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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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NTSB Report

December 22, 1992 · Hughes 369D · N113RS

Hilo, HI

Overview

Report Status
Probable Cause
Event Type
Accident
Date
December 22, 1992
Injury Outcomes
No injuries (5 uninjured)
Location
Hilo, HI
Aircraft
Hughes 369D
Tail Number
N113RS
Operator
Mauna Kea Helicopters
Injuries
None
Aircraft Damage
Substantial
NTSB Number
LAX93LA071

During cruise the pilot detected a buffeting in the airframe followed by a left yaw. The engine gages indicated decreasing power output with a high turbine outlet temperature, and, the engine chip and failure lights illuminated. The pilot executed an auto rotation and had to stretch the glide slightly to reach the only suitable area which involved a down wind landing. The main rotor sliced off the tail boom as the helicopter slid to a stop. Review of the operators daily flight sheets for the accident helicopter revealed that a engine chip light had illuminated on the flight prior to this one. The corrective action taken was to clean the chip plug and reinstall it. No test flight and further check of the plug was done as required in the maintenance manuals. Disassembly of the engine revealed that the number 1 and 2 bearings in the compressor module had failed. Review of maintenance records revealed that the compressor module was formerly installed in an engine which was involved in a helicopter accident in May of 1992. The compressor module was not disassembled for inspection as required in the overhaul and maintenance manual, and was not signed off for return to service. It was installed by the operator in the accident helicopter engine on November 21, 1992.

NTSB Probable Cause

THE BEARING FAILURES DUE TO THE OPERATOR'S USE OF IMPROPER MAINTENANCE INSPECTION AND OVERHAUL PROCEDURES BY INSTALLING AN UNSERVICEABLE COMPRESSOR MODULE IN THE HELICOPTER ENGINE. FACTORS IN THE ACCIDENT WERE THE UNSUITABLE NATURE OF THE TERRAIN FOR THE FORCED LANDING AND THE TAIL WIND CONDITION DURING THE LANDING TOUCHDOWN.

Full Narrative

DURING CRUISE THE PILOT DETECTED A BUFFETING IN THE AIRFRAME FOLLOWED BY A LEFT YAW. THE ENGINE GAGES INDICATED DECREASING POWER OUTPUT WITH A HIGH TURBINE OUTLET TEMPERATURE, AND, THE ENGINE CHIP AND FAILURE LIGHTS ILLUMINATED. THE PILOT EXECUTED AN AUTO ROTATION AND HAD TO STRETCH THE GLIDE SLIGHTLY TO REACH THE ONLY SUITABLE AREA WHICH INVOLVED A DOWN WIND LANDING. THE MAIN ROTOR SLICED OFF THE TAIL BOOM AS THE HELICOPTER SLID TO A STOP. REVIEW OF THE OPERATORS DAILY FLIGHT SHEETS FOR THE ACCIDENT HELICOPTER REVEALED THAT A ENGINE CHIP LIGHT HAD ILLUMINATED ON THE FLIGHT PRIOR TO THIS ONE. THE CORRECTIVE ACTION TAKEN WAS TO CLEAN THE CHIP PLUG AND REINSTALL IT. NO TEST FLIGHT AND FURTHER CHECK OF THE PLUG WAS DONE AS REQUIRED IN THE MAINTENANCE MANUALS. DISASSEMBLY OF THE ENGINE REVEALED THAT THE NUMBER 1 AND 2 BEARINGS IN THE COMPRESSOR MODULE HAD FAILED. REVIEW OF MAINTENANCE RECORDS REVEALED THAT THE COMPRESSOR MODULE WAS FORMERLY INSTALLED IN AN ENGINE WHICH WAS INVOLVED IN A HELICOPTER ACCIDENT IN MAY OF 1992. THE COMPRESSOR MODULE WAS NOT DISASSEMBLED FOR INSPECTION AS REQUIRED IN THE OVERHAUL AND MAINTENANCE MANUAL, AND WAS NOT SIGNED OFF FOR RETURN TO SERVICE. IT WAS INSTALLED BY THE OPERATOR IN THE ACCIDENT HELICOPTER ENGINE ON NOVEMBER 21, 1992.

Flight

Event TypeAccident
Event Time14:00 HST
Nearest Airport0nm N
Runway0
Flight Plan FiledCvfr
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftHughes 369D
Tail NumberN113RS
Aircraft CategoryHeli
DamageSubstantial
OperatorMauna Kea Helicopters
Operating RulePart 135
Engines1
Engine TypeTurboshaft
Engine DetailsAllison · 250 C20B · Turboshaft · 420
Seats5

People & Injuries

Injury SummaryNo injuries (5 uninjured)
Fatal0
Serious0
Minor0
Uninjured5
Total5
Crew 1Age 30 · First Class

Conditions

ConditionsVMC
LightDaylight
Wind50° @ 5 kt
Visibility10 sm
CeilingNone
Temperature / Dew Point68 F / 0 C
Altimeter29.00 inHg
Weather SourcePILO

Appendix: Source Data