LAX97LA224

NTSB accident investigation · Enstrom F-28-F · Riverside, CA · June 25, 1997

Accident · Minor injuriesLimited investigationFinal report
Date
June 25, 1997, 12:43 local (19:43 UTC)
Place
Riverside, CA
Injuries
3 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N99YCEnstrom F-28-F
Weather
Visual (VMC) · Day
Status
Completed · report February 2, 1998
Report
Approved by Office Director
FAA report
19970625040829A
Case key
29821

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

failure by unknown maintenance personnel to retorque the nuts on the retainer cover.

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(partial) - mech failure/malfClimb - to cruise
Engine assembly,rocker arm/tappet - shiftedCause
Engine assembly,rocker arm/tappet - loose part/bolt/nut/clamp/etcCause
Engine assembly,valve,intake - inoperativeCause
Maintenance,installation - not verifiedOther maintenance personnelCause
Hard landingDescent - emergency
Autorotation - not performedPilot in commandFactor

Analysis

During takeoff, the helicopter lost power and landed hard. Postaccident examination revealed the No. 2 cylinder intake valve rocker shaft migrated out of the shaft bosses of the cylinder head. The shaft, cover, and nuts were found; the washers were not. According to owner/pilot there were internal star washer imprints on the cover plate commonly caused by torque or tightening of the nut. The helicopter had 61.5 total hours since new, and received one 50-hour inspection since delivery to the owner/pilot. The owner/pilot changed the oil and filter just prior to the inspection.

Factual narrative

On June 25, 1997, at 1243 hours Pacific daylight time, an Enstrom F-28-F helicopter, N99YC, was substantially damaged after a loss of power during a takeoff/climb at Riverside, California. The pilot and two passengers received minor injuries. Visual meteorological conditions prevailed for the local flight and no flight plan was filed. The flight was destined for Corona Airport, Corona, California.

According to the pilot, the loss of engine power occurred less than 200 feet agl. He attempted an auto rotation and landed hard. Postaccident examination of the engine revealed that the intake valve rocker shaft migrated out of the shaft bosses of the cylinder head. The shaft, cover, and nuts were found; the washers were not. The pilot stated that there were internal star washer imprints on the cover plate that is commonly caused by the torque or tightening of the nut. The helicopter had 61.5 total hours since new and received one inspection at 50.9 hours since delivery to the owner/pilot.

The owner/pilot changed the oil and filter prior to the formal 50-hour inspection by a private contractor. The inspection form revealed no specific inspection of the retainer plates are required except for a general condition inspection of the engine, accessories, and of the fluid systems for leaks.

Aircraft

Registration
N99YC
Reported as
Enstrom F-28-F
Category
Helicopter
Serial number
809
Airframe hours
61
Engine
Lycoming HIO-360-F1AD, 205 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Stits Aircraft
Registered owner
Enstrom Helicopter
Airworthiness certificate
Standard, Normal
Last inspection
Unknown · May 19, 1997 · 1 hours before
Departed
RAL · CA
Destination
L66 · Corona, CA
Airport
RAL · Riverside Municipal

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
76
Certificate
Commercial
Airplane ratings
Single-engine sea, Multi-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
2,500 total

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 9 knots
Visibility
4 statute miles
Lowest ceiling
None
Observed at
KRA

FAA reports on this event · 1

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