LAX90FA060

NTSB accident investigation · McDonnell Douglas 369E · Santa Rosa, CA · December 29, 1989

Accident · FatalField investigationFinal report
Date
December 29, 1989, 11:30 local (19:30 UTC)
Place
Santa Rosa, CA
Injuries
1 fatal, 1 serious, 3 minor
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N1604LMcDonnell Douglas 369E
Weather
Visual (VMC) · Day
Status
Completed · report August 26, 1994
Report
Approved by Office Director
FAA report
19891229054279A
Case key
26603

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

The pilot's improper preflight planning/decision which resulted in the loss of tail rotor effectiveness. Contributing to the accident was the pilot allowing the maximum gross weight of the aircraft to be exceeded, and the tailwind.

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 control - in flightTakeoff - initial climb
Weather condition - tailwindFactor
Planning/decision - improperPilot in commandCause
Aircraft weight and balance - exceededPilot in commandFactor
Directional control - not possiblePilot in commandFactor
Lack of total experience in type of aircraftPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The pilot executed an immediate left downwind climbing turn when he departed the helipad and experienced a loss of tail rotor effectiveness. Before departing, the pilot failed to account for the downwind turn and the helicopter's exceeding the maximum gross weight. The post accident investigation disclosed the lateral trim motor exceeded its physical extension limits which indicates that the trim motor was operating during the impact sequence when its airframe attachment point was broken.

Aircraft

Registration
N1604L
Reported as
McDonnell Douglas 369E
Category
Helicopter
Serial number
0266E
Airframe hours
367
Engine
Allison 250-C20, 375 horsepower, turbo shaft
Damage
Destroyed
Flight
Business · Part 91
Operator
Interwest, Inc.
Registered owner
John M. & Ona R. Roth
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · November 21, 1989
Departed
STS
Airport
STS · Sonoma County

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
34
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
4,123 total · 57 in this make and model · 3,705 as pilot in command · 106 in the last 90 days · 27 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 5 knots
Visibility
30 statute miles
Lowest ceiling
None
Temperature
59 °F, dew point 37 °F
Altimeter
30.00 inHg

FAA reports on this event · 1

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