# NTSB LAX95TA328: Mcdonnell Douglas 369D, N58388, Pearl City, HI, September 8, 1995 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Final report - Date: September 8, 1995, 11:45 local (21:45 UTC) - Place: Pearl City, HI - Coordinates: 21.400316, -157.959274 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=21.4003&lon=-157.9593&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report January 29, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 29232 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX95TA328 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29232/pdf - Page: https://openairdocs.org/ntsb/LAX95TA328 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Rotor failure/malfunction, cruise - aircraft preflight - inadequate, pilot in command (cause) - cargo/baggage - not secured - rotor system,tail rotor - blade strike - rotor system,tail rotor - separation - Forced landing, emergency descent/landing - terrain condition - none suitable - Hard landing, emergency 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 (not matched to a registry record) - Reported make and model: MCDONNELL DOUGLAS 369D - Category: Helicopter - Serial number: 200674D - Airframe hours: 8584 - Engines: 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. - Pilot; age 36; 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 (OpenAirDocs). - [Accident 19950908049099A](https://openairdocs.org/incident/19950908049099A), Sep 8, 1995: Pearlcity, HI, Substantial damage. (-16) See narrative 8020-16. 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.