# NTSB LAX03FA232: Sikorsky S-58ET, N15AH, Rancho P.Verdes, CA, July 12, 2003 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: July 12, 2003, 10:28 local (17:28 UTC) - Place: Rancho P.Verdes, CA - Coordinates: 33.754444, -118.330001 - Nearby events: https://openairdocs.org/map.md?lat=33.7544&lon=-118.3300&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report March 28, 2006 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 57490 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX03FA232 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/57490/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=57490 - Page: https://openairdocs.org/ntsb/LAX03FA232 ## Probable cause A total loss of antitorque control, due to the fatigue-induced failure of a gear within the drive shaft's intermediate gear box (IGB). Contributing factors were the pilot's improper on-ground decision to continue flight operations following discovery of material on the IGB's chip plug, and his failure to immediately jettison the external load. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, maneuvering - operation with known deficiencies in equipment - continued, pilot in command (contributing factor) - warning system(other) - activated - rotor drive system,intermediate gearbox(42 deg) - fatigue (cause) - tail rotor/anti-torque control - unavailable, pilot in command - rotor drive system,intermediate gearbox(42 deg) - failure,total (cause) - Loss of control - in flight, maneuvering - directional control - not possible, pilot in command (contributing factor) - load jettison - not performed, pilot in command (contributing factor) - height/velocity curve - exceeded, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - congested/confined area ## Analysis The helicopter experienced a loss of tail rotor drive while maneuvering during a Federal Aviation Administration authorized low altitude external long line host operation, and collided with the ground in the subsequent descent. At the time, the operation was being performed in an area of the height-velocity curve that did not allow for a successful autorotative landing. Witnesses reported that minutes prior to the accident the pilot had made a precautionary landing due to illumination of the intermediate gearbox (IGB) chip light. The pilot removed, inspected, and cleaned the chip plug that contained metallic-like particles. During this action, the pilot was overheard to express concern to a ground crewmember by stating "this can be a problem." The pilot elected to continue flight operations. About 13 minutes later, within 200 feet above ground level while lifting an air conditioner (AC) unit from a school building, the pinion gear (part number S1635-64114-101) going into the drive side of the helicopter's intermediate gearbox (IGB) failed. This resulted in a total loss of antitorque control, and the helicopter yawed and spun in a clockwise direction while descending, and the helicopter impacted the unoccupied schoolyard. The pinion gear for the intermediate gearbox was examined. The laboratory reported that the initiating failure event had resulted from a fatigued gear tooth. The failure occurred about 175 hours prior to the part reaching its 2,000-hour life limit. The external long line was still connected to the cargo hook. Examination of the cockpit disclosed that the electrical cargo release switch was not armed. Post accident tests established that both the electrical release and manual backup cargo release mechanisms functioned. ## Factual narrative HISTORY OF FLIGHT On July 12, 2003, about 1028 Pacific daylight time, a Sikorsky S-58ET, N15AH, experienced a loss of control while maneuvering over the Miraleste Intermediate School, Rancho Palos Verdes, California. The pilot made a forced landing, and during the descent the helicopter impacted school bungalows and touched down hard. The helicopter came to rest in a basketball court adjacent to the bungalows, both unoccupied. Aris Helicopters, Ltd., San Jose, California, owned and operated the helicopter. The external load operation was performed under the provisions of 14 CFR Part 133. The helicopter was destroyed, and the commercial certificated pilot was seriously injured. Visual meteorological conditions prevailed at the time. The flight originated from the school property about 1015. On June 9, 2003, Aris provided the contractor with its bid for the helicopter external load operation that involved removing and replacing several dozen air conditioner (AC) units located on top of various school buildings. In the bid, the maximum weight of an individual AC unit was indicated at 2,000 pounds. The following day, the contractor advised Aris that the maximum AC unit weight was 3,500 pounds. On June 26, 2003, Aris provided the Federal Aviation Administration (FAA) with the requisite "Congested Area Lift Plan" for the work project. In the plan, Aris informed the FAA that the maximum AC unit weight was 2,500 pounds, and the operational altitude during the lifts was within 200 feet above ground level. On June 30, the FAA approved the plan. One of the Aris ground crewmembers reported to the National Transportation Safety Board investigator that the first portion of the July 12, 2003, external load operation was performed without incident. However, after a number of AC units were relocated, the pilot made a precautionary landing in an open field on school grounds. The landing was performed after the pilot observed the illumination of a tail rotor gearbox chip light. The pilot landed and shut down the helicopter. Thereafter, the pilot removed the chip plug from the tail rotor drive shaft's intermediate gearbox (IGB) and examined it. The ground crewmember, who reported that he was near the pilot, further indicated to the Safety Board investigator that the pilot stated he looked at the chip plug and did not observe any metal on it, but he did observe "lots of black carbon." After the pilot completed his examination, the chip plug was reinserted into its orifice. Another of the operator's ground crewmembers, who reported that he was standing next to the pilot during the examination, provided the Safety Board investigator with the following (summarized) statement regarding the event: I accompanied the pilot to the tail area of the helicopter where I observed him open an access door. The pilot removed an object that he indicated was, I think, the chip plug. It was connected to the helicopter with a wire. When the plug was removed, between 1 and 2 ounces of fluid dripped out of this area of the helicopter. I saw the pilot wipe off the plug. I went into the helicopter and obtained a piece of masking tape onto which 2 or 3 little chips were placed. The chips looked like metal objects. I do not know if the pilot actually touched the chips; I did. We both thought it might be metal. The chips had a dark color and definitely had some sort of rigidity to them. They were not sludge-like in feel. The pilot stated something like "this can be a problem." The pilot did not make any entry into the helicopter's maintenance records regarding his observations of the chip light having illuminated. He did not make any entry into the records of having removed, cleaned, or reinserted the chip plug. Witnesses reported that the pilot then resumed the external load operation. About five additional lifts were performed before the accident occurred. The pilot reported to the Safety Board investigator that during flight, seconds before the accident, he had detected a high frequency vibration and the helicopter lost tail rotor thrust. His ground crewmembers reported that while the pilot was repositioning one of the larger sized AC units using the 100-foot-long line, the helicopter suddenly began rotating in a clockwise direction and descending. During the Safety Board's on scene examination of the wreckage, the input portion of the tail rotor's drive shaft into the IGB was found disconnected from the corresponding output shaft. Metal particles were observed on the gearbox's chip plug, which was found dangling from an electrical connection wire in the tail boom housing adjacent to the IGB. PERSONNEL INFORMATION: The pilot held the following FAA airman certificates: airline transport pilot, rotorcraft-helicopters. He had commercial privileges for airplane single engine land and sea, and instrument airplane. The pilot also held a certified flight instructor certificate for rotorcraft-helicopters. The pilot held the following type ratings: BH-14ST, BH-206, and SK-58. The pilot was hired by Aris Helicopters in 1995, and thereafter, was appointed to the position of chief pilot and check airman. In 2001, his employment with the company ceased, and the pilot acquired employment flying for a municipality. In January 2003, the pilot reacquired employment with Aris, on a part-time basis, and he performed flights under FAR Part 91 and 133. The pilot reported that his total aircraft and rotorcraft flight times were approximately 14,500 and 13,600 hours, respectively. His total flight time in the accident model of helicopter was 1,500 hours, and he had flown the helicopter 50, 20, and 1.5 hours during the preceding 90-day, 30-day, and 24-hour period. AIRCRAFT INFORMATION Ownership and Model Change History. The helicopter was manufactured in 1962, and it bore serial number 58-1563. The helicopter was sold to the German Army as a model H-34A. The German Army operated the helicopter until about 1975, when it was converted to an S-58ET and operated by the German Government, Geological Society. Following an inspection by a team from Sikorsky Aircraft and maintenance, the helicopter was found to conform to FAA type certificate requirements. The FAA issued the helicopter a Standard Airworthiness Certificate after Aris purchased it in 1986. On March 25, 1987, the FAA issued the helicopter (N15AH) an airworthiness certificate indicating that the helicopter, serial number 58-1563, was a model "S-58ET (H34A)." The following day, the FAA issued another airworthiness certificate indicating that the helicopter was a model "S-58JT." By the accident date, the FAA's aircraft registry had classified the helicopter as being in the Standard Normal category, and as being a model S-58ET. Authorized Operations and Maintenance. In November 2002, the FAA authorized Aris to operate the helicopter for external load purposes under Part 133. During this accident investigation, FAA flight standards personnel reviewed the helicopter's maintenance records. According to the FAA, no discrepancies were noted with airworthiness compliance, time life components, and required inspection intervals. During external load operations, the helicopter's operating limitations indicated that its maximum sling load was either 4,000 or 5,000 pounds, depending upon the sling in use. Aris management reported to the Safety Board investigator that it maintained the helicopter in accordance with Sikorsky's "S-58T Equalized Inspection and Maintenance Program, SA 4047-20." According to this program, the IGB chip detector and/or magnetic plug must be checked for metal every 500 hours. According to the helicopter's aircraft maintenance logbook, as of the start of flight operations on July 12, 2003, the helicopter's total flight time was 7,878.1 hours, and the collective Hobbs meter registered 1,420.5 hours. Pos ## Aircraft - Registration: [N15AH](https://openairdocs.org/deregistered/N15AH-2017-07-07), registration cancelled 2017-07-07, S/N 58-1563, built 1962 (OpenAirDocs) - Reported make and model: Sikorsky S-58ET - Registry model: [Sikorsky S-58ET](https://openairdocs.org/model/sikorsky-s-58et) (registry code 8141803) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6T-6](https://openairdocs.org/engine/pratt-whitney-canada-pt6t-6) (registry code 52106, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 58-1563 - Airframe hours: 7879 - Engines: Pratt & Whitney PT6T-6 1875 horsepower turbo shaft - Damage: Destroyed - Flight: Other work use, Part 133 - Registered owner: ARIS Helicopters, Ltd. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, June 1, 2003, 11 hours before - Departed: Rancho P.Verdes, CA - Destination: Rancho P.Verdes, CA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: serious; airline transport; airplane ratings: single-engine land, single-engine sea; instrument ratings: helicopter, airplane; medical: class 2, with waivers/limitations; last flight review December 1, 2002; seat: right; flight hours: 14,500 total, 1,500 in this make and model, 14,300 as pilot in command, 100 in the last 90 days, 40 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 5 knots - Visibility: 4 statute miles - Lowest ceiling: 15,000 ft broken - Temperature: 73 °F, dew point 64 °F - Altimeter: 30.04 inHg - Observed at: TOA, 3 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 20030712017769A](https://openairdocs.org/incident/20030712017769A), Jul 12, 2003: Skrsky S58ET, Ranchopalosverd, CA, Destroyed. (-23) On July 12, 2003 N15AH as involved in 14 CFR part 133 operations at miralest intermediate school removing air conditioning units from the roofs of the… ## Docket (36 files) The files NTSB released with the investigation on December 28, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=57490. 13.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 from Operator (item 1, .PDF, 264 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241948&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20from%20Operator-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 from Pilot (item 2, .PDF, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241949&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20from%20Pilot-Redacted.PDF - Statement of Pilot (item 3, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241950&FileExtension=.PDF&FileName=Statement%20of%20Pilot-Redacted.PDF - Statement of Witness (item 4, .PDF, 276 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422482&FileExtension=.PDF&FileName=Statement%20of%20Witness-Redacted.PDF - Weather Report (item 5, .PDF, 8 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241952&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Reports from FAA regarding Inspections (item 6, .PDF, 725 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241953&FileExtension=.PDF&FileName=Reports%20from%20FAA%20regarding%20Inspections-Redacted.PDF - Report From Operator (ARIS Helicopters) (item 7, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241954&FileExtension=.PDF&FileName=Report%20From%20Operator%20(ARIS%20Helicopters)-Redacted.PDF - Report from Sikorsky Materials Lab (item 8, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422483&FileExtension=.PDF&FileName=Report%20from%20Sikorsky%20Materials%20Lab-Redacted.PDF - FAA Airworthiness Certificate (item 9, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241956&FileExtension=.PDF&FileName=FAA%20Airworthiness%20Certificate-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241957&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Extract from Rotorcraft Flight Manual (item 11, .PDF, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241958&FileExtension=.PDF&FileName=Extract%20from%20Rotorcraft%20Flight%20Manual-Redacted.PDF - Extract from Load Combination Flight Manual (item 12, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241960&FileExtension=.PDF&FileName=Extract%20from%20Load%20Combination%20Flight%20Manual-Redacted.PDF - Certificate of Pilot Training (item 13, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241963&FileExtension=.PDF&FileName=Certificate%20of%20Pilot%20Training-Redacted.PDF - Congested Area Lift Plan (item 14, .PDF, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241964&FileExtension=.PDF&FileName=Congested%20Area%20Lift%20Plan-Redacted.PDF - Flight Log (Day of Accident) (item 15, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241965&FileExtension=.PDF&FileName=Flight%20Log%20(Day%20of%20Accident)-Redacted.PDF - Memo from Project Manager (item 16, .PDF, 265 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241966&FileExtension=.PDF&FileName=Memo%20from%20Project%20Manager-Redacted.PDF - Memo from Aris Regarding Aircraft Certification and Maintenance (item 17, .PDF, 291 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422484&FileExtension=.PDF&FileName=Memo%20from%20Aris%20Regarding%20Aircraft%20Certification%20and%20Maintenance-Redacted.PDF - Photo 1 - Helicopter Exam by Pilot While in School Field Minutes Before Crash (item 18, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241968&FileExtension=.PDF&FileName=Photo%201%20-%20Helicopter%20Exam%20by%20Pilot%20While%20in%20School%20Field%20Minutes%20Before%20Crash-Master.PDF - Photo 2 - Helicopter, Overall View, Left Side (item 19, .PDF, 410 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241969&FileExtension=.PDF&FileName=Photo%202%20-%20Helicopter,%20Overall%20View,%20Left%20Side-Master.PDF - Photo 3 - Helicopter, Close Up View Left Side Cracked Main Wheel (item 20, .PDF, 431 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241970&FileExtension=.PDF&FileName=Photo%203%20-%20Helicopter,%20Close%20Up%20View%20Left%20Side%20Cracked%20Main%20Wheel-Master.PDF - Photo 4 - Helicopter, Top View (item 21, .PDF, 423 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241971&FileExtension=.PDF&FileName=Photo%204%20-%20%20Helicopter,%20Top%20View-Master.PDF - Photo 5 - Helicopter, Right Side (item 22, .PDF, 415 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241972&FileExtension=.PDF&FileName=Photo%205%20-%20Helicopter,%20Right%20Side-Master.PDF - Photo 6 - Helicopter, Top View and AC Unit (item 23, .PDF, 386 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241973&FileExtension=.PDF&FileName=Photo%206%20-%20Helicopter,%20Top%20View%20and%20AC%20Unit-Master.PDF - Photo 7 - AC Unit With Attached Host Line (item 24, .PDF, 385 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241974&FileExtension=.PDF&FileName=Photo%207%20-%20AC%20Unit%20With%20Attached%20Host%20Line-Master.PDF - Photo 8 - AC Unit, Close Up (item 25, .PDF, 392 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241975&FileExtension=.PDF&FileName=Photo%208%20-%20AC%20Unit,%20Close%20Up-Master.PDF - Photo 9 - Long 100-Foot Line Between Helicopter & AC Unit (item 26, .PDF, 437 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241976&FileExtension=.PDF&FileName=Photo%209%20-%20Long%20100-Foot%20Line%20Between%20Helicopter%20%26%20AC%20Unit-Master.PDF - Photo 10 - Cockpit (item 27, .PDF, 437 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241977&FileExtension=.PDF&FileName=Photo%2010%20-%20Cockpit-Master.PDF - Photo 11 - Helicopter, Right Side Close Up (item 28, .PDF, 418 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241978&FileExtension=.PDF&FileName=Photo%2011%20-%20Helicopter,%20Right%20Side%20Close%20Up-Master.PDF - Photo 12 - Tail Rotor Blades (item 29, .PDF, 432 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241979&FileExtension=.PDF&FileName=Photo%2012%20-%20Tail%20Rotor%20Blades-Master.PDF - Photo 13 - Tail Rotor Blade Tip Held Against Ground Scar (item 30, .PDF, 454 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241980&FileExtension=.PDF&FileName=Photo%2013%20-%20Tail%20Rotor%20Blade%20Tip%20Held%20Against%20Ground%20Scar-Master.PDF - Photo 14 - Tail Rotor Blade Tip Held Against Ground Scar (item 31, .PDF, 441 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241983&FileExtension=.PDF&FileName=Photo%2014%20-%20Tail%20Rotor%20Blade%20Tip%20Held%20Against%20Ground%20Scar-Master.PDF - Photo 15 - Intermediate Gear Box, Found Without Chip Plug (item 32, .PDF, 381 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241984&FileExtension=.PDF&FileName=Photo%2015%20-%20Intermediate%20Gear%20Box,%20Found%20Without%20Chip%20Plug-Master.PDF - Photo 16 - Intermediate Gear Box, Removed fm Wreckage (item 33, .PDF, 465 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241985&FileExtension=.PDF&FileName=Photo%2016%20-%20Intermediate%20Gear%20Box,%20Removed%20fm%20Wreckage-Master.PDF - Photo 17 - Intermediate Gear Box, Found Without Chip Plug, Orifice Close Up (item 34, .PDF, 409 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241986&FileExtension=.PDF&FileName=Photo%2017%20-%20Intermediate%20Gear%20Box,%20Found%20Without%20Chip%20Plug,%20Orifice%20Close%20Up-Master.PDF - Photo 18 - Cargo Hook Beneath Helicopter (item 35, .PDF, 407 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241987&FileExtension=.PDF&FileName=Photo%2018%20-%20Cargo%20Hook%20Beneath%20Helicopter-Master.PDF - Photo 19 - Cargo Release Master Switch (item 36, .PDF, 463 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241988&FileExtension=.PDF&FileName=Photo%2019%20-%20Cargo%20Release%20Master%20Switch-Master.PDF 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.