LAX94FA106

NTSB accident investigation · Sikorsky S-58 · San Jose, CA · January 28, 1994

Accident · FatalField investigationFinal report
Date
January 28, 1994, 07:37 local (15:37 UTC)
Place
San Jose, CA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N4995GSikorsky S-58
Weather
Visual (VMC) · Day
Status
Completed · report January 27, 1995
Report
Approved by Office Director
Safety recommendations
Yes
FAA report
19940128001069A
Case key
28514

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's inadequate preflight planning/preparation and subsequent fuel starvation, due to an inadequate supply of fuel. A factor related to the accident was: the proximity of high obstructions.

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) - nonmechanicalHover
All engines
Preflight planning/preparation - inadequatePilot in commandCause
Fluid,fuel - starvationCause
Fuel supply - inadequatePilot in commandCause
Forced landingDescent - emergency
Autorotation - performedPilot in command
In flight collision with objectEmergency landing
Terrain condition - high obstruction(s)Factor
Object - building(nonresidential)

Analysis

The pilot was conducting an external load operation about 1-1/2 miles from the departure airport. After finishing a lift, the helicopter was hovering at about 100 feet over a 13-story building. Witnesses heard the engines spool down and saw the rotor blades slowing. The helicopter descended onto a two-level penthouse on the building roof and rolled onto its right side. A parking lot adjacent to the building had been selected by the company as a landing area in an faa-approved lift plan, but obstructions prevented its use. The helicopter, comprised primarily of magnesium, was consumed by a postcrash fire. Fuel consumption was about 11 pounds per minute. The pilot began the flight with about 266 pounds of fuel; during the 17 minute flight, the engine would have consumed about 190 pounds of fuel. Unusable fuel for the helicopter was 64 pounds. Operations at minimal fuel required fuel tank crossfeeding.

Factual narrative

History of the Flight

On January 28, 1994, about 0737 hours Pacific standard time, a Sikorsky S58-JT, N4995G, crashed on a high-rise building during an external load operation at San Jose, California. The helicopter was being operated as a visual flight rules (VFR) local flight under Title 14 CFR Part 133 when the accident occurred. The helicopter, registered to and operated by Air One Helicopters Inc., San Jose, California, was destroyed by impact and postimpact fire. The certificated airline transport pilot, the sole occupant, received fatal injuries. Visual meteorological conditions prevailed. The flight originated at the San Jose International Airport about 0722 hours.

The operator reported that the helicopter was being utilized to remove a large cooling tower fan from the top of a 13-floor building located in the business district of the city. The pilot contacted the ground controller at the San Jose Air Traffic Control Tower (ATCT) at 0720:18 hours and requested permission to taxi for takeoff. At 0722:05 hours, the aircraft was cleared for departure by the local controller and at 0724:08 hours, the pilot reported as "on station". The building is located about 1 1/2 miles southeast of the airport.

A three-man ground crew from the helicopter operator and an air conditioning company were assigned to the operation. A helicopter company employee, a member of the ground crew, reported that the helicopter was originally going to land in the west parking lot of the building to attach a 100-foot Kevlar lifting cable to the belly of the aircraft; however, the landing area was restricted by numerous light poles. The crew member attached the cable to the helicopter while it was at a hover over the top of the building. The crew disassembled a portion of the cooling tower and the helicopter successfully removed a large fan to the ground level parking lot. The helicopter then deposited a 1,800-pound steam cleaning machine on the roof, adjacent to the tower.

The crew on the building unhooked the machine from the lifting cable and was preparing to unhook the cable from the helicopter. As the helicopter was at a 100-foot hover above the building, the crew heard the engine sounds decrease and observed the main rotor blades begin to slow. The helicopter then descended vertically onto the top of a two-level central core penthouse building that housed elevator, boiler, and air-conditioning machinery. After contacting the penthouse roof, the helicopter began to roll onto its right side.

The main rotor blades contacted the building parapet wall and separated near the inboard ends of the blades. A postcrash fire erupted and the crew attempted to fight the fire with hand extinguishers. The crew indicated that during the impact the vertical tail section of the fuselage separated. After the helicopter came to rest, the main rotor blade roots still attached to the mast were still turning and they could hear the engines still spooling down and then stop completely. The crew was not injured and no persons on the ground level were injured. At 0737:12 hours, a pilot reported the fire on the roof of the building to the San Jose ATCT.

A Federal Aviation Administration (FAA) operations inspector, San Jose Flight Standards District Office (FSDO), was observing the lifting operation from the ground-level west parking lot to monitor the flight's compliance with a 14 CFR Part 133 external load plan. He reported that the helicopter was facing toward the west while hovering above the roof and heard the sound of the engine(s) spooling down. The helicopter nose pitched down about 5 degrees and descended vertically without any fuselage yaw. The main rotor blades began slowing down and the helicopter descended out of view. Portions of the main rotor blades fell away from the roof top into the parking lot. The inspector observed smoke and fire about 5 seconds after the crash.

Numerous ground witnesses also reported hearing the engine sounds decrease and the main rotor blades slowing down. The initial fire started as a small flame near the cabin area that quickly spread, engulfing the helicopter. The witnesses reported seeing extremely bright sparks emanating from the fire.

The accident occurred during the hours of daylight at attitude 37 degrees, 20.91 minutes north and longitude 121 degrees 54.08 minutes west.

Other Damage

The building received impact and fire damage to the penthouse building and exterior of the roof area. In addition, several upper floors of the building received water damage.

Crew Information

The pilot held an airline transport pilot certificate with a rotorcraft helicopter rating, and type ratings in Bell 206 and Sikorsky S58 aircraft. He held commercial pilot privileges with a single-engine land rating. In addition, the pilot held a flight instructor certificate with a rotorcraft helicopter rating. He also held a mechanics certificate with airframe and powerplant ratings. The most recent second-class medical certificate was issued to the pilot on August 19, 1993, and contained no limitations.

No personal flight records were located for the pilot and the aeronautical experience listed on page 6 of this report was obtained from a review of the airmen FAA records on file in the Airman and Medical Records Center located in Oklahoma City. In addition, information was obtained from a review of records maintained by the operator.

According to the information entered on the pilot's application for medical certificate dated August 19, 1994, his total aeronautical experience consisted of 7,000 hours. The operator reported that the pilot had accrued 6,200 hours in helicopters and 1,500 hours in the accident aircraft make and model. In the preceding 90 and 30 days prior to the accident, the report lists a total of 43 and 19 hours, respectively, flown. The operator provided an undated letter from the San Jose FSDO indicating that the pilot was qualified as serve as pilot-in-command in external load operations.

The chief pilot reported that the pilot received annual recurrent training, including a check ride, for 14 CFR Part 135 operations. The company does not conduct (nor is one required under Part 133) ground or flight training in external load operations. Since external loads are constantly being conducted, the accident pilot was routinely observed by ground personnel including the chief pilot. The ground crew indicated that no mission briefing was conducted prior to the accident flight.

Aircraft Information

The accident aircraft is equipped with twin Pratt and Whitney PT-6T engines that provide independent power to a combining gearbox. The gearbox drives a single output shaft connected to an angle gearbox, which provides power input to the main rotor transmission. The aircraft is certified as a single-engine helicopter.

The recording hour meter in the aircraft was destroyed. Prior to departure on the accident flight, the aircraft maintenance log sheet indicated that the helicopter had accumulated a total time in service of 8,523.8 flight hours. The helicopter was utilized almost exclusively for external load operations and was maintained according to the manufacturers' inspection program. Examination of the maintenance records revealed that the most recent Phase III inspection was accomplished on August 8, 1993, 47.4 hours before the accident. The left engine had accrued a total time in service of 6,456 hours of operation. The maintenance records note that a major overhaul was accomplished on February 5, 1980, 2,927.5 hours of operation before the accident.

The right engine had accrued a total time in service of 5,661.7 hours of operation. The engine was overhauled on September 10, 1984, 2,206.7 hours before the accident.

The combining gearbox had accrued a total time in service of 5,747.6 hours of operation. The gearbox was overhauled on November 21, 1983, 2,778.1 hour

Aircraft

Registration
N4995G
Reported as
Sikorsky S-58
Category
Helicopter
Serial number
58-1561
Airframe hours
8,524
Engine
P&W PT6T-3, 900 horsepower, turbo shaft
Damage
Destroyed
Fire
On-Ground
Flight
Other work use · Part 133
Operator
Air One Helicopters Inc.
Registered owner
Air One Helicopters Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · November 8, 1993 · 47 hours before
Departed
SJC
Destination
SJC
Airport
SJC · San Jose International

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
46
Certificates
Flight instructor, Airline transport, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Right
Toxicology
Performed
Flight hours
7,000 total · 1,500 in this make and model · 43 in the last 90 days · 19 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
35 statute miles
Lowest ceiling
None
Temperature
37 °F
Altimeter
30.00 inHg
Observed at
SJC, 1 nm away

Docket · 58

The files NTSB released with the investigation on June 5, 1995, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.6 MB in all.

Supplement CItem 1 · .PDF · 310 KBSupplement DItem 2 · .PDF · 356 KBSupplement KItem 3 · .PDF · 303 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 4 · .PDF · 289 KBOperations Group Chairman Report w/Interview TranscriptsItem 5 · .PDF · 2.0 MBPowerplant Group Chairman ReportItem 6 · .PDF · 451 KBPhoto No. 1Item 7 · .PDF · 50 KBPhoto No. 2Item 8 · .PDF · 53 KBPhoto No. 3Item 9 · .PDF · 30 KBPhoto No. 4Item 10 · .PDF · 29 KBPhoto No. 5Item 11 · .PDF · 28 KBPhoto No. 6Item 12 · .PDF · 21 KBPhoto No. 7Item 13 · .PDF · 31 KBPhoto No. 8Item 14 · .PDF · 32 KBPhoto No. 9Item 15 · .PDF · 29 KBPhoto No. 10Item 16 · .PDF · 49 KBPhoto No. 11Item 17 · .PDF · 48 KBPhoto No. 12Item 18 · .PDF · 41 KBPhoto No. 13Item 19 · .PDF · 46 KBPhoto No. 14Item 20 · .PDF · 30 KBPhoto No. 15Item 21 · .PDF · 38 KBPhysical Science Technician's ReportItem 22 · .PDF · 99 KBWitness StatementsItem 23 · .PDF · 486 KBRecord of Telephone CallsItem 24 · .PDF · 122 KBInterview Transcripts - AIG AviationItem 25 · .PDF · 1.5 MBMaps and Wreckage DiagramItem 26 · .PDF · 241 KBWeather Report - San Jose AirportItem 27 · .PDF · 64 KBTranscript of Radio CommunicationItem 28 · .PDF · 153 KBFAA Personnel StatementsItem 29 · .PDF · 170 KBFuel Calibration Report - San Jose FSDOItem 30 · .PDF · 47 KBSan Jose Police Dept. ReportItem 31 · .PDF · 990 KBSikorsky Aircraft Transmission Inspection ReportItem 32 · .PDF · 180 KBFAA Certification Office Briefing ReportItem 33 · .PDF · 206 KBAir One Helicopters External Load ManualItem 34 · .PDF · 290 KBAir One Helicopters Lift Plan, Maintenance Logs, Fuel System Description, Fuel LogItem 35 · .PDF · 1.0 MBFAA Fuel Configuration Test ReportItem 36 · .PDF · 144 KBStatement of Party Representatives to NTSB InvestigationItem 37 · .PDF · 220 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 38 · .PDF · 367 KBToxicological ReportItem 39 · .PDF · 65 KBPhoto No. 1 View of building from west parking lot.Item 40 · .PDF · 38 KBPhoto No. 2 Main rotor impact marks and damage to inside face of north parapet wall.Item 41 · .PDF · 39 KBPhoto No. 3 View of upper level roof vent housing, looking west. Note downward crushing of vent stack.Item 42 · .PDF · 52 KBPhoto No. 4 View of oval depression in northwest corner of upper level roof, looking east.Item 43 · .PDF · 52 KBPhoto No. 5 View of engine cowling and engines at point of rest on lower roof, looking east.Item 44 · .PDF · 48 KBPhoto No. 6 View of underside of engines at point of rest on lower roof.Item 45 · .PDF · 53 KBPhoto No. 7 View of aft side of engines and right landing gear, positioned next to hole burned in lower roof area.Item 46 · .PDF · 54 KBPhoto No. 8 View of tail section of helicopter with tail wheel resting on penthouse building wall.Item 47 · .PDF · 48 KBPhoto 9. View of tail section resting next to north wall of penthouse building. Note absence of damage to the tail rotor blades, looking west.Item 48 · .PDF · 35 KBPhoto 10. View of main rotor transmission at point of rest, upside down next to the north wall of penthouse building.Item 49 · .PDF · 47 KBPhoto No. 11 View of collective control mechanism, pilot's control is on the right.Item 50 · .PDF · 62 KBPhoto No. 12 Close-up view of engine throttle grips positioned in the full open position on the pilot's collective control.Item 51 · .PDF · 34 KBPhoto No. 13 Close-up view of left side collective control throttle grips.Item 52 · .PDF · 47 KBPhoto No. 14 View of angle gearbox. Note impact and fire damage.Item 53 · .PDF · 53 KBPhoto No. 15 View of aft end of engine twin-pac. Note melted end of drive shaft from the combining gearbox.Item 54 · .PDF · 58 KBPhoto No. 16 View of damage to main rotor hub from yellow blade spindle. Also note broken damper assembly.Item 55 · .PDF · 45 KBPhoto No. 17 View of damaged main rotor blades.Item 56 · .PDF · 39 KBPhoto No. 18 View of main rotor transmission input module.Item 57 · .PDF · 49 KBPhoto No. 19 View of main rotor transmission during inspection.Item 58 · .PDF · 53 KB

FAA reports on this event · 1

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