# NTSB LAX00LA047: Boeing 369E, N5238C, Taft, CA, November 30, 1999 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: November 30, 1999, 13:45 local (21:45 UTC) - Place: Taft, CA - Coordinates: 35.159641, -119.429992 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.1596&lon=-119.4300&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report August 21, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 47830 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX00LA047 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/47830/pdf - Page: https://openairdocs.org/ntsb/LAX00LA047 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, hover - out of ground effect - compressor assembly,stator vane - eroded (cause) - maintenance,inspection - inadequate, company maintenance personnel (cause) - compressor assembly,stator vane - fatigue (cause) - procedures/directives - not followed, company maintenance personnel (contributing factor) - Forced landing, emergency descent/landing - On ground/water collision with object, landing - flare/touchdown - object - other - landing gear,skid assembly - separation - Roll over, landing - 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](https://openairdocs.org/aircraft/N5238C), registered now, S/N 0151E (OpenAirDocs) - Reported make and model: Boeing 369E - Registry model: [Hughes Helicopters 369E](https://openairdocs.org/model/hughes-helicopters-369e) (registry code 4470707) (OpenAirDocs) - Registry engine: [Allison 250-C20 series](https://openairdocs.org/engine/allison-250-c20-series) (registry code 03020, turbo-prop) (OpenAirDocs) - Category: Helicopter - Serial number: 0151E - Airframe hours: 2548 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; 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 (OpenAirDocs). - [Accident 19991130042909A](https://openairdocs.org/incident/19991130042909A), Nov 30, 1999: Hughes 369E, Taft, CA, Substantial damage. (-23) The MD-500E helicopter was hovering at approx. 100' AGL with an external load of 800 pounds. Upon lifting this load an audible "pop" was heard from the… 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.