# NTSB CHI91LA131: Enstrom F-28A, N294Q, Grand Ledge, MI, April 12, 1991

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: April 11, 1991, 21:50 local (Apr 12, 1991, 01:50 UTC)
- Place: Grand Ledge, MI
- Coordinates: 42.749069, -84.740921 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=42.7491&lon=-84.7409&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed, report March 24, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 15042
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI91LA131
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15042/pdf
- Page: https://openairdocs.org/ntsb/CHI91LA131

## Probable cause

THE STUDENT'S FAILURE TO MAINTAIN A PROPER ALTITUDE AND CLEARANCE FROM THE TERRAIN ALONG WITH THE CFI'S FAILURE TO ADEQUATELY SUPERVISE THE STUDENT'S ACTIONS. A FACTOR CONTRIBUTING TO THE ACCIDENT WAS THE INADEQUATE VISUAL LOOKOUT AVAILABLE DUE TO THE NIGHT LIGHT CONDITIONS.

## Sequence of events

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

- Dragged wing,rotor,pod,float or tail/skid, hover
  - visual lookout - inadequate, dual student (contributing factor)
  - visual lookout - inadequate, pilot in command(cfi) (contributing factor)
  - proper altitude - not maintained, dual student (cause)
  - clearance - inadequate, dual student (cause)
  - supervision - inadequate, pilot in command(cfi) (cause)
- Roll over, taxi - aerial

## Analysis

THE CFI AND HIS STUDENT WERE TAXIING BACK TO THE RAMP AFTER A NIGHT INSTRUCTIONAL HELICOPTER LESSON WHEN THE ACCIDENT OCCURRED.  THE CFI STATED THE STUDENT ASCENDED TO AN ALTITUDE OF APPROXIMATELY 15 FEET DURING THE TAXI AT WHICH TIME THE CFI INSTRUCTED THE STUDENT TO DECREASE ALTITUDE. THE STUDENT DESCENDED TOO LOW AND THE SKID CONTACTED THE TAXIWAY RESULTING IN A DYMANIC ROLL OVER.

## Aircraft

- Registration: [N294Q](https://openairdocs.org/deregistered/N294Q-2012-09-24), registration cancelled 2012-09-24, S/N 314, built 1975 (OpenAirDocs)
- Reported make and model: ENSTROM F-28A
- Registry model: [Enstrom F-28A](https://openairdocs.org/model/enstrom-f-28a) (registry code 3300406) (OpenAirDocs)
- Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs)
- Category: Helicopter
- Serial number: 314
- Airframe hours: 2950
- Engines: LYCOMING HIO-360-C1B 205 horsepower reciprocating
- Damage: Substantial damage
- Flight: Instructional, Part 91
- Operator: Paul Concienne
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, April 1, 1991, 5 hours before
- Airport: 4D0, Abrams, runway 9, 3,200 × 75 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 34; flight instructor, commercial; medical: class 2, valid medical--no waivers/lim.; seat: right; flight hours: 1,400 total, 300 in this make and model, 750 as pilot in command, 20 in the last 90 days, 10 in the last 30 days, 5 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Night/dark
- Wind: 50° at 9 knots
- Visibility: 15 statute miles
- Lowest ceiling: 14,000 ft broken
- Temperature: -0 °F, dew point -0 °F
- Observed at: LAN, 10 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 19910411010119A](https://openairdocs.org/incident/19910411010119A), Apr 11, 1991: Enstrm F28A, Grand Ledge, MI, Substantial damage. While aerial taxiing in from a night dual a skid contacted terrain causing a dynamic rollover. Visual cues limited.

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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