- Date
- September 22, 1994, 11:45 local (18:45 UTC)
- Place
- Genoa, NV
- Injuries
- 2 minor
- Damage
- Substantial damage
- Phase of flight
- Emergency descent
- Aircraft
- N58352Hughes 369D
- Weather
- Visual (VMC) · Day
- Status
- Completed · report August 1, 1995
- Report
- Approved by Office Director
- FAA report
- 19940922029829A
- Case key
- 28554
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/operator's operation of the helicopter with a disconnected throttle on the right collective; the FAA inspector's inadequate preflight/pretakeoff checks of the flight control/throttle systems; and the pilot/operator's failure to adequately inform the inspector of the disconnected right throttle, which resulted in an inadequate power recovery from an inspector initiated autorotation.
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.
Analysis
The FAA operations inspector was obtaining flight time for recurrency while administering a proficiency check to the pilot/operator (plt). Before flight, the inspector gave an oral exam to the plt. While preparing for flight, the plt told the inspector that the throttle on the right collective was inoperative (disconnected), but the inspector did not assimilate this information. Also, during the preflight inspection, the inspector (in the left seat) did not check throttle continuity to the right collective control. During the first part of the flight, the inspector flew the helicopter most of the time. He then proceeded to have the plt perform specific maneuvers to satisfy the requirements of a proficiency check. While returning to the airport, the inspector reduced his throttle to flight idle to simulate an engine failure; he then transferred the controls to the plt & told him to perform an autorotation. The plt did not realize that the inspector had reduced power to flight idle with the operable (left) throttle until he raised the right collective in an attempt to fly out of the autorotation near the ground. Subsequently, the helicopter sustained a hard landing. An investigation disclosed that the pilot/operator had the right collective throttle linkage disconnected about 2 years before the flight.
Factual narrative
History of the Flight
On September 22, 1994, at 1145 hours Pacific daylight time, a Hughes (McDonnell Douglas) 369D helicopter, N58352, collided with the terrain at Genoa, Nevada. The pilots were conducting a local area visual flight rules pilot recurrency check and a Title 14 CFR 135.293 pilot proficiency flight check. The helicopter, operated by Skydance Helicopters, Inc., El Cajon, California, sustained substantial damage. The certificated commercial pilot (first pilot) and the certificated airline transport pilot, a Federal Aviation Administration (FAA) operations inspector, sustained minor injuries. Visual meteorological conditions prevailed. The flight originated at Douglas County Airport, Minden, Nevada, at 1000 hours.
National Transportation Safety Board investigators interviewed the FAA inspector (herein called the examining inspector) at the Reno Flight Standards District Office on September 26, 1994. In addition, the examining inspector provided the Safety Board with a written statement. Safety Board investigators also conducted two other telephone interviews on September 22 and September 23, 1994, respectively.
The examining inspector said that the accident flight was a dual purpose flight. Initially he was going to become recurrent in the accident helicopter make and model; he had not flown one in over a year. Secondly, he was going to provide the pilot with a Title 14 CFR Part 135.293 pilot proficiency check as required by the regulations.
The examining inspector arrived at the operator's facility at 0900 hours. The pilot/operator (the pilot) then provided the examining inspector with some changes in the helicopter operations and ground checks. The inspector continued the preflight inspection and also asked the pilot some questions to satisfy the oral portion of the pilot's pilot proficiency check.
During the preflight inspection, the inspector did not check the right seat flight controls, including the throttle continuity. (The flight manual does not specifically require this action.) The inspector and operator discussed in depth the starting procedure while the examining inspector was in the left front seat; the seat normally used by the flying pilot.
The examining inspector helped the pilot in removing the helicopter from the hangar. The inspector sat in the left seat when the helicopter was on the ramp. The pilot operator stood to the left of the inspector during the start. The inspector thought that the pilot was doing fire guard duties. After the inspector initiated the engine start, the pilot returned to the helicopter and occupied the right front seat.
The examining inspector did a hovering maneuver and made some pedal turns to assure that the helicopter was operating normally before he departed on the accident flight. The flight departed the airport and flew to a lower mountain range east of the airport. He also did several maneuvers including a power off autorotation to a power on recovery.
While in this area, the examining inspector asked the pilot to do some maneuvers to satisfy the pilot's required items under the 14 CFR 135.293; the inspector reasoned that by having the pilot do these maneuvers, the flight would not have to return to the area. The maneuvers included a pinnacle approach, a confined area approach, and a slope landing. The pilot satisfactorily executed these maneuvers.
The examining inspector reassumed the controls and flew to a higher mountainous area about 4 miles west of the airport and about 1 mile east of the accident site. Upon arrival over the mountainous area, the inspector did several maneuvers including those he asked the pilot to do. During this time, the pilot also demonstrated a few slope landing techniques. Afterwards, the examining inspector flew toward the airport.
After passing over the mountainous area, the examining inspector reduced the power and asked the pilot to do a power off autorotation to a designated landing area. The pilot entered the autorotation and began to fly toward the designated landing area. The examining inspector said the pilot's technique during the autorotation flight pattern was "textbook"; the pilot's airspeed control and glide path were perfect.
During the final approach, about 300 feet above the ground, the examining inspector said he saw the N2 (the turbine power indicator) and the main rotor rpm needles come together. When the helicopter approached the landing area, the examining inspector did not feel any heavy collective movement; he did feel some cyclic movement. The helicopter then sustained a hard landing.
On touchdown, the helicopter began to violently "rock back and forth." The main rotor blades severed the tailboom assembly and the engine continued to run. When the helicopter was rocking back and forth, the examining inspector attempted to reach for the fuel control shut off valve located on the lower section of the instrument panel, but was unable to do so. He shut off the engine by placing the left collective throttle to the cut-off position.
Before exiting the helicopter, the examining inspector reported that he observed the right collective on the floor and either one or two of the pedals lying on the front of the helicopter. After both pilots exited the helicopter, the inspector saw the pilot place the collective and one or two of the pedals on the right front seat.
Safety Board investigators interviewed the pilot/operator on September 26, 1994, at his maintenance facility, Douglas County Airport. The pilot said that his son prearranged the accident flight. He concurred the scheduled flight was a dual purpose flight as stated by the examining inspector. He said that the examining inspector arrived at his facility at 0930 hours.
He then observed the examining inspector preflight the helicopter. During the preflight inspection, he informed the examining inspector of certain changes in the helicopter. He told Safety Board investigators that he considered the initial flight was a dual instructional flight to help the examining inspector in becoming current in the helicopter make and model. The pilot also confirmed the examining inspector's statement that he explained the start procedure in depth. He said after he and the examining inspector moved the helicopter out of the hangar he stood by the examining inspector while he started the engine. He said this was the only time he told the examining inspector that the right seat throttle was inoperative; he did not go into a detailed explanation. He stood at the door next to the examining inspector during the start so he could shut off the engine in case of a hot start.
The pilot concurred with the examining inspector's statement regarding the route of the flight. He said, however, that the examining inspector did all of the flying except during the accident rotation. He concurred that the examining inspector told him to do a simulated emergency landing (autorotation) to a designated area. The pilot said that he always does autorotations with full power and that he normally "flys out at the bottom of the autorotation."
He said that he was not aware that the examining inspector had retarded the throttle to idle before he began the autorotation. Both he and the examining inspector were talking via the "hot mike" during the maneuver. When the helicopter was between 8 and 10 feet above the ground, he applied up collective.
During the collective application, the pilot realized that engine power was not available and then knew a hard landing was imminent. He said that after the accident, his foot was jammed between the antitorque pedals. He removed the pedals to release his foot, but he did not recall removing the collective. He said he could have, but did not have a clear recollection of doing so.
The pilot also said that the examining inspector emphasized that he was the pilot-in-command (PIC), but that if
Aircraft
- Registration
- N58352
- Reported as
- Hughes 369D
- Category
- Helicopter
- Serial number
- D1290626D
- Airframe hours
- 9,437
- Engine
- Allison 250-C20B, 420 horsepower, turbo shaft
- Damage
- Substantial damage
- Flight
- Instructional · Part 91
- Operator
- Same As Registered Owner
- Registered owner
- Skydance Helicopters, Inc.
- Airworthiness certificate
- Standard, Normal
- Last inspection
- 100 hour · September 9, 1994 · 21 hours before
- Departed
- MEV · Minden, NV
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
- 62
- Certificate
- Commercial
- Medical
- Class 2, Valid Medical--w/ waivers/lim
- Seat
- Right
- Flight hours
- 15,000 total · 6,000 in this make and model · 150 in the last 90 days · 100 in the last 30 days · 4 in the last 24 hours
Weather
- Conditions
- Visual (VMC) · Day
- Wind
- 270° at 5 knots
- Visibility
- 10 statute miles
- Lowest ceiling
- None
- Temperature
- 81 °F
FAA reports on this event · 1
The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.