FTW89FA093

NTSB accident investigation · MBB BO-105S · W Cameron Blk · May 7, 1989

Accident · FatalField investigationFinal report
Date
May 7, 1989, 14:04 local (19:04 UTC)
Place
W Cameron Blk
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N2785BMBB BO-105S
Weather
Visual (VMC) · Day
Status
Completed · report September 9, 1992
Report
Approved by Office Director
FAA report
19890507010829A
Case key
22771

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 electrical failure of the micro-switch for the outboard lateral guide assembly, and the incorrect guard installed on the hydraulic test switch, resulting in a total hydraulic failure. Factors were: the incorrect installation of the guard by an unknown person, the failure of the company to comply with the specified service bulletin.

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 control - in flightCruise
Electrical system - failure,partialCause
Hydraulic system - not switchedCause
Hydraulic system - failure,totalCause
Maintenance,service bulletin/letter - not performedCompany maintenance personnelFactor
Electrical system,circuit breaker - popped/tripped
Maintenance,installation - improperUnknownFactor
Remedial action - not possiblePilot in command
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - water

Analysis

The twin engine helicopter was in cruise flight over the gulf of Mexico, when it suddenly pitched nose down and descended uncontrolled to impact inverted into the water. It sank to a depth of approximately 380 feet. After recovery of the helicopter, examination revealed that an incorrect hydraulic switch guard held the test switch in the reset position, electrically isolating hydraulic system number two from operation, and that the hydraulic module was in the number 1 system. Further inspection and testing found a defective micro-switch in the outboard lateral guide assembly of the hydraulic module. Additionally, the operator had not complied with a required service bulletin for the module.

Aircraft

Registration
N2785B
Reported as
MBB BO-105S
Category
Helicopter
Serial number
636
Airframe hours
1,781
Engine
Allison 250-C20B, 420 horsepower, turbo shaft
Damage
Destroyed
Flight
Part 135
Operator
Air Logistics
Registered owner
Mcdonnell Douglas Finance Corp
Last inspection
AAIP · May 6, 1989 · 3 hours before
Departed
NONE · Hi-A330, GM
Destination
NONE · Wc-643, GM
Flight plan
Company VFR
Airport
NONE

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
Pilot
Age
51
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
7,459 total · 2,397 in this make and model · 6,526 as pilot in command · 168 in the last 90 days · 43 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
25 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 63 °F
Altimeter
30.00 inHg

FAA reports on this event · 1

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

Other investigations on N2785B · 1

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