LAX00LA047

NTSB accident investigation · Boeing 369E · Taft, CA · November 30, 1999

Accident · No injuriesLimited investigationFinal report
Date
November 30, 1999, 13:45 local (21:45 UTC)
Place
Taft, CA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N5238CBoeing 369E
Weather
Visual (VMC) · Day
Status
Completed · report August 21, 2001
Report
Approved by Office Director
FAA report
19991130042909A
Case key
47830

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 fatigue failure of a second stage compressor vane due to erosion, which resulted in a catastrophic engine failure. An inadequate inspection of the compressor section by company maintenance personnel during the last 300-hour inspection was also causal in this accident. The maintenance personnel's failure to conduct the periodic recommended compressor washes was a factor.

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 engine power(total) - mech failure/malfHover - out of ground effect
Compressor assembly,stator vane - erodedCause
Maintenance,inspection - inadequateCompany maintenance personnelCause
Compressor assembly,stator vane - fatigueCause
Procedures/directives - not followedCompany maintenance personnelFactor
Forced landingEmergency descent/landing
On ground/water collision with objectLanding - flare/touchdown
Object - other
Landing gear,skid assembly - separation
Roll overLanding - flare/touchdown

Analysis

During a forced landing after an engine failure, the helicopter struck a standpipe, shearing its cross tube, and rolling onto its side. The pilot was in the process of picking up an 800-pound sling load on a 100-foot-long line. As his load reached about 90 to 100 feet agl, the engine quit. He released his load, turned to the right to avoid people and equipment on the ground, and entered autorotation. The conditions at the accident site were dusty and gritty. The engine teardown revealed that a second stage compressor vane had failed in fatigue, which resulted in a catastrophic failure of the compressor section. All first stage vanes were intact, and all third, fourth, fifth, and sixth stage vanes exhibited some degree of foreign object damage (FOD). The plastic coating on the first and second stage vanes exhibited erosion that exceeded the maximum allowable limits specified by the Rolls-Royce Allison 250-C20 Series Operation and Maintenance Manual. The first stage compressor blades were eroded, with the leading edges rolled over and scalloped. Metallurgical examination of the failed vanes revealed that they met all chemical and manufacturing process specifications. According to the maintenance records, a 300-hour inspection had been performed on the engine 130.1 flight hours before the accident. The manufacturer recommends a compressor case inspection be accomplished every 300 hours when operating in a corrosive environment. No evidence was found in the maintenance records of compressor washes being performed as recommended by the manufacturer.

Factual narrative

On November 30, 1999, at 1345 hours Pacific standard time, a MDHI 369E, N5238C, collided with a standpipe during a forced, autorotative landing near Taft, California, following a loss of engine power. The helicopter sustained substantial damage; however, the certificated commercial pilot, the sole occupant, was not injured. The helicopter was being operated as an external load flight by Omni Energy Services under 14 CFR Part 133 when the accident occurred. The flight originated from a private helipad near Taft at 1135. Visual meteorological conditions prevailed at the time and no flight plan was filed.

The pilot reported that he was in the process of picking up an 800-pound sling load on a 100-foot-long line. As his load reached about 90 to 100 feet agl, the engine quit. He released his load, turned to the right to avoid people and equipment on the ground, and entered autorotation. After touchdown, the left rear cross tube struck a standpipe, shearing the left skid tube and strut off the helicopter. As the main rotor slowed, the helicopter rolled onto its left side.

The ground at the accident site had been disturbed by vehicles and construction equipment, producing dusty and gritty conditions.

A representative of the engine manufacturer, Rolls-Royce Allison, participated in the investigation. The engine teardown revealed that the second stage compressor vanes had failed. All first stage vanes were intact, and all third, fourth, fifth, and sixth stage vanes exhibited some degree of foreign object damage (FOD). Additionally, erosion of the plastic coating on first and second stage vanes exceeded the maximum allowable limits specified by the Rolls-Royce Allison 250-C20 Series Operation and Maintenance Manual. The first stage compressor blades were found eroded with the leading edges rolled over and scalloped. Metallurgical examination of the failed vanes revealed that they conformed to all chemical and process specifications for the components.

According to maintenance records, a 300-hour inspection had been performed on the engine at 2,418.8 flight hours, about 130 hours prior to the accident. The manufacturer recommends that an inspection of the compressor case be performed every 300 flight hours when operating in an erosive environment. In addition, there were no records found for compressor washes.

Aircraft

Registration
N5238C
Reported as
Boeing 369E
Category
Helicopter
Serial number
0151E
Airframe hours
2,548
Engine
Rolls-Royce 250-C20, 420 horsepower, turbo shaft
Damage
Substantial damage
Flight
Other work use · Part 133
Registered owner
Omni Energy Services
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · November 3, 1999 · 62 hours before

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
45
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
8,000 total · 5,700 in this make and model · 7,000 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
156 °F, dew point 115 °F
Altimeter
30.00 inHg
Observed at
BFL, 25 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.