LAX89LA197

NTSB accident investigation · Aerospatiale AS350D · Waialae Falls, HI · May 21, 1989

Accident · Minor injuriesLimited investigationFinal report
Date
May 20, 1989, 16:00 local (May 21, 1989, 02:00 UTC)
Place
Waialae Falls, HI
Injuries
7 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N6003SAerospatiale AS350D
Weather
Visual (VMC) · Day
Status
Completed · report April 15, 1991
Report
Approved by Office Director
FAA report
19890520012479A
Case key
26410

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

Improper maintenance/adjustment of the engine fuel control unit by company maintenance personnel, which resulted in a slight loss of engine power, and failure of the pilot to maintain rotor RPM, while turning and taking off from a hover with a relatively heavy gross weight. Factors related to the accident were: the high density altitude and rough/uneven (rocky) terrain in the emergency landing area.

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(partial) - mech failure/malfManeuvering
Fuel system,fuel control - output lowCause
Maintenance,adjustment - improperCompany maintenance personnelCause
Weather condition - high density altitudeFactor
Rotor rpm - not maintainedPilot in commandCause
Forced landingTakeoff - initial climb
In flight collision with terrain/waterLanding
Terrain condition - rough/unevenFactor

Analysis

The on-demand air taxi helicopter was on a local sightseeing flt to Waialae Falls with six pax aboard. Elevation of the Falls was about 3000 ft. after hovering at low alt near the Falls, the plt began a pedal turn & began forward movement for the initial climb away from the Falls. The main rotor RPM decayed & the plt turned back toward the upper Falls, where he thought he could land. However, the helicopter settled into a ravine, impacted rocks & came to rest. An exam of the eng fuel control revealed the maximum stop was set at 93% versus 99% as specified by the manufacturer. Also, the governor break was set 400 RPM early, there was no seal on the metering valve sleeve & the safety wire thru the governor adjustment had been cut & not replaced.

Aircraft

Registration
N6003S
Reported as
Aerospatiale AS350D
Category
Helicopter
Serial number
1552
Airframe hours
2,203
Engine
Lycoming LTS-101, 531 horsepower, turbo shaft
Damage
Substantial damage
Flight
Part 135
Operator
Papillion Helicopters
Registered owner
N. American Helicopter Airways
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 2, 1989 · 64 hours before
Departed
HPV · Princeville, HI
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
37
Certificates
Private, Commercial
Airplane ratings
Single-engine land
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
2,599 total · 250 in this make and model · 1,950 as pilot in command · 250 in the last 90 days · 93 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
90° at 5 knots
Visibility
15 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 55 °F
Altimeter
30.00 inHg
Observed at
KOKE, 4 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.