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September 15, 2018 · Schweizer 300Cbi 269C1 · N2128T

Granada Hills, CA

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
September 15, 2018
Injury Outcomes
No injuries (2 uninjured)
Location
Granada Hills, CA
Aircraft
Schweizer 300Cbi 269C1 (2009)
Tail Number
N2128T
Operator
Group 3 Aviation
Injuries
None
Aircraft Damage
Substantial
NTSB Number
WPR18LA265

The flight instructor reported that during the instructional flight, when the helicopter was about 1,600 ft mean sea level (msl) and about 65 knots, the engine experienced “a significant and abrupt change in engine sound and power.” Shortly after, the engine rpm rose to 3,000. He immediately chose to initiate a partial-power, emergency landing on a nearby golf course instead of an autorotation because the engine was still producing partial power. He stated that it was difficult to control the throttle as he was lowering the collective and beginning the descent. He flared the helicopter when it was about 20 ft agl, and it subsequently landed hard on the level golf course fairway. During the examination of the wreckage, the tail rotor assembly, including the horizontal and vertical stabilizers, was found separated. The tail rotor blades were undamaged. The tailboom remained attached to the fuselage but had separated near the tail rotor assembly due to the upper tailboom support rod separating in overload near its midsection. All three main rotor blades remained attached to the hub assembly. Two of the blades exhibited impact damage, consistent with the blades contacting the tailboom. A section of the drive shaft had separated from the transmission and tailboom. During the engine examination, thumb compression tests, the Nos. 1 and 4 cylinders could not obtain compression. Examination of the No. 1 cylinder with a borescope revealed that the exhaust valve head exhibited thermal discoloration in three areas, consistent with combustion blowby. Cracking was visible near the valve head’s edge, and a small amount of material was missing from the head’s outer edges. Additionally, the No. 4 cylinder piston head and combustion chamber exhibited mechanical damage. The exhaust valve head was missing about one-third of its material. The last annual inspection was accomplished one month before the accident. The maintenance records indicated that a service bulletin that directed the inspection of the exhaust valves’ condition had been complied with. The bulletin indicated that failure to comply with the provisions of the bulletin could result in engine failure due to excessive carbon build up between the valve guide and valve stem resulting in sticking valves or broken exhaust valves that result from excessive wear (bell-mouthing) of the exhaust valve guide. Given the condition of the No. 1 and 4 exhaust valves, it is likely that the inspection that had been accomplished in accordance with the service bulletin was not adequate and that the damage and material loss from the valve heads resulted in the loss of compression in those cylinders and partial loss of engine power.

NTSB Probable Cause

A partial loss of engine power that was the result of a loss of compression in the No. 1 and 4 cylinders due to damage and material separation from the exhaust valve heads, which resulted in a subsequent forced, hard landing. Contributing to the accident was inadequate maintenance inspection.

Full Narrative

On September 15, 2018, about 1233 Pacific daylight time, a Schweizer 300CBi helicopter, N2128T, sustained substantial damage when it was involved in an accident near Granada Hills, California. The flight instructor and the student pilot were uninjured. The helicopter was operated by Group 3 Aviation, Inc., as a 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor and pilot receiving instruction were conducting an instructional flight in the helicopter, which was primarily used for flight instruction. The instructor reported that, after departure from Van Nuys Airport (VNY), Van Nuys, California, when the helicopter was about 1,600 ft mean sea level (msl), it “experienced a significant and abrupt change in engine sound and power.” Shortly after, the engine rpm rose to 3,000. The instructor immediately chose to initiate a partial-power, emergency landing to a nearby golf course instead of an autorotation because the engine was still producing partial power. He stated that it was difficult to control the throttle as he was lowering the collective and began the descent. The instructor flared the helicopter when it was about 20 ft agl, and it subsequently landed hard on the golf course fairway. During examination of the accident site, the tail rotor assembly, including the horizontal and vertical stabilizers, was found forward of the main wreckage area. The tail rotor blades were undamaged. The tailboom remained attached to the fuselage but had separated near the tail rotor assembly. The upper tailboom support rod had separated in overload near its midsection. All three main rotor blades remained attached to the hub assembly. Two of the blades exhibited impact damage, and the third blade was buckled near the hub. A section of the drive shaft assembly had separated from the transmission and tailboom section. During the engine examination, thumb compression tests on the Nos.1 and 4 cylinders could not obtain compression. A boroscopic examination of the No. 1 cylinder combustion chamber revealed that the piston head and chamber exhibited normal deposits. The exhaust valve head exhibited thermal discoloration in three areas, consistent with combustion blowby. Cracking was visible near the valve head’s edge, and a small amount of material was missing from the head’s outer edges. A boroscopic examination of the No. 4 cylinder combustion chamber revealed that the surfaces of the piston head and chamber exhibited mechanical damage. The exhaust valve head was missing about one-third of its material. Review of the helicopter’s maintenance records revealed that the engine was installed on July 31, 2014. The last annual inspection was conducted on August 17, 2018, when the engine had 1,571 total flight hours. Service Bulletin No. 388C, “Exhaust Valve and Guide Inspection,” was complied with during the inspection. The bulletin describes the approved procedures for checking exhaust valve guide condition. Failure to comply with the bulletin could result in engine failure due to excessive carbon build up between the valve guide and valve stem resulting in sticking valves or broken exhaust valves which result from excessive wear (bel-mouthing) of the exhaust valve guide. The Nos. 1 through 4-cylinder compressions were reported as 76/80, 77/80, 76/80, 78/80, respectively. The helicopter was subsequently flown another 31 hours before the time of the accident.

Flight

Event TypeAccident
Event Time12:33 PDT
Nearest Airport0nm
Flight Plan FiledNone
Flight Plan ActivatedNo
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftSchweizer 300Cbi 269C1
Tail NumberN2128T
Aircraft CategoryHeli
DamageSubstantial
OperatorGroup 3 Aviation
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsLycoming · HIO-360-G1A · Reciprocating · 180
Seats2

People & Injuries

Injury SummaryNo injuries (2 uninjured)
Fatal0
Serious0
Minor0
Uninjured2
Total2
Crew 1Age 45 · First Class · None
Crew 2Age 52 · First Class · None

Conditions

ConditionsVMC
LightDaylight
Wind120° @ 5 kt
Visibility10 sm
CeilingNone
Temperature / Dew Point37 C
Altimeter29.88 inHg
Observation Time19:55
Weather SourceWFAC

Appendix: Source Data