# NTSB GAA19CA284: Schweizer 269C, N269P, Riverside, CA, May 24, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: May 24, 2019, 13:45 local (20:45 UTC) - Place: Riverside, CA - Coordinates: 33.951946, -117.444999 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.9519&lon=-117.4450&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Hard landing](https://openairdocs.org/ntsb-events/092) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report April 13, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 99493 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA284 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99493/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99493 - Page: https://openairdocs.org/ntsb/GAA19CA284 ## Probable cause The student pilot's failure to maintain yaw control and the engine's rpm during transition to a hover, which resulted in hard landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Schweizer 269C, 8 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=8059502), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: powerplant parameters](https://openairdocs.org/ntsb-findings/01062050): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Schweizer 269C, 4 cases](https://openairdocs.org/ntsb-findings/01062050/cases.md?model=8059502), [All aircraft, 81 cases](https://openairdocs.org/ntsb-findings/01062050/cases.md) - [Performance/control parameters: yaw control](https://openairdocs.org/ntsb-findings/01062024): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Schweizer 269C, 2 cases](https://openairdocs.org/ntsb-findings/01062024/cases.md?model=8059502), [All aircraft, 149 cases](https://openairdocs.org/ntsb-findings/01062024/cases.md) - [Policy/procedure: adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015): Organizational issues › Management · Operator; cases with it: [Schweizer 269C, 1 case](https://openairdocs.org/ntsb-findings/04021015/cases.md?model=8059502), [All aircraft, 106 cases](https://openairdocs.org/ntsb-findings/04021015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-hover: Unknown or undetermined](https://openairdocs.org/ntsb-events/000); cases with it: [Schweizer 269C, 4 cases](https://openairdocs.org/ntsb-events/000/sequence.md?model=8059502), [All aircraft, 1,703 cases](https://openairdocs.org/ntsb-events/000/sequence.md) - [Landing: Hard landing](https://openairdocs.org/ntsb-events/092) (defining event); cases with it: [Schweizer 269C, 17 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=8059502), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis The day of the accident, the student pilot had flown three takeoffs and landings in the pattern with the instructor. After the third landing, the instructor exited the helicopter and authorized the student to perform her third flight solo. The student accomplished the before takeoff checks and increased the throttle, and as she increased the collective pitch, she felt an "abnormal vibration," but she decided to continue with the flight. She increased the collective and applied left pedal, and the helicopter ascended, but the nose yawed rapidly left. The student noted that the engine rpm had increased, and she lowered the collective. The left skid contacted the ground hard, followed by the right skid, and the student then decreased power, shut down the engine, and exited the helicopter. The helicopter sustained substantial damage to the aft skid tube cross-member. The student reported that several mechanical malfunctions existed with the helicopter during previous flights. Although examination of the helicopter and the operator's maintenance logbooks revealed that there were maintenance deficiencies that were incorrectly annotated, postaccident examination revealed no evidence of any preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operation. After the accident, the operator implemented a policy to document and clear all future maintenance discrepancies associated with helicopters in their fleet. ## Factual narrative The student helicopter pilot reported that she had been working on her private helicopter pilot certificate over an extended period of time. The student reported that the helicopter's throttle governor had been operational during previous solo flights, but it had failed months prior to the accident flight. She confirmed that she had flown the helicopter several times without the use of the governor, under the supervision of the instructor. The day of the accident, she had flown three takeoffs and landings in the pattern with the flight instructor. After the third landing, the instructor exited the helicopter and authorized the student to perform her third solo flight. The student reported that after accomplishing the before takeoff checks, the throttle was increased, and as she increased the collective pitch, she felt an "abnormal vibration," but she decided to continue with the flight. She increased the collective and applied left pedal, and the helicopter ascended, but the nose yawed rapidly to the left. The student noted that the engine RPM increased, and she lowered the collective. The left skid contacted the ground hard, followed by the right skid, and the student decreased power, shut down the engine and exited the helicopter. The helicopter sustained substantial damage to the aft skid tube cross-member. The student pilot reported that several mechanical malfunctions existed with the helicopter during previous flights. Examination of the helicopter and the operator's maintenance logbooks revealed that there were maintenance squawks that were incorrectly annotated, however, there were no mechanical malfunctions or failures that were observed during the examination that would have prevented normal helicopter operation. The operator has implemented a policy to document and clear all future maintenance squawks associated with helicopters in their fleet. ## Aircraft - Registration: [N269P](https://openairdocs.org/deregistered/N269P-2019-12-17), registration cancelled 2019-12-17, S/N S1328, built 1988 (OpenAirDocs) - Reported make and model: Schweizer 269C (Undesignat) - Registry model: [Schweizer 269C](https://openairdocs.org/model/schweizer-269c) (registry code 8059502) (OpenAirDocs) - Registry engine: [Lycoming HIO-360-D1A](https://openairdocs.org/engine/lycoming-hio-360-d1a) (registry code 41893, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: S1328 - Year built: 1988 - Airframe hours: 2109.7 - Engines: LYCOMING HIO-360-D1A 190 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Western Helicopters, Inc., doing business as Western Helicopters, Inc. - Registered owner: Ingoma Aero Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 2019 - Departed: RAL, Riverside, CA - Destination: RAL, Riverside, CA - Airport: RAL, Riverside Muni, runway H1, 60 × 60 ft, asphalt - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 57; injuries: none; student; medical: class 2, with waivers/limitations; seat: left; restraint: 4-point; flight hours: 69 total, 1 as pilot in command, 15 in the last 90 days, 4 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Dusk - Visibility: 7 statute miles - Temperature: 72 °F, dew point 54 °F - Altimeter: 29.89 inHg - Observed at: KRAL ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20190524011159I](https://openairdocs.org/incident/20190524011159I), May 24, 2019: Schweizer 269C, Riverside, CA, Minor damage. This part 91 flight was intended to be a supervised solo in the traffic pattern. Reported winds 290/05 knots. Student and CFI performed three dual traffic… ## Docket (5 files) The files NTSB released with the investigation on November 29, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99493. 4.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478469&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Student Pilot's Statement -1 (item 2, .PDF, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478470&FileExtension=.PDF&FileName=Student%20Pilot%27s%20Statement%20-1-Master.PDF - Student Pilot's Statement -2 (item 3, .PDF, 214 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478471&FileExtension=.PDF&FileName=Student%20Pilot%27s%20Statement%20-2-Master.PDF - Operator's Policy Change Notification (item 4, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478472&FileExtension=.PDF&FileName=Operator%27s%20Policy%20Change%20Notification-Master.PDF - Photo (item 5, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478473&FileExtension=.PDF&FileName=Photo-Master.PDF 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.