# NTSB LAX01LA009: Aerospatiale AS350BA, N189ND, El Cajon, CA, October 3, 2000 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 3, 2000, 14:30 local (21:30 UTC) - Place: El Cajon, CA - Coordinates: 32.789264, -116.95919 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.7893&lon=-116.9592&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report November 6, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 51220 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX01LA009 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/51220/pdf - Page: https://openairdocs.org/ntsb/LAX01LA009 ## Probable cause Improper torquing procedure of the aft tail rotor drive shaft coupling by maintenance personnel after tracking the tail rotor. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, landing - maintenance,annual inspection - improper, other maintenance personnel (cause) - rotor drive system,tail rotor drive shaft coupling - disconnected (contributing factor) - Hard landing, emergency descent/landing - autorotation - initiated, pilot in command - In flight collision with terrain/water, landing - terrain condition - ground ## Analysis While positioning the helicopter from the ground to a storage cart, the pilot lost directional, made a hard landing, and the tail boom struck the ground. Prior to the loss of directional control, the pilot saw something depart the tail section. He attributed the loss of directional control to a tail rotor failure. He initiated an autorotation over the landing cart. He maneuvered away from the cart in order to land on the ground and prevent a partial landing on the cart. The on-scene investigation revealed the aft drive shaft coupling was detached from the tail rotor drive shaft. Three bolts retain the coupling. One bolt was found attached to the coupling, another bolt was found on the ground, and the third bolt, and two of the retaining nuts, were not located. Neither bolt exhibited stripped threads or deformation. The last maintenance performed on the helicopter was by the previous owner. A track and balance of the tail rotor system was performed about 48 flight hours prior to the accident. According to the manufacturer's maintenance instructions, the balancing is accomplished by placement of washers under the nuts that are used to secure the bolts that attach to the aft drive shaft coupling. These are the same nuts that were not located at the accident site. Maintenance instructions also specify that the bolts in this area should be checked for proper torque and safety after an inspection. ## Factual narrative On October 3, 2000, at 1430 hours Pacific daylight time, an Aerospatiale AS350BA, N189ND, made a hard landing after experiencing a loss of directional control at Gillespie Field Airport, El Cajon, California. Vortex Helicopters, LLC, operated the helicopter under the provisions of 14 CFR Part 91. The helicopter sustained substantial damage when the tail boom contacted the ground. The airline transport pilot and one passenger were not injured. Visual meteorological conditions prevailed for the positioning flight, and no flight plan had been filed. The helicopter had been returned from another operator after 15 hours of training flights in which a series of full autorotations to the ground were conducted. The purpose of the accident flight was to reposition the helicopter from the ground onto a landing cart for storage. While over the landing cart, the pilot experienced difficulty maintaining directional control. He suspected an antitorque failure and initiated an autorotation. The pilot stated at the time the landing cart was partially beneath the helicopter. The pilot maneuvered away from the cart in order to land on the ground and prevent a partial landing on the cart. As he increased power to maneuver away from the cart, there was a further loss of directional control. After clearing the landing cart, the subsequent hard landing resulted in the tail boom contacting the ground. In an interview with a Federal Aviation Administration (FAA) inspector, the pilot stated that while he was attempting to land on the cart, he saw something fly off the helicopter prior to losing directional control. During the on-scene investigation conducted by the FAA inspector, the aft tail rotor drive shaft coupling was found remotely located from the main wreckage. The FAA inspector noted that three bolts retain the coupling. One bolt was found attached to the coupling with no nut. He stated that there was no evidence of the nut having stripped the bolt. The second bolt was found on the ground with the threads intact. He was not able to find the third bolt or the other two nuts. The FAA inspector reviewed the maintenance logbooks and noted the University of North Dakota, Grand Forks, North Dakota, performed the last annual on March 9, 2000. The University of North Dakota performed a track and balance inspection on the tail rotor system about 48 hours prior to the accident. According to maintenance instructions provided by the manufacturer, the balancing is accomplished by placing washers under the nuts used to secure the bolts that attach to the aft drive shaft coupling. These were the same nuts that were not located at the scene of the accident. A caution to the maintenance instructions specifies that the bolts in this area should be checked for proper torque and safety after an inspection. The FAA San Diego, California, Flight Standards District Office reported the accident to the Safety Board on October 12, 2000. ## Aircraft - Registration: N189ND (not matched to a registry record) - Reported make and model: Aerospatiale AS350BA - Category: Helicopter - Serial number: 2152 - Airframe hours: 5764 - Engines: Turbomeca ARRIEL 1B 510 horsepower turbo shaft - Damage: Substantial damage - Flight: Positioning, Part 91 - Registered owner: Vortex Helicopters, LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 2, 2000, 73 hours before - Departed: SEE - Airport: SEE, Gillespie Field Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; commercial, airline transport; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: right; flight hours: 4,000 total, 75 in this make and model, 4,000 as pilot in command, 50 in the last 90 days, 40 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: 2,200 ft overcast - Temperature: 154 °F, dew point 142 °F - Altimeter: 29.00 inHg - Observed at: SEE ## 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 20001003018939A](https://openairdocs.org/incident/20001003018939A), Oct 3, 2000: Snias AS350BA, El Cajon, CA, Substantial damage. (-23) Pilot reported that during landing, the tail rotor became ineffective and he dropped the collective to get the a/c on the ground, resulting in a hard… 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.