LAX95FA033

The student flew to the assigned practice area, performed undetermined maneuvers, and crashed into a dirt embankment adjacent to an open field. There were no witnesses. Examination of the wreckage revealed a main rotor blade (mrb) had severed the tail rotor assembly prior to the helicopter coming to final rest. The mrb, the tail rotor blade assembly, the horizontal stabilizer, and the tail stinger were found in the field up to 147 feet from the main wreckage. The mrb was observed coned upward at a 30-degree angle over the outboard 5-foot-long portion of its span. No evidence was found in the heavily fire damaged wreckage of preimpact mechanical or structural failure. Structural deformation to the frame was consistent with the helicopter having impacted the embankment while descending with forward airspeed. No ground scar was observed in the soft dirt surrounding the main wreckage. Review of the student's reconstructed flight training records indicated that possible training deficiencies existed in areas including responding to equipment malfunctions and crosswind takeoffs and landings.

History of flight

On November 11, 1994, at 1540 Pacific standard time, a Schweizer 269C, N60TA, operated by Pacific Shore Aviation, Van Nuys, California, crashed into an open field about 6 miles west of Valencia, California. Visual meteorological conditions prevailed at the time, and no flight plan was filed for the solo instructional flight. The helicopter was destroyed by impact forces and postimpact fire, and the student pilot was fatally injured. The flight originated from the Van Nuys airport at 1508.

The student pilot's certified flight instructor (CFI) stated that his student had blocked the accident helicopter for use between 1500 and 1700. The student was authorized to fly to the "Pico Plateau" training area, where he had previously performed maneuvers in both dual and solo flight. The National Transportation Safety Board has not received information that anyone witnessed the accident.

Personnel information

The pilot's personal flight record logbook was not located. A reconstruction of the pilot's flight time/experience revealed the pilot had a total of about 90 hours of rotorcraft flight time. This flight time included initially about 25 instructional flight hours in the Bell 47 and Robinson R-22 helicopters, and then about 65 instructional flight hours in the Schweizer 269 helicopter.

The pilot performed his first solo flight on September 11, 1994. The flight was in a Schweizer 269 helicopter. At that time, his total rotorcraft flight experience was approximately 73 hours.

On November 12, 1994, during a face-to-face interview with the accident pilot's CFI, he reported that he had authorized his student to practice normal and vertical takeoffs and landings, hovering, and normal approaches. No emergency-type maneuvers were to be practiced solo. The student was authorized to fly the helicopter from Van Nuys to the practice area where the crash occurred.

The CFI further reported that the student's previous five solo flights were made to the accident site area, which he called the "Pico Plateau." The CFI stated that, in his judgement, the pilot had demonstrated good technique and was very conscientious.

The CFI provided the Safety Board with a copy of his student's primary flight training records. The CFI reported that the records encompassed the students entire training at Pacific Shore, and were from June 29, 1994, to November 8, 1994.

In part, the records itemized each dual and solo flight, and grades indicating the student's performance flying specific maneuvers. Each flight lesson was dated, and each dual lesson bore the CFI's initials. The flight records contained over an estimated 250 separate entries which the CFI stated he made by hand. The records showed the respective flight dates, maneuvers, grades, and the CFI's initials (see attached record).

During the interview, the CFI indicated that he had produced the entire flight school record after being notified of his student's fatal accident.

The record was examined by the Federal Aviation Administration (FAA) in concert with the regulatory solo flight requirements for student pilots (reference 14 CFR Part 61.87(d)). The FAA reported to the Safety Board that its record review did not indicate the CFI had provided the student pilot with presolo flight training involving crosswind takeoffs and landings, wake turbulence avoidance, and emergency procedures/equipment malfunctions.

Aircraft information

The operator reported that the helicopter was maintained by Rotorcraft Support, Van Nuys, California. According to Rotorcraft Support, the helicopter was equipped with a main transmission chip detector. Schweizer reported that, by design, the chip detector was not electrically wired to any cockpit warning light.

1. Logbook Review.

A review of the helicopter's logbooks indicated that on August 5, 1994, the helicopter underwent maintenance by a company called Rotorcraft Support, Inc. In part, the maintenance involved removing the fuel servo and the R.P.M. limiter box. The maintenance was related to an unspecified "engine problem." No record was found in the rotorcraft or engine logbooks indicating that the R.P.M. limiter box had been replaced in the helicopter before it was "APPROVED FOR RETURN TO SERVICE." At the time of the maintenance, the engine logbook indicated that the helicopter's time was 1,164.8 hours.

On August 18, 1994, at 1,196.0 hours, Rotorcraft Support personnel indicated in the engine logbook that a 100-hour inspection was performed.

On August 29, 1994, at 1,204.8 hours, Rotorcraft Support personnel indicated in the engine logbook that a new starter and alternator were installed in the helicopter. Also, the alternator mount bracket was found worn and was replaced. On November 2, 1994, at 1,313.1 hours, Rotorcraft Support personnel indicated in the rotorcraft logbook that the helicopter had received a 100, 200, 300, and 1,200-hour inspection and was "DETERMINED TO BE AIRWORTHY."

The next entry in the helicopter logbooks was dated November 8, 1994, at 1,340.00 hours. Rotorcraft Support personnel indicated in the rotorcraft logbook that they removed the over speed limiter for repair, tightened the cylinder head temperature probe, and repaired the compass mount. No logbook entry was found indicating that the over speed limiter had been reinstalled in the helicopter prior to the helicopter being "APPROVED FOR RETURN TO SERVICE."

The next (and final) entry in the helicopter logbooks was found dated November 10, 1994, at 1,341.01 hours, by Rotorcraft Support. The entry indicated that a 25-hour inspection was performed in accordance with Schweizer requirements. In part, the following was also written in the logbook: "TORQUE CHECKED TAIL DRIVE SHAFT PINION NUT, AND ADJUSTED IDLER PULLEY TENSION. AIRCRAFT APPROVED FOR RETURN TO SERVICE."

The flight school operator, Pacific Shore Aviation, completed the National Transportation Safety Board's "Aircraft Accident Report" Form 6120.1/2. Pacific Shore Aviation reported that the helicopter had been operated for 2.1 hours since last receiving an inspection on November 10, 1994, and the helicopter's total airframe time at the accident flight was 1,343.2 hours.

2. Complaints Related to Maintenance.

The Safety Board received a letter from a commercial rotorcraft pilot in which he reported his recent experiences associated with the accident helicopter, and with the accident pilot's CFI with whom he was taking instruction to become a flight instructor. In part, the commercial rotorcraft pilot indicated that:

A. On November 2, 1994, the CFI picked up N60TA from Rotorcraft Support immediately following maintenance. At the conclusion of the 0.7-hour-long flight between Rotorcraft Support and Pacific Shore, the CFI heard "a vibration from the tail area." The CFI was not able to locate the source of the vibration. However, during the flight the CFI detected "a different problem with the helicopter" and had returned it to Rotorcraft Support for (unspecified) "additional work."

B. Later during November 2, the helicopter was delivered to Rotorcraft Support and was available for rental. During his subsequent preflight inspection, he observed that "the eight bolts which secured the vertical stabilizer to the tail boom were loose."

C. The CFI requested that Rotorcraft Support repair the helicopter. Several minutes later, personnel from Rotorcraft Support tightened the loose bolts. He and the CFI then took off for the instructional flight.

D. Passing the Los Angeles International Airport, the odor of "burning oil" was smelled, and a prompt landing was made at the Hawthorne Airport.

E. The CFI exited the helicopter and examined the running engine. The CFI reported observing "a small amount of oil leaking from around the magneto area." The CFI "assumed pilot-in-command control authority of the h