LAX05LA050

NTSB accident investigation · Schweizer 269C · Ontario, CA · December 11, 2004

Accident · No injuriesLimited investigationFinal report
Date
December 11, 2004, 12:50 local (20:50 UTC)
Place
Ontario, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N130JSSchweizer 269C
Weather
Visual (VMC) · Day
Status
Completed · report May 30, 2006
Report
Approved by Office Director
Parties
Federal Aviation Administration, Textron Lycoming
FAA report
20041211033969A
Case key
60711

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 loss of engine power due to the Designated Pilot Examiner's failure to follow the flight manual procedures and directives regarding throttle settings to be used for practice autorotations.

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.

Loss of engine power(total) - nonmechanicalDescent
Autorotation - initiatedDesignated examiner
Improper use of procedureDesignated examinerCause
Throttle/power control - incorrectDesignated examinerCause
Procedures/directives - not followedDesignated examinerCause
Forced landingEmergency descent/landing
On ground/water encounter with terrain/waterEmergency landing
Terrain condition - berm
Roll overLanding - roll

Analysis

The helicopter rolled over during an autorotation following a loss of engine power. During a practical flight test examination for a private pilot certificate, the Designated Pilot Examiner (DPE) simulated a loss of engine power by retarding the throttle to idle. The student pilot lowered the collective and was performing an autorotation to the ground. The DPE noticed loss of engine noise then detected that the engine had lost power. The student pilot unsuccessfully attempted to restart the engine. During the landing sequence, the tail rotor stinger and blades impacted the ground. As the helicopter was sliding to a stop, it veered to the left and rolled over. Examination of the aircraft systems and the engine failed to disclose any abnormality, and an engine operational run test was conducted. After the engine was started, the cockpit mounted oil pressure gauge displayed an oil pressure indication within the normal operating range, and proper operation of the electrical fuel boost pump and engine driven fuel pump were verified. Once the engine was operating at temperature, the throttle was advanced to about 2,500 rpm, at which time the magnetos were checked utilizing the cockpit mounted ignition switch. Both magnetos operated within manufacturer's specifications. The engine ran smoothly during the operational check and exhibited no unusual indications and no fuel or oil leaks. The Rotorcraft Flight Manual for the Schweizer 300C Helicopter Model 269C provides the following procedure for practice autorotations: "Split the needles by lowering the collective while maintaining throttle setting. The throttle correlation will establish a high idle rpm (approximately 2,500 rpm), which will aid in preventing the engine from loading up or stalling during recovery."

Factual narrative

History of flight

On December 11, 2004, about 1250 Pacific standard time, a Schweizer 269C, N130JS, made a hard landing and rolled over after a loss of power during a private pilot examination flight near Ontario, California. Western Helicopters, Inc, was operating the helicopter under the provisions of 14 CFR Part 91. The student pilot and the Designated Pilot Examiner (DPE) were not injured; the helicopter sustained substantial damage. The personal local examination flight departed Rialto, California, about 1230. Day visual meteorological conditions prevailed, and no flight plan had been filed. The primary wreckage was at 34 degrees 00.044 minutes north latitude and 117 degrees 34.386 minutes west longitude.

The DPE reported that during a flight examination for a private pilot rating, while in cruse flight about 2,200 mean sea level (msl), he simulated a loss of engine power by retarding the throttle. The student pilot lowered the collective and was performing an autorotation to the ground. The DPE noticed the loss of engine noise. He got on the controls with the student pilot and told the student pilot to try to start the engine. The engine would not start despite several attempts. The DPE realized the field they originally intended to land on was very wet and muddy. Instead, they attempted to land on a 10-foot-high dirt berm. During the flaring portion of the landing, the tail rotor stinger and blades impacted the ground. As the helicopter was sliding to a stop, it veered to the left and rolled over.

Tests and research

Investigators from the National Transportation Safety Board, the Federal Aviation Administration (FAA), and Textron Lycoming were parties to the investigation. On December 15, 2004, the wreckage was examined by investigators at the facilities for the operator, Western Operations, Inc., Rialto, California.

An initial cursory examination of the engine found no evidence of catastrophic mechanical malfunction. Engine control system continuity was established from the cockpit controls to their respective locations on the engine. The top spark plugs were removed. The spark plug electrodes remained mechanically undamaged and exhibited coloration consistent with normal operation. Although the spark plugs at the number one and three cylinders were oil soaked, the oil soaking was attributed to the engine positioning at the accident location. The combustion signatures observed at the exhaust system tail pipe displayed coloration consistent with normal operation. There was no oil residue observed in the exhaust system gas path.

After the spark plugs were reinstalled, investigators conducted an engine operation check. The electric fuel boost pump was electrically energized. The cockpit mounted fuel pressure gauge displayed a fuel pressure indication within the normal operating range. After the engine was started, the cockpit mounted oil pressure gauge displayed an oil pressure indication within the normal operating range.

Once the engine stabilized above idle, the electric fuel pump was de-energized; the engine continued to run smoothly. The engine driven fuel pump delivered a fuel pressure indication within the normal operating range. Once the engine was operating at temperature, the throttle was advanced to about 2500 rpm, at which time the magnetos were checked utilizing the cockpit mounted ignition switch. Both magnetos operated within manufacturer's specifications.

The throttle on the pilot's collective handle was moved to the idle position, indicating about 1400 rpm on the tachometer. The mixture handle was momentarily moved to the idle cutoff (ICO) position, at which time a momentary rise in engine rpm occurred before the handle was moved out of the ICO.

The engine ran smoothly during the operation check and exhibited no unusual indications and no fuel or oil leaks.

The Pilot's Flight Manual for the Schweizer 300C Helicopter Model 269C as reissued on September 21, 1988, and as revised on October 24, 2001, provides the following procedure for practice autorotations: "Split the needles by lowering the collective while maintaining throttle setting. The throttle correlation will establish a high idle rpm (approximately 2,500 rpm) which will aid in preventing the engine from loading up or stalling during recovery. Conversely, when the collective is raised without increasing the throttle, the correlation is such that only minor throttle adjustments will be required to perform a smooth recovery without exceeding 3,200 rpm."

Additional information

On July 15, 2005, the Safety Board investigator-in-charge (IIC) released the wreckage to the owner's representative.

Aircraft

Registration
N130JS
Reported as
Schweizer 269C
Category
Helicopter
Serial number
S1571
Airframe hours
2,695.7
Engine
Lycoming HIO-360-DIA, 190 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Registered owner
Western Operations Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · October 1, 2004 · 89.7 hours before
Departed
L67 · Rialto, CA

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Student pilot
Age
48
Injuries
None
Certificate
Student
Medical
Class 2, With waivers/limitations
Seat
Left
Flight hours
66 total · 66 in this make and model · 7 as pilot in command · 28 in the last 90 days · 9 in the last 30 days · 1 in the last 24 hours
Role
Check pilot
Age
38
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 2
Seat
Right

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 45 °F
Altimeter
30.09 inHg
Observed at
ONT

FAA reports on this event · 1

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