# NTSB FTW91FA002: Enstrom F28-C, N88RA, Mesquite, TX, October 7, 1990 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 7, 1990, 14:47 local (19:47 UTC) - Place: Mesquite, TX - Coordinates: 32.760028, -96.589698 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.7600&lon=-96.5897&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report December 30, 1992 - Report: Approved by Office Director - NTSB case key (mKey): 23234 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW91FA002 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/23234/pdf - Page: https://openairdocs.org/ntsb/FTW91FA002 ## Probable cause INSTALLATION ERROR OF COMPANY MAINTENANCE PERSONNEL. FACTORS WERE THE UNSUITABLE TERRAIN, THE TAILWIND, THE INABILITY OF THE PILOT TO MAINTAIN MAIN ROTOR RPM, AND THE INADEQUATE ANNUAL INSPECTION BY COMPANY MAINTENANCE PERSONNEL. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - mech failure/malf, cruise - ignition system,magneto grounding lead (p-lead) - arcing (cause) - ignition system,magneto grounding lead (p-lead) - loose - maintenance,adjustment - improper, company maintenance personnel (cause) - ignition system,ignition harness - chafed - maintenance,annual inspection - inadequate, company maintenance personnel (contributing factor) - Forced landing, maneuvering - turn to landing area (emergency) - terrain condition - none suitable (contributing factor) - weather condition - tailwind (contributing factor) - Loss of control - in flight, descent - emergency - adequate rotor rpm - not possible, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - Roll over, landing - flare/touchdown ## Analysis THE HELICOPTER HAD DEPARTED THE RANCH FOR A LOCAL AREA PLEASURE FLIGHT WHEN AT APPROXIMATELY 300 FEET AGL A LOSS OF POWER OCCURRED. IT WAS OVER A HEAVILY WOODED AREA. THE PILOT ATTEMPTED TO EXTEND THE GLIDE BY PULLING IN COLLECTIVE PITCH AND MAKING A RIGHT TURN (QUARTERING TAILWIND) TO THE ONLY AVAILABLE CLEAR AREA. THE MAIN ROTOR RPM CONTINUED TO DECAY AND THE HELICOPTER DESCENDED VERTICALLY OUT OF CONTROL TO IMPACT ONTO THE OPEN FIELD. THE SKIDS COLLAPSED AND THE HELICOPTER ROLLED RIGHT. POST-ACCIDENT EXAMINATION OF THE WRECKAGE REVEALED THAT A MISALIGNED P-LEAD WIRE IN THE MAGNETO HAD CHAFED AND ARCED. ADDITIONALLY, BOTH P-LEAD CAPS WERE FOUND LOOSE. THE DIRECTOR OF MAINTENANCE FOR THE OPERATOR STATED THAT HE AND HIS MECHANIC DID NOT ADJUST THE MAGNETO TIMING BECAUSE IT WAS TO HARD TOO REACH ON THE HELICOPTER. THE ENGINE WAS TEST RUN WITHOUT DUPLICATION OF THE POWER LOSS. ## Aircraft - Registration: [N88RA](https://openairdocs.org/deregistered/N88RA-1993-12-20), registration cancelled 1993-12-20, S/N 344 (OpenAirDocs) - Reported make and model: ENSTROM F28-C - Registry model: [Enstrom F-28C](https://openairdocs.org/model/enstrom-f-28c) (registry code 3300407) (OpenAirDocs) - Category: Helicopter - Serial number: 344 - Airframe hours: 1089 - Engines: LYCOMING HIO-360-E1AD 205 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Dr. Donald Gillum, doing business as Sky-Ads Inc. - Last inspection: 100 hour, July 26, 1990, 27 hours before - Airport: NONE ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; flight instructor, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; flight hours: 1,250 total, 4 in this make and model, 1,200 as pilot in command, 50 in the last 90 days, 25 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 10 knots - Visibility: 20 statute miles - Lowest ceiling: 10,000 ft broken - Temperature: 93 °F, dew point 68 °F - Altimeter: 29.00 inHg - Observed at: DAL, 5 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 19901007044219A](https://openairdocs.org/incident/19901007044219A), Oct 7, 1990: Enstrm F28C, Mesquite, TX, Destroyed, 1 fatal. Lost power on sightseeing flight. Rotor speed decayed clearing trees. Dual magneto improperly installed still worked ## Other investigations on N88RA (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 DEN89LA118](https://openairdocs.org/ntsb/DEN89LA118), May 9, 1989: Enstrom F-28C (N88RA), Regina, NM, substantial damage. Probable cause: THE PILOT'S POORLY PLANNED APPROACH AND DISREGARD OF THE HELICOPTERS PERFORMANCE DATA. CONTRIBUTING TO THE ACCIDENT WAS THE HIGH DENSITY ALTITUDE CONDITIONS WHICH EXISTED AT THE TIME OF THE ACCIDENT. 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.