CHI04CA237

NTSB accident investigation · Enstrom F-28A · Leroy, MN · August 23, 2004

Accident · Serious injuriesData collectionFinal report
Date
August 23, 2004, 09:50 local (14:50 UTC)
Place
Leroy, MN
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N9573Enstrom F-28A
Weather
Visual (VMC) · Day
Status
Completed · report October 28, 2004
Report
Approved by Office Director
FAA report
20040823019509A
Case key
60098

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The partial loss of engine power due to the missing 1/8-27 NPT Allen plug as a result of other maintenance personnel undertorquing the plug. Additionally, the pilot improperly excecuted a run on landing. A factor was the loss of tail rotor effectiveness.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(partial) - mech failure/malfTakeoff
Maintenance,installation - inadequateOther maintenance personnelCause
Engine assembly,other - undertorquedCause
Engine assembly,other - missingCause
Forced landingEmergency descent/landing
Loss of control - on ground/waterEmergency descent/landing
Loss of tail rotor effectiveness - encounteredPilot in commandFactor
Run on landing - improperPilot in commandCause
On ground/water encounter with terrain/waterEmergency descent/landing
Terrain condition - ground

Analysis

The helicopter sustained substantial damage when it impacted terrain and rolled over after a loss of engine power during takeoff. The pilot reported that the engine was producing 3,000 rpm's when he brought the helicopter into a hover. He transitioned into forward flight and cleared a fence, and then the engine lost power. He reported that he thought that an exhaust valve was stuck. He attempted to do a run on landing to a field. The helicopter touched down on its left skid two times but the helicopter was not straight. He reported that the third time the helicopter touched down on its left skid, the helicopter was not straight and the rpm's were low. He reported that he ran out of tail rotor authority. The helicopter rolled over on its left side. The engine was inspected and an engine run was conducted. The engine was run at 1,800 to 2,000 rpm, and then at 1,110 to 1,200 rpm; but the engine popped and ran unevenly. A re-inspection of the engine revealed that the 1/8-27 NPT Allen plug to the number four cylinder was missing. Once the hole was plugged, the engine ran smoothly.

Factual narrative

On August 23, 2004, at 0950 central daylight time, an Enstrom F-28A helicopter, N9573, sustained substantial damage when it impacted terrain and rolled over after a loss of engine power during takeoff near Leroy, Minnesota. The pilot received serious injuries, but the passenger was not injured. The 14 CFR Part 91 aerial observation flight was departing to conduct a local observation flight. Visual meteorological conditions prevailed. No flight plan was filed.

The pilot reported that the engine was producing 3,000 rpm's when he brought the helicopter into a hover. He reported that he transitioned into forward flight and cleared a fence, and then the engine lost power. He reported that he thought that an exhaust valve was stuck. He attempted to do a run on landing to a field. The helicopter touched down on its left skid two times but the helicopter was not straight. He reported that the third time the helicopter touched down on its left skid, the helicopter was not straight and the rpm's were low. He reported that he ran out of tail rotor authority. The helicopter rolled over on it left side.

A Federal Aviation Administration airworthiness inspector examined the engine at the Marion Airport, Marion, Iowa, on September 1, 2004. Representatives from Enstrom Helicopter, Textron Lycoming, and the operator attended the engine inspection. An engine run was conducted. The engine was run at 1,800 to 2,000 rpm, and then at 1,110 to 1,200 rpm; but the engine popped and ran unevenly. The engine inspection revealed that the 1/8-27 NPT Allen plug to the number four cylinder was missing. Once the hole was plugged, the engine ran smoothly.

Aircraft

Registration
N9573
Reported as
Enstrom F-28A
Category
Helicopter
Serial number
131
Engine
Lycoming HIO-360-CIA, reciprocating
Damage
Substantial damage
Flight
Aerial observation · Part 91
Operator
P & N Corporation, doing business as Powerline Inspection
Registered owner
P & N Corporation
Airworthiness certificate
Standard, Utility
Departed
Leroy, MN

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Co-pilot
Age
61
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2
Flight hours
50,000 total · 7,000 in this make and model · 100 in the last 90 days · 30 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.