# NTSB MIA92FA156: Bell 47J2, N8476E, Adjuntas, PR, July 29, 1992

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: July 29, 1992, 08:30 local (12:30 UTC)
- Place: Adjuntas, PR
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 4 fatal
- Status: Completed, report January 4, 1994
- Report: Approved by Office Director
- NTSB case key (mKey): 32991
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA92FA156
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/32991/pdf
- Page: https://openairdocs.org/ntsb/MIA92FA156

## Probable cause

THE FAILURE OF THE PILOT-IN-COMMAND TO MAINTAIN ADEQUATE ROTOR RPM DURING A PRECAUTIONARY LANDING FOLLOWING THE LOSS OF ENGINE OIL. IN ADDITION, THE PILOT FAILED TO INSURE THAT THE ENGINE CONTAINED ADEQUATE OIL, AND THAT THE OIL DIP STICK WAS SECURE PRIOR TO TAKEOFF. A FACTOR WHICH CONTRIBUTED TO THE ACCIDENT WAS THE PILOT'S IMPAIRMENT DUE TO MARIJUANA.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Miscellaneous/other, cruise - normal
  - lubricating system,oil filler cap - loose (cause)
  - aircraft preflight - improper, pilot in command (cause)
  - impairment(drugs), pilot in command (contributing factor)
  - fluid,oil - leak (cause)
  - fluid,oil - starvation (cause)
- Forced landing, landing - flare/touchdown
- Hard landing, landing - flare/touchdown
  - rotor rpm - not maintained, pilot in command (cause)

## Analysis

WITNESSES OBSERVED THE HELICOPTER, AND THEN A LOUD BANG WAS HEARD & THE ENGINE WAS NO LONGER AUDIBLE. THE HELICOPTER IMMEDIATELY MADE A TURN TO THE LEFT & DESCENDED. AS IT APPROACHED THE GROUND, THE ENGINE NOISE INCREASED. THE HELICOPTER IMPACTED HARD ON TOP OF A HILL. POST-CRASH EXAMINATION INDICATED THAT THE ENGINE AND TRANSMISSION OIL TANK AND ENGINE OIL SYSTEM CONTAINED 2 QTS OF OIL. THE TURN-TO-LOCK TYPE OIL STICK WAS NOT LOCKED, AND OIL RESIDUE WAS VISIBLE EXITING THE FILLER NECK AND FLOWING OUT OF THE ENGINE COMPARTMENT AND DOWN THE TAIL BOOM. NO OIL LEAKAGE WAS FOUND ON THE GROUND AT THE CRASH SITE. THE DAY BEFORE THE ACCIDENT, AN FAA INSPECTOR HAD NOTED OIL LEAKAGE IN AND AROUND THE HELICOPTER'S ENGINE COMPARTMENT. TOXICOLOGY TESTS RESULTS ON THE PILOT WAS POSITIVE FOR FOR 0.010 UG/ML (BLOOD-TETRAHYDROCANNABINOL CARBOXYLIC ACID) MARIJUANA, ONE PASSENGER WAS POSITIVE FOR 0.038 UG/ML (BLOOD) MARIJUANA, AND ANOTHER PASSENGER WAS POSITIVE FOR 2.4 MCG/ML (URINE) DIPHENHYDRAMINE OR BENADRYL.

## Aircraft

- Registration: [N8476E](https://openairdocs.org/deregistered/N8476E-1993-02-18), registration cancelled 1993-02-18, S/N 1837 (OpenAirDocs)
- Reported make and model: BELL 47J2
- Registry model: [Bell 47J-2](https://openairdocs.org/model/bell-47j-2) (registry code 1181104) (OpenAirDocs)
- Category: Helicopter
- Serial number: 1837
- Airframe hours: 7732
- Engines: LYCOMING VO-540-B1B3 305 horsepower reciprocating
- Damage: Destroyed
- Fire: On-Ground
- Flight: Part 135
- Operator: Western Helicopters, Inc.
- Registered owner: Western Helicopters, Inc.
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, July 13, 1992, 29 hours before
- Departed: ABO, ARECIBO, PR
- Destination: PSE, PONCE, PR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 33; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; medical: class 1, valid medical--w/ waivers/lim; seat: front; toxicology performed; flight hours: 1,078 total, 355 in this make and model, 904 as pilot in command, 35 in the last 90 days, 25 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 100° at 7 knots
- Visibility: 15 statute miles
- Lowest ceiling: none
- Temperature: 88 °F, dew point 72 °F
- Altimeter: 30.00 inHg
- Observed at: PSE, 25 nm away

## 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 19920729027999A](https://openairdocs.org/incident/19920729027999A), Jul 29, 1992: Bell 47J2, Adjuntas, Puerto Rico, Destroyed, 4 fatal. Oil filler cap not secured. Ran out of useful oil. Crashed in trees. Generally poor engine maintenance.

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.

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