# NTSB LAX94LA387: Hughes 369D, N58400, Pacific Ocean (Pacific Ocean), September 24, 1994 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 23, 1994, 14:30 local (Sep 24, 1994, 00:30 UTC) - Place: Pacific Ocean (Pacific Ocean) - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report April 5, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 28880 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX94LA387 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28880/pdf - Page: https://openairdocs.org/ntsb/LAX94LA387 ## Probable cause failure of the helicopter's main rotor pitch change link (control rod). The helicopter was not recovered and the Safety Board was unable to determine the pitch change link's failure mode. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, cruise - rotorcraft flight control,pitch change rod/link - failure,total (cause) - Forced landing, descent - emergency - Ditching, descent - emergency - terrain condition - water,rough ## Analysis THE PILOT WAS CONDUCTING A FISH SPOTTING FLIGHT OVER THE PACIFIC OCEAN ABOUT 480 FEET ABOVE THE OCEAN. THE CYCLIC CONTROL BEGAN TO SHAKE VIOLENTLY IN PILOT'S HAND. THE PILOT REGAINED CONTROL OF THE HELICOPTER AND EXECUTED AN AUTOROTATION. DURING THE AUTOROTATION, THE MAIN ROTOR BLADES TRACK WAS NOTICED TO BE ABOVE ITS NORMAL TIP PATH PLANE. THE HELICOPTER LANDED ON ITS FLOATS AND BEFORE IT SANK, THE PILOT SAW THE YELLOW CODED PITCH CHANGE LINK (CONTROL ROD) HANGING FROM THE SWASH PLATE. THE HELICOPTER SANK INTO THE OCEAN AND WAS NOT RECOVERED. ## Factual narrative On September 23, 1994, at 1430 hours Hawaii standard time, a Hughes 369D, N58400, crashed into the Pacific Ocean about 130 miles southeast of Canton Island. The pilot was conducting a local visual flight rules fish spotting flight. The helicopter, operated by Caribbean Fishing Company, Terminal Island, California, was destroyed and sunk into the ocean. The certificated commercial pilot and his passenger sustained serious injuries. Visual meteorological conditions prevailed. The flight originated near the accident area from a fishing vessel, the Eliza M. The pilot's attorney reported this accident to the National Transportation Safety Board, Southwest Regional Office, Gardena, California, on November 9, 1994. The attorney said the pilot told him that while flying to a rendezvous point with the Eliza M. at 480 feet above the ocean, the helicopter cyclic control began shaking about its lateral axis. The shaking was so violent it jerked the cyclic from the pilot's hand. The pilot regained control of the helicopter using both hands and immediately executed an autorotation. During the autorotation, the pilot observed the main rotor disc tip path plane traveling at a higher angle above the horizon for its full forward cyclic position. He also noticed that one rotor blade was higher than the others. The helicopter floated before sinking into the ocean. While floating, the pilot observed the yellow coded pitch change link hanging from the rotating portion of the swash plate with its upper bearing assembly missing. The pilot repeated the attorney's statement in the National Transportation Safety Board's Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2. ## Aircraft - Registration: [N58400](https://openairdocs.org/deregistered/N58400-2013-04-23), registration cancelled 2013-04-23, S/N 1200862D, built 1980 (OpenAirDocs) - Reported make and model: HUGHES 369D - Registry model: [Hughes Helicopters HUGHES 369D](https://openairdocs.org/model/hughes-helicopters-hughes-369d) (registry code 4470706) (OpenAirDocs) - Registry engine: [Allison 250 SER 250HP](https://openairdocs.org/engine/allison-250-ser-250hp) (registry code 03002, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 1200862D - Airframe hours: 9059 - Engines: ALLISON 250-C20B 250 horsepower turbo shaft - Damage: Destroyed - Flight: Other work use, Part 91 - Operator: Caribbean Fishing Co. - Registered owner: Ferriera, Arthur - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, August 26, 1994, 100 hours before - Destination: PO ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; commercial; instrument ratings: helicopter; medical: class 2, valid medical--w/ waivers/lim; seat: left; flight hours: 8,700 total, 1,000 in this make and model ## Weather - Conditions: Visual (VMC), Day - 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 (OpenAirDocs). - [Accident 19940923038739A](https://openairdocs.org/incident/19940923038739A), Sep 23, 1994: Hughes 369D, Pacific Ocean, CA, Destroyed. On fish spotting mission. Cylic control began vibration. Autorotated to Ocean. Yellow pitch change link came off. 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.