# Accident 20030721037089A: Hughes 369D, Ketchikan, AK, July 21, 2003

- Type: FAA accident report (Accident/Incident Data System), as reported
- Date: July 21, 2003, 09:00 local time
- Place: Ketchikan, AK
- Damage: Substantial damage
- Phase of flight: Pwr Off Vert Land/Autorotate
- Operating rules: Air taxi and commuter (Part 135)
- Operator: HSXA
- Location: 55.8694° N, 131.4656° W: From the FAA
- Nearby events: https://openairdocs.org/map.md?lat=55.8694&lon=-131.4656&mi=10
- Aircraft: N1091S, registered now (https://openairdocs.org/aircraft/N1091S) (OpenAirDocs)
- Registry model: Hughes Helicopters HUGHES 369D (registry code 4470706, https://openairdocs.org/model/hughes-helicopters-hughes-369d) (OpenAirDocs)
- Registry engine: Allison 250 SER 250HP (registry code 03002, https://openairdocs.org/engine/allison-250-ser-250hp) (OpenAirDocs)
- Reported make and model: HUGHES 369D
- People aboard: 3
- Fatal injuries: 0
- NTSB investigation: [NTSB ANC03LA082](https://openairdocs.org/ntsb/ANC03LA082) (OpenAirDocs)
- FAA source: FAA Aviation Safety Information Portal (https://asip.faa.gov/)
- Page: https://openairdocs.org/incident/20030721037089A

## Narrative

As the FAA filed it, in capitals; the FAA replaces private details with ^PRIVACY DATA OMITTED^.

(-23) THE CONNECTION OF THE GOVERNOR CONTROL ARM TO THE AIRFRAME COLLECTIVE DROOP COMPENSATION LINKAGE BECAME DISCONNECTED, APPARENTLY THROUGH IMPROPER SECURING OF THE NUT AND COTTER PIN. THIS BREAK IN THE CONTINUITY OF THE ENGINE CONTROL SYSTEM SEEMS TO HAVE INITIALLY ALLOWED THE GOVERNOR ARM, ONCE DISCONNECTED, TO MOVE IN THE DECREASE DIRECTION. THE RESULTING DECREASE IN N2 CAUSED THE NR TO DROOP AND THE PILOT EXPERIENCED A YAW TO THE LEFT COMBINED WITH A LOW ROTOR WARNING. REDUCTION OF THE COLLECTIVE BY THE PILOT WHEN ENTERING AUTOROTATION FURTHER ALLOWED THE AIRFRAME CONTROL ROD TO MOVE AWAY FROM THE GOVERNOR ARM THUS ALLOWING THE GOVERNOR TO (A) DECREASE MORE AND (B) ALLOW THIS ROD TO POSITION ITSELF IN THE AREA OF THE GOVERNOR ARM STOP EAR, LOCATED DIRECTLY BELOW THE NORMAL ATTACHMENT POINT. PRIOR TO TOUCH DOWN, THE PILOT PULLED FULL COLLECTIVE AND EXECUTED AN AUTOROTATION. UNKNOWN TO THE PILOT AT THAT TIME WAS THE ACTION ON THE GOVERNOR STOP EAR BY THE DISCONNECTED CONTROL ROD IN THE FULL INCREASE DIRECTION. THIS SUDDEN MOVEMENT OF THE AIRCRAFT CAUSED BY AN UNEXPECTED INCREASE IN N2/NR RESULTED IN AN ALMOST INSTANTANEOUS LIFT-OFF OF THE AIRCRAFT AFTER TOUCHDOWN AND SUBSEQUENT IMPACT WITH THE TREES.

## The NTSB's investigation of this event (1)

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

- [NTSB ANC03LA082](https://openairdocs.org/ntsb/ANC03LA082), Jul 21, 2003: Hughes 369D (N1091S), Ketchikan, AK, substantial damage. Probable cause: The improper installation of a bolt in the gas generator governor linkage by company maintenance personnel, which resulted in a loss of the bolt, a loss of engine power while maneuvering, and…

## Other reports on N1091S (1)

Matched to the same aircraft by N-number and date.

- [Accident 19830913057759A](https://openairdocs.org/incident/19830913057759A), Sep 13, 1983: Hughes 369D (N1091S), Wrangell, AK, Destroyed. Engine quit during a long line operation. Crashed into trees. Attitude and low fuel allowed fuel pump to entrain air

From the FAA Accident/Incident Data System. Reports are matched to registry aircraft by N-number and event date, checked against the reported make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. For accidents, the NTSB's own investigation is the fuller record.

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