LAX02LA032

NTSB accident investigation · McDonnell Douglas 369HS · Pacific Ocean (Pacific Ocean) · November 23, 2001

Accident · Minor injuriesLimited investigationFinal report
Date
November 23, 2001
Place
Pacific Ocean (Pacific Ocean)
Injuries
1 minor, 1 uninjured
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N4265DMcDonnell Douglas 369HS
Weather
Visual (VMC) · Day
Status
Completed · report May 28, 2002
Report
Approved by Office Director
Parties
Federal Aviation Administration, SFO IFO
FAA report
20011123030589A
Case key
53812

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

A dynamic roll over due to the pilot's inadequate preflight inspection and failure to ensure that all tiedowns were removed. A factor in the accident may have been the lack of clear communications between the pilot and the shipboard helper assigned as the helicopter ground crewman.

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.

Roll overTakeoff
Aircraft preflight - inadequatePilot in commandCause
Tie down - not removedPilot in commandCause
Instructions,written/verbal - not understoodGround personnelFactor

Analysis

As the pilot began to lift the fish spotting helicopter off a helipad on a tuna fishing vessel, it rolled off the right side of the ship. The rotor blades hit the side of the ship and the helicopter entered the water inverted and sank. The operator stated that the probable cause was that the right side tiedowns and the APU cable were not removed by the shipboard helper prior to the pilot attempting to liftoff. The pilot reported to the operator that he believed he had checked the tiedowns before getting in the helicopter's left seat, but that it was also hard to see the right-hand side of the aircraft on the pad. The operator also noted that the shipboard helper is a Chinese national who does not speak English well and that communications between the two may not have been good.

Factual narrative

On November 23, 2001, at 1409 local ship time, a MDHI 369HS helicopter, N4265D, rolled over on takeoff from a fishing vessel in international waters of the Pacific Ocean near Rabul, Papua New Guinea. The helicopter was operated by Hoffman Helicopters, Inc., of Tamuning, Guam, for fish spotting operations from a tuna fishing vessel under 14 CFR Part 91 of the Federal Aviation Regulations. The helicopter was destroyed when it rolled off the ship's right side, sank, and was not recovered. The commercial pilot sustained minor injuries and the observer was not injured. Visual meteorological conditions prevailed for the local aerial observation flight, which was originating at the time of the accident.

According to the operator's written report of the event, the helicopter rolled off the right side of the fishing vessel as the pilot began to liftoff the helipad. The rotor blades hit the side of the ship and the helicopter entered the water inverted and sank. The operator stated that the probable cause was that the right side tiedowns and the APU cable were not removed by the shipboard helper prior to the pilot attempting to liftoff. The pilot reported to the operator that he believed he had checked the tiedowns before getting in the helicopter, but that it was also hard to see the right-hand side of the aircraft on the pad. The operator also noted that the shipboard helper is a Chinese national who does not speak English well and that communications may not have been good.

In the operator's written accident report, he noted that a Allison T63-A-720 engine was installed in the helicopter. According to Allison, the T63-A-720 is an engine type produced for the military and has a close equivalency to a 250-C20C civilian engine. The Federal Aviation Administration Type Certificate Data Sheet for the 250 series Rolls Royce Allison engines notes that certain military engines are eligible for use under the Civil Type Certificate if the civilian model is stamped on the data plate next to the military model designation, and, certain modifications are made prior to civilian use. The engine sank with the airframe and no determination could be made regarding the status of the engine installed in the helicopter.

Review of the MDHI 369 series Type Certificate Data Sheet disclosed that the model 369HS should be equipped with a Rolls Royce Allison 250-C18A or 250-C18C engine; however, an acceptable alternate engine is the Rolls Royce Allison 250-C20. Comparison of the data for the 250-C20C and 250-C20 engines revealed differences in horsepower output, gas producer rpm, and temperature limits, among others.

Aircraft

Registration
N4265D
Reported as
McDonnell Douglas 369HS
Category
Helicopter
Serial number
430464S
Airframe hours
7,660
Engine
Allison T63-A-720, 370 horsepower, turbo shaft
Damage
Destroyed
Flight
Aerial observation · Part 91
Registered owner
Hoffman Helicotpers, Inc.
Airworthiness certificate
Special, Restricted (Special)
Last inspection
100 hour · November 2, 2001 · 60 hours before
Departed
Pacific Ocean

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
Injuries
Minor
Certificate
Commercial
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
June 18, 2001
Seat
Left
Flight hours
2,495 total · 2,059 in this make and model · 109 in the last 90 days · 70 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
30 statute miles
Lowest ceiling
None
Temperature
90 °F

FAA reports on this event · 1

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