# NTSB LAX89LA197: Aerospatiale AS350D, N6003S, Waialae Falls, HI, May 21, 1989

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Limited investigation · Final report
- Date: May 20, 1989, 16:00 local (May 21, 1989, 02:00 UTC)
- Place: Waialae Falls, HI
- Coordinates: 21.95086, -159.669937 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=21.9509&lon=-159.6699&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Highest injury: Minor injuries
- Injuries: 7 minor
- Status: Completed, report April 15, 1991
- Report: Approved by Office Director
- NTSB case key (mKey): 26410
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX89LA197
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/26410/pdf
- Page: https://openairdocs.org/ntsb/LAX89LA197

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(partial) - mech failure/malf, maneuvering
  - fuel system,fuel control - output low (cause)
  - maintenance,adjustment - improper, company maintenance personnel (cause)
  - weather condition - high density altitude (contributing factor)
  - rotor rpm - not maintained, pilot in command (cause)
- Forced landing, takeoff - initial climb
- In flight collision with terrain/water, landing
  - terrain condition - rough/uneven (contributing factor)

## 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](https://openairdocs.org/deregistered/N6003S-1996-03-29), registration cancelled 1996-03-29, S/N 1552 (OpenAirDocs)
- Reported make and model: AEROSPATIALE AS350D
- Registry model: [S N I A S AS350D ASTAR](https://openairdocs.org/model/s-n-i-a-s-as350d-astar) (registry code 8680803) (OpenAirDocs)
- Category: Helicopter
- Serial number: 1552
- Airframe hours: 2203
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 37; 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 (OpenAirDocs).

- [Accident 19890520012479A](https://openairdocs.org/incident/19890520012479A), May 20, 1989: Snias AS350D, Waialae Falls, HI, Substantial damage. Lost engine RPM during sightseeing hover. Crash landed in rocks. Fuel control governor set too low. P3 filter leak

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.