LAX95LA138

NTSB accident investigation · Bell 47 · Harmon Field · March 17, 1995

Accident · No injuriesLimited investigationFinal report
Date
March 17, 1995
Place
Harmon Field
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N6569HBell 47
Weather
Visual (VMC) · Day
Status
Completed · report September 24, 1995
Report
Approved by Office Director
Case key
29058

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

an engine failure due to oil exhaustion from a missing oil pressure relief valve as the result of an improper maintenance inspection.

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) - nonmechanicalApproach - vfr pattern - downwind
Lubricating system,oil regulator - missingCause
Maintenance,installation - improperCompany maintenance personnelCause
Forced landingEmergency descent/landing
Terrain condition - high vegetation
In flight collision with objectEmergency descent/landing
Object - tree(s)
Terrain condition - none suitable

Analysis

The pilot was proceeding to a landing area at 400 feet AGL when he experienced a loss of engine power. He autorotated into dense jungle terrain. Examination of the engine revealed that the oil pressure relief valve was missing. This was the first flight since a 100-hour inspection was made the day before. The inspection of the safety wire securing the valve is not a preflight item for the pilot, nor is it required to be inspected prior to flight.

Factual narrative

On March 17, 1995, at 1520 hours Guam standard time, a Bell 47 helicopter, N6569H, crashed after a loss of engine power near Harmon Field, Guam. Visual meteorological conditions existed at the time of the local maintenance test flight. The helicopter sustained substantial damage and the two occupants were not injured.

The investigation revealed that the engine lost oil pressure shortly after departure from Harmon Field. The pilot made a downwind landing into dense jungle. The tail boom separated from the aircraft during the crash sequence.

The aircraft had a 100-hour inspection on March 16, 1995, and this was the first flight since the inspection.

A Federal Aviation Administrator (FAA) inspector was on the island at the time on other business. This inspector interviewed the operator and the pilot a few days afterwards. The pilot was flying to an open field area at 400 feet above ground level when he noticed a change in the engine rpm and a loss of engine power. Due to obstacles, a 15 to 20 knot tailwind, and a loss of hydraulic power, the pilot was unable to make the open field and autorotated into the jungle.

An examination of the aircraft, after it was removed from the accident site, revealed that the oil pressure relief valve was missing. According to the FAA inspector, the valve vibrated out within a short period of time after takeoff with a corresponding loss of engine oil.

The operator told the FAA inspector that the valve was probably loose prior to takeoff. When asked if the valve was a normal preflight item, he stated that it should be at least checked to see if the safety wire securing the valve was broken. The operator does not have a published preflight procedures and/or preflight checklist nor is it a requirement under FAR Part 91 operations.

Aircraft

Registration
N6569H
Reported as
Bell 47
Category
Helicopter
Serial number
3683
Airframe hours
8,132
Engine
Lycoming VO-435-A/F, 220 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Registered owner
Hansen Helicopters, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 16, 1995 · 1 hours before

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
31
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
1,045 total · 70 in this make and model · 1,000 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 15 knots, gusting 20
Visibility
20 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 84 °F
Altimeter
29.00 inHg
Observed at
NGM, 5 nm away

Other investigations on N6569H · 1

Matched to the same aircraft by N-number and date.