# NTSB CHI92LA017: Mcdonnell Douglas MD369D, N88SE, Beech Grove, IN, October 23, 1991

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: October 23, 1991, 11:00 local (16:00 UTC)
- Place: Beech Grove, IN
- Coordinates: 39.720405, -86.089622 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=39.7204&lon=-86.0896&mi=10
- Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 3 uninjured
- Status: Completed, report December 4, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 15341
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI92LA017
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15341/pdf
- Page: https://openairdocs.org/ntsb/CHI92LA017

## Probable cause

IMPROPER INSTALLATION OF THE FLIGHT CONTROL LINKAGE DURING MAINTENANCE. COMPLACENCY AND INADEQUATE INSPECTION OF THE HELICOPTER BY MAINTENANCE PERSONNEL AND THE PILOT ARE FACTORS IN THE ACCIDENT.

## Sequence of events

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

- Airframe/component/system failure/malfunction, taxi - aerial
  - rotorcraft flight control,cyclic bellcrank - disconnected
  - maintenance,installation - improper, other maintenance personnel (cause)
  - complacency, other maintenance personnel (contributing factor)
  - maintenance,inspection - improper, other maintenance personnel (contributing factor)
  - aircraft preflight - improper, pilot in command (contributing factor)
  - complacency, pilot in command (contributing factor)
- Roll over, taxi - aerial
  - aircraft control - not possible, pilot in command

## Analysis

THE ACCIDENT HELICOPTER EXPERIENCED A LOSS OF CYCLIC PITCH CONTROL DURING LIFTOFF TO A HOVER AT THE START OF A BUSINESS FLIGHT.  THE HELICOPTER PITCHED UP, STRIKING THE TAIL ROTOR INTO THE GROUND AND THEN ROLLED ONTO ITS RIGHT SIDE.  THE HELICOPTER SUSTAINED SUBSTANTIAL DAMAGE.  THE COMMERCIAL PILOT AND TWO PASSENGERS WERE NOT INJURED.  ON SCENE INSPECTION OF THE WRECKAGE SHOWED A FLIGHT CONTROL LINKAGE DISCONNECT.  THE MISSING BOLT WAS FOUND ON THE GROUND NEXT TO THE HELICOPTER.  THE OTHER CONNECTING HARDWARE WAS NOT FOUND.  THE PILOT STATED THAT HE DID NOT NOTICE THE MISSING NUT DURING HIS PREFLIGHT INSPECTION.

## Aircraft

- Registration: [N88SE](https://openairdocs.org/deregistered/N88SE-2013-10-29), registration cancelled 2013-10-29, S/N 800775D, built 1980 (OpenAirDocs)
- Reported make and model: MCDONNELL DOUGLAS MD369D
- Registry model: [Hughes Helicopters HUGHES 369D](https://openairdocs.org/model/hughes-helicopters-hughes-369d) (registry code 4470706) (OpenAirDocs)
- Registry engine: [Allison 250 SER 250HP](https://openairdocs.org/engine/allison-250-ser-250hp) (registry code 03002, turbo-shaft) (OpenAirDocs)
- Category: Helicopter
- Serial number: 775D
- Airframe hours: 1236
- Engines: ALLISON 250-C20B 375 horsepower turbo shaft
- Damage: Substantial damage
- Flight: Business, Part 91
- Operator: Miami Valley Services
- Registered owner: Miami Valley Services
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, September 26, 1991, 24 hours before
- Destination: NONE, RICHMOND, IN

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 54; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 3,000 total, 400 in this make and model, 2,800 as pilot in command, 100 in the last 90 days, 25 in the last 30 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 190° at 11 knots
- Visibility: 4 statute miles
- Lowest ceiling: 1,100 ft overcast
- Temperature: 66 °F, dew point 63 °F
- Altimeter: 30.00 inHg
- Observed at: IND, 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 19911023047419A](https://openairdocs.org/incident/19911023047419A), Oct 23, 1991: Hughes 369D, Beech Grove, OH, Substantial damage. Flight control linkage disconnect on liftoff. Hit tail first and rolled over. Bolt connecting pitch control missing

## Other investigations on N88SE (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 SEA06LA124](https://openairdocs.org/ntsb/SEA06LA124), Jun 20, 2006: Hughes 369D (N88SE), Salt Lake City, UT, substantial damage. Probable cause: A loss of rotor rpm for undetermined reasons, resulting in a hard landing on top of the commercial building over which the helicopter was working.

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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