995 · Bell 47 · N6569H

Harmon Field

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
March 17, 1995
Injury Outcomes
No injuries (2 uninjured)
Location
Harmon Field
Aircraft
Bell 47
Tail Number
N6569H
Injuries
None
Aircraft Damage
Substantial
NTSB Number
LAX95LA138

THE PILOT WAS PROCEEDING TO A LANDING AREA AT 400 FEET AGL WHEN HE EXPERIENCED A LOSS OF ENGINE POWER. HE AUTOROTATED INTO DENSE JUNGLE TERRAIN. EXAMINATION OF THE ENGINE REVEALED THAT THE OIL PRESSURE RELIEF VALVE WAS MISSING. THIS WAS THE FIRST FLIGHT SINCE A 100-HOUR INSPECTION WAS MADE THE DAY BEFORE. THE INSPECTION OF THE SAFETY WIRE SECURING THE VALVE IS NOT A PREFLIGHT ITEM FOR THE PILOT, NOR IS IT REQUIRED TO BE INSPECTED PRIOR TO FLIGHT.

NTSB Probable Cause

an engine failure due to oil exhaustion from a missing oil pressure relief valve as the result of an improper maintenance inspection.

Full Narrative

On March 17, 1995, at 1520 hours Guam standard time, a Bell 47 helicopter, N6569H, crashed after a loss of engine power near Harmon Field, Guam. Visual meteorological conditions existed at the time of the local maintenance test flight. The helicopter sustained substantial damage and the two occupants were not injured. The investigation revealed that the engine lost oil pressure shortly after departure from Harmon Field. The pilot made a downwind landing into dense jungle. The tail boom separated from the aircraft during the crash sequence. The aircraft had a 100-hour inspection on March 16, 1995, and this was the first flight since the inspection. A Federal Aviation Administrator (FAA) inspector was on the island at the time on other business. This inspector interviewed the operator and the pilot a few days afterwards. The pilot was flying to an open field area at 400 feet above ground level when he noticed a change in the engine rpm and a loss of engine power. Due to obstacles, a 15 to 20 knot tailwind, and a loss of hydraulic power, the pilot was unable to make the open field and autorotated into the jungle. An examination of the aircraft, after it was removed from the accident site, revealed that the oil pressure relief valve was missing. According to the FAA inspector, the valve vibrated out within a short period of time after takeoff with a corresponding loss of engine oil. The operator told the FAA inspector that the valve was probably loose prior to takeoff. When asked if the valve was a normal preflight item, he stated that it should be at least checked to see if the safety wire securing the valve was broken. The operator does not have a published preflight procedures and/or preflight checklist nor is it a requirement under FAR Part 91 operations.

Flight

Event TypeAccident
Event Time15:20
Nearest Airport0nm
Runway0
Flight Plan FiledNone
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftBell 47
Tail NumberN6569H
Aircraft CategoryHeli
DamageSubstantial
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsLycoming · VO-435-A/F · Reciprocating · 220
Seats2

People & Injuries

Injury SummaryNo injuries (2 uninjured)
Fatal0
Serious0
Minor0
Uninjured2
Total2
Crew 1Age 31 · Second Class

Conditions

ConditionsVMC
LightDaylight
Wind60° @ 15 kt, gusting 20 kt
Visibility20 sm
CeilingNone
Altimeter29.00 inHg
Observation Time15:00
Weather SourceWFAC

Appendix: Source Data