LAX01FA006

NTSB accident investigation · McDonnell Douglas 369E · Kernville, CA · October 8, 2000

Accident · Minor injuriesField investigationFinal report
Date
October 7, 2000, 17:40 local (Oct 8, 2000, 00:40 UTC)
Place
Kernville, CA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N819CEMcDonnell Douglas 369E
Weather
Visual (VMC) · Day
Status
Completed · report September 30, 2003
Report
Approved by Office Director
Parties
Federal Aviation Administration, Southern California Edison, Rolls-Royce, Boeing
FAA report
20001007015019A
Case key
50422

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 pilot's improper storage of personal items and his inadequate preflight inspection, which resulted in the unlatching of the left rear cabin door during flight and allowing a plastic garment bag to blow out and strike the tail rotor.

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.

Airframe/component/system failure/malfunctionCruise
Security of cargo - inadequatePilot in commandCause
Door,passenger - not securedCause
Aircraft preflight - inadequatePilot in commandCause
Rotor system,tail rotor blade - sudden stoppage
Rotor drive system,tail rotor drive shaft - overload
Forced landingDescent - emergency
Roll overLanding - flare/touchdown
Terrain condition - mountainous/hillyFactor
Terrain condition - none suitableFactor

Analysis

The helicopter rolled over during an emergency landing following a severe vibration and loss of antitorque control. The pilot stated that he was descending from 7,500 feet msl with an indicated airspeed of 125 knots in mountainous terrain and light turbulence. The first indication of trouble was a loud snap sound from the rear of the helicopter, followed by violent airframe vibrations. The pilot reported that there were no unusual vibrations in any of the controls. He made a right turn to land on the best available terrain. As the turn was completed, antitorque control was lost, and the helicopter began a series of rapid clockwise spins. The helicopter spun at least three times before impact. Examination of the helicopter revealed a torsional failure of the tail rotor drive shaft at 8 inches forward of the aft Kamatics coupling. This failure is consistent with a tail rotor sudden stoppage. Leading edge tail rotor blade damage was observed to both blades, with red and blue color and material transfers evident. Examination of the tail rotor blade leading edges by Fourier Transform Infrared (FTIR) Spectrometer of the accumulation revealed the material to be of a cellophane base. The pilot reported that prior to departure from Big Creek, he placed a red and blue checkered shirt contained in a plastic bag on the rear seat with other personal baggage. He speculated that during his descent from 7,500 feet, he had experienced some turbulence and the left rear door may have popped open. Neither the bag nor the shirt was recovered at the accident site.

Factual narrative

History of flight

On October 7, 2000, about 1740 Pacific daylight time, a McDonnell Douglas (MD) 369E helicopter, N819CE, was substantially damaged during an emergency landing in mountainous terrain near Kernville, California. The helicopter was operated by Southern California Edison under the provisions of 14 CFR Part 91. The airline transport rated pilot received minor injuries. Visual meteorological conditions prevailed for the positioning flight, and a company flight plan was filed. The flight originated at Big Creek, California, about 1645, and was destined for Ontario, California.

The helicopter was being repositioned to the Edison maintenance facility at Ontario for a 300-hour inspection. The pilot stated that he was descending from 7,500 feet mean sea level (msl) with an indicated airspeed of 125 knots. The first indication of trouble was a loud snap sound from the rear of the helicopter, followed by a violent airframe vibration. He noted that the only warning panel light that was illuminated was the generator fail light. He reported that there were no unusual vibrations in any of the controls.

The pilot made a right turn to land on the best available terrain. As the turn was completed, tail rotor effectiveness was lost, and the helicopter began a series of rapid clockwise spins. The helicopter spun at least three times before impact.

Personnel information

Review of the Federal Aviation Administration (FAA) Airman Certification Records disclosed the pilot held an airline transport certificate with ratings for airplane single and multiengine land and rotorcraft/helicopters. He is instrument rated for airplanes and helicopters. The pilot's most recent first-class medical certificate was issued on September 18, 2000, with the limitation to have glasses available for near vision.

According to flight department records, at the time of the accident the pilot had accumulated 24,424 total flight hours, with 9,647 hours in the accident make and model. In the 90 days prior to the accident, he had accumulated 176 flight hours.

Aircraft information

The most recent 100-hour inspection per the manufacturer's program occurred 93 hours prior to the accident. The helicopter had accumulated a total flight time of 7,772 hours, and was inbound to Ontario for a 300-hour inspection.

Wreckage and impact information

The Safety Board, with the parties to the investigation, viewed the wreckage at the operator's facility in Ontario.

The tail boom was separated at FS258.0 by an angular slash with sheet metal skin displaced in the direction of main rotor rotation. The separation point is within the disk radius of the main rotor.

The tail rotor drive shaft remained attached at the main transmission via the forward Kamatics coupling and at the tail rotor gearbox via the aft Kamatics coupling. The drive shaft evidenced two fractures, one at FS 258.0 and the second at 8 inches forward of the aft Kamatics coupling. The forward (FS258.0) fracture was accompanied by significant bending of the drive shaft. The drive shaft immediately aft of the rear fracture was torsionally twisted. Leading edge tail rotor blade damage was observed to both blades, with red and blue color and material transfers evident. Examination of the tail rotor blade leading edges by Fourier Transform Infrared (FTIR) Spectrometer of the accumulation revealed the material to be of a cellophane base.

The pilot reported that prior to departure from Big Creek, he placed a red and blue checkered shirt contained in a plastic bag on the rear seat with other personal baggage. He speculated that during his descent from 7,500 feet msl he had experienced some turbulence, and the left rear door may have popped open. Neither the bag nor the shirt was recovered at the accident site.

Additional information

The Safety Board did not take possession of the wreckage.

Aircraft

Registration
N819CE
Reported as
McDonnell Douglas 369E
Category
Helicopter
Serial number
0028E
Airframe hours
7,772
Engine
Allison 250-C20R/2, 450 horsepower, turbo shaft
Damage
Substantial damage
Flight
Positioning · Part 91
Registered owner
Southern California Edison Co.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 25, 2000 · 93 hours before
Departed
NONE · Big Creek, CA
Destination
ONT · Ontario, CA
Flight plan
Company VFR

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
59
Injuries
Minor
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
24,424 total · 9,647 in this make and model · 23,920 as pilot in command · 176 in the last 90 days · 90 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 14 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 61 °F

Docket · 9

The files NTSB released with the investigation on July 1, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.4 MB in all.

FAA reports on this event · 1

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