# NTSB ATL89FA220: Aerospatiale AS 350D, N57689, Chamblee, GA, September 28, 1989

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: September 28, 1989, 14:00 local (18:00 UTC)
- Place: Chamblee, GA
- Coordinates: 33.899551, -84.300994 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=33.8996&lon=-84.3010&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 1 fatal
- Status: Completed, report May 15, 1992
- Report: Approved by Office Director
- ADs cited in the narratives: [AD 89-21-01](https://openairdocs.org/ad/89-21-01) (OpenAirDocs)
- NTSB case key (mKey): 7920
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL89FA220
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/7920/pdf
- Page: https://openairdocs.org/ntsb/ATL89FA220

## Probable cause

FAILURE OF THE MAIN ROTOR SWASHPLATE BEARING DUE TO LACK OF LUBRICANT.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Airframe/component/system failure/malfunction, approach
  - maintenance,service bulletin/letter - not followed, other maintenance personnel
  - rotorcraft flight control,swashplate assembly - failure,total (cause)
  - maintenance,lubrication - inadequate (cause)
- In flight collision with terrain/water, landing

## Analysis

AS THE HELICOPTER APPROACHED THE AIRPORT, IT WAS OBSERVED TO PITCH UP & YAW UNCONTROLLABLY. ACCORDING TO WITNESSES, THE ROTOR SYSTEM SLOWED AS THE HELICOPTER DESCENDED TO IMPACT ON A CITY GOLF COURSE. AN INVESTIGATION REVEALED THAT THE MAIN ROTOR SWASHPLATE BEARING HAD FAILED FROM INADEQUATE LUBRICATION. THE STATIONARY SWASHPLATE VENTING HOLE HAD NOT BEEN BLOCKED OFF IN ACCORDANCE WITH AEROSPATIALE SVC BULLETIN #62.02. THE PURPOSE OF THE SVC BULLETIN WAS TO PREVENT LEAKAGE OF THE LUBRICANT.  THE SWASHPLATE BEARING HAD BEEN LUBRICATED 249 HRS PRIOR TO THE ACCIDENT.  PRIORITY AD 89-21-01 WAS ISSUED TO REDUCE THE LUBRICATION INTERVAL FROM 400 TO 100 HOURS & TO BLOCK THE VENT HOLE IN THE STATIONARY SWASHPLATE. THE FUEL FLOW CONTROL LEVER & FUEL SHUT-OFF CONTROL WERE FOUND IN THE CLOSED POSITION (AS IF THE PLT HAD SHUT DOWN THE ENG BEFORE THE ACDNT).

## Aircraft

- Registration: [N57689](https://openairdocs.org/deregistered/N57689-1990-10-09), registration cancelled 1990-10-09, S/N 1312 (OpenAirDocs)
- Reported make and model: AEROSPATIALE AS 350D
- Registry model: [S N I A S AS350D ASTAR](https://openairdocs.org/model/s-n-i-a-s-as350d-astar) (registry code 8680803) (OpenAirDocs)
- Category: Helicopter
- Serial number: 1312
- Airframe hours: 1174
- Engines: LYCOMING LTS-101-600A2 531 horsepower turbo shaft
- Damage: Destroyed
- Flight: Positioning, Part 91
- Operator: Dooley Helicopters, Inc.
- Last inspection: Continuous airworthiness, September 1, 1989, 29 hours before
- Departed: ROME, GA
- Destination: PDK, CHAMBLEE, GA

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 33; commercial; airplane ratings: single-engine land; medical: class 2, valid medical--w/ waivers/lim; toxicology performed; flight hours: 3,500 total, 3,400 as pilot in command, 27 in the last 30 days, 2 in the last 24 hours

## Weather

- Conditions: Instrument (IMC), Day
- Wind: 70° at 9 knots
- Visibility: 3 statute miles
- Lowest ceiling: 800 ft broken
- Temperature: -0 °F, dew point -0 °F
- Observed at: PDK, 1 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 19890928036979A](https://openairdocs.org/incident/19890928036979A), Sep 28, 1989: Snias AS350D, Atlanta, GA, Destroyed, 1 fatal. Lost rotor RPM. Tried to autorotate,lost control due low rotor RPM and crashed. Swash plate separated.

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.

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