LAX95TA328

NTSB accident investigation · Mcdonnell Douglas 369D · Pearl City, HI · September 8, 1995

Accident · Serious injuriesFinal report
Date
September 8, 1995, 11:45 local (21:45 UTC)
Place
Pearl City, HI
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N58388Mcdonnell Douglas 369D
Weather
Visual (VMC) · Day
Status
Completed · report January 29, 1996
Report
Approved by Office Director
FAA report
19950908049099A
Case key
29232

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

The pilot's failure to secure his cargo/personal belongings which departed from the aircraft and struck the tail rotor.

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.

Rotor failure/malfunctionCruise
Aircraft preflight - inadequatePilot in commandCause
Cargo/baggage - not secured
Rotor system,tail rotor - blade strike
Rotor system,tail rotor - separation
Forced landingEmergency descent/landing
Terrain condition - none suitable
Hard landingEmergency descent/landing

Analysis

The fire department helicopter pilot was returning to the home base after surveying a brushfire. His route of flight was across a mountain ridgeline. Just after the crossing, the pilot felt a bump to the rear of the helicopter. A severe vibration was felt in the tail rotor antitorque pedals. The pilot attempted to guide the helicopter to a suitable landing area. Upon reaching the only site available, the helicopter began to rotate about the vertical axis, landing hard on a ridgeline. The helicopter was being operated with the doors off and the pilot's flight jacket was missing. Laboratory analysis of fibers found on a tail rotor blade matched fibers from a standard issue fire department jacket similar to the pilot's jacket that was missing.

Factual narrative

History of flight

On September 8, 1995, about 1145 hours Hawaii standard time, a McDonnell Douglas 369D, N58388, operated by the Honolulu Fire Department (HFD) as a public-use aircraft, was substantially damaged during an emergency landing near Pearl City, on the island of Oahu, Hawaii. The pilot, the sole occupant, received serious injuries. Visual meteorological conditions prevailed for the local flight which originated at Honolulu International Airport at 1035 on the morning of the accident.

The pilot was returning after completing an aerial survey of a brushfire. After crossing a ridgeline of the Koolau Mountains, the pilot reported feeling a bump, and then a vibration feedback through the antitorque pedals. The helicopter rotated about the vertical axis several times as the pilot attempted to land with power. The helicopter landed hard on the side of a ridgeline.

The helicopter was being operated with the doors off. The pilot reported that his jacket was missing and that he had put it in the bench seat box in the aft compartment of the helicopter. The box was secured with hook-type latches, with a locking safety pin in one latch. The jacket was not found in the box.

Personnel information

The commercial instrument rated helicopter pilot reported a total flight time of 2,188 total flight hours, with 1,052 hours in the accident helicopter's make and model. The pilot's last biennial flight review was conducted on January 11, 1992. His last second-class flight physical was dated December 6, 1994.

Aircraft information

Postaccident examination of the helicopter revealed that the tail rotor boom had sheared off at the same area where the tail rotor driveshaft had sheared. The tail rotor blades exhibited minor damage. There was leading edge imprinting, paint loss, and abrasion strip disturbance noted on one of the tail rotor blades.

Testing and research

Tests were conducted by the Honolulu Police Department (HPD) Scientific Lab of the material and fibers found on the leading edge of a tail rotor blade. There was a scuff mark on the same rotor blade that revealed a series of striations that are consistent with fabric impression damage. The material found on the leading edge of the blade was found to be a component consistent with polyester. Fibers found under the mylar tape abrasion strip were very similar to fibers from jackets worn by the HFD pilots.

According to their report: "The microscopic examination of the scuff area of the rotor blade revealed a series of striations which are consistent with fabric impression damage. The instrumental analysis of this grey transfer material was identified to be a component consistent with polyester. Although no fibers could be identified in this area, based on the transfer pattern and type of substance present, this type of damage could be consistent with fabric transfers."

Aircraft

Registration
N58388
Reported as
Mcdonnell Douglas 369D
Category
Helicopter
Serial number
200674D
Airframe hours
8,584
Engine
Allison 250-C20B, 450 horsepower, turbo shaft
Damage
Substantial damage
Flight
Public aircraft · Public use
Registered owner
City And County Of Honolulu
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 20, 1995 · 70 hours before
Departed
HNL · Honolulu, HI
Destination
HNL · HI
Flight plan
Company VFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
36
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
2,188 total · 1,052 in this make and model · 1,821 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 13 knots
Visibility
20 statute miles
Lowest ceiling
4,500 ft broken
Temperature
90 °F, dew point 64 °F
Altimeter
30.00 inHg
Observed at
HNL

FAA reports on this event · 1

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