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NTSB Report
May 7, 1989 · Mbb BO-105S · N2785B
W Cameron Blk
Overview
Report Status
Probable Cause
Event Type
Accident
Date
May 7, 1989
Injury Outcomes
1 injury (1 fatality)
Location
W Cameron Blk
Aircraft
Mbb BO-105S
Tail Number
N2785B
Operator
Air Logistics
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
FTW89FA093
THE TWIN ENGINE HELICOPTER WAS IN CRUISE FLIGHT OVER THE GULF OF MEXICO, WHEN IT SUDDENLY PITCHED NOSE DOWN AND DESCENDED UNCONTROLLED TO IMPACT INVERTED INTO THE WATER. IT SANK TO A DEPTH OF APPROXIMATELY 380 FEET. AFTER RECOVERY OF THE HELICOPTER, EXAMINATION REVEALED THAT AN INCORRECT HYDRAULIC SWITCH GUARD HELD THE TEST SWITCH IN THE RESET POSITION, ELECTRICALLY ISOLATING HYDRAULIC SYSTEM NUMBER TWO FROM OPERATION, AND THAT THE HYDRAULIC MODULE WAS IN THE NUMBER 1 SYSTEM. FURTHER INSPECTION AND TESTING FOUND A DEFECTIVE MICRO-SWITCH IN THE OUTBOARD LATERAL GUIDE ASSEMBLY OF THE HYDRAULIC MODULE. ADDITIONALLY, THE OPERATOR HAD NOT COMPLIED WITH A REQUIRED SERVICE BULLETIN FOR THE MODULE.
NTSB Probable Cause
THE PARTIAL ELECTRICAL FAILURE OF THE MICRO-SWITCH FOR THE OUTBOARD LATERAL GUIDE ASSEMBLY, AND THE INCORRECT GUARD INSTALLED ON THE HYDRAULIC TEST SWITCH, RESULTING IN A TOTAL HYDRAULIC FAILURE. FACTORS WERE: THE INCORRECT INSTALLATION OF THE GUARD BY AN UNKNOWN PERSON, THE FAILURE OF THE COMPANY TO COMPLY WITH THE SPECIFIED SERVICE BULLETIN.
Full Narrative
THE TWIN ENGINE HELICOPTER WAS IN CRUISE FLIGHT OVER THE GULF OF MEXICO, WHEN IT SUDDENLY PITCHED NOSE DOWN AND DESCENDED UNCONTROLLED TO IMPACT INVERTED INTO THE WATER. IT SANK TO A DEPTH OF APPROXIMATELY 380 FEET. AFTER RECOVERY OF THE HELICOPTER, EXAMINATION REVEALED THAT AN INCORRECT HYDRAULIC SWITCH GUARD HELD THE TEST SWITCH IN THE RESET POSITION, ELECTRICALLY ISOLATING HYDRAULIC SYSTEM NUMBER TWO FROM OPERATION, AND THAT THE HYDRAULIC MODULE WAS IN THE NUMBER 1 SYSTEM. FURTHER INSPECTION AND TESTING FOUND A DEFECTIVE MICRO-SWITCH IN THE OUTBOARD LATERAL GUIDE ASSEMBLY OF THE HYDRAULIC MODULE. ADDITIONALLY, THE OPERATOR HAD NOT COMPLIED WITH A REQUIRED SERVICE BULLETIN FOR THE MODULE.
Flight
Event TypeAccident
Event Time19:04 UTC
Nearest Airport0nm N
Runway0
Flight Plan FiledCvfr
Aircraft FireNo
Aircraft ExplosionNo
Aircraft
AircraftMbb BO-105S
Tail NumberN2785B
Aircraft CategoryHeli
DamageDestroyed
OperatorAir Logistics
Operating RulePart 135
Engines2
Engine TypeTurboshaft
Engine DetailsAllison · 250-C20B · Turboshaft · 420
Seats5
People & Injuries
Injury Summary1 injury (1 fatality)
Fatal1
Serious0
Minor0
Uninjured0
Total1
Crew 1Age 51 · First Class
Conditions
ConditionsVMC
LightDaylight
WindCalm
Visibility25 sm
CeilingNone
Temperature / Dew Point63 F
Altimeter30.00 inHg
Weather SourceWIT