SEA95FA064

NTSB accident investigation · McDonnell Douglas 369E · Lakecreek, OR · March 7, 1995

Accident · FatalField investigationFinal report
Date
March 7, 1995, 13:40 local (21:40 UTC)
Place
Lakecreek, OR
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N59HSMcDonnell Douglas 369E
Weather
Visual (VMC) · Day
Status
Completed · report January 29, 1996
Report
Approved by Office Director
FAA report
19950307003369A
Case key
42047

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 maintain adequate clearance from the surrounding terrain. A factor was the transmission lines.

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.

In flight collision with terrain/waterHover
Object - wire,transmissionFactor
Clearance - not maintainedPilot in commandCause

Analysis

The pilot was on a local practice flight. There were no witnesses to the accident. The wreckage was located almost directly beneath transmission lines, the lowest which was no more than 26 feet AGL. Wreckage distribution indicated a slow velocity or hover condition at the time of the accident. The lower vertical stabilizer stinger tube was found imbedded in the soil alongside a gouge made by the tail rotor impacting the ground. The bottom wire was severed when one of the main rotor blades striking the ground separated and impacted the wire during its free flight.

Factual narrative

History of flight

On March 7, 1995, approximately 1340 hours Pacific standard time, a McDonnell/Hughes 369E, N59HS, being operated/flown by an airline transport pilot, was destroyed during collision with terrain while in a hover, near Lakecreek, Oregon. The pilot sustained fatal injuries. Visual meteorological conditions existed and no flight plan had been filed. The flight, which was an instructional student solo, was to have been operated in accordance with 14CFR91, and originated from the Medford Airport, Medford, Oregon, approximately 1225. The pilot departed approximately 1225 from the Medford Airport on a local practice flight and failed to return. An ELT (emergency locator transmitter) signal was picked up late in the day and the aircraft was subsequently located just before 0800 on March 8. There were no known witnesses to the accident, however, a witness did report observing the aircraft maneuvering near his location early in the afternoon of March 7th (refer to attached statement). The witness's description was consistent with a rotorcraft engaged in practice auto-rotation maneuvers.

Personnel information

The near 10,000 hour airline transport pilot did not have a rotorcraft rating at the time of the accident. His logbook showed approximately 70 hours total of rotorcraft time (44 hours in the Hughes 369E) and 37 hours pilot-in-command rotorcraft time (all in the Hughes 369E). His logbook indicated that he had commenced rotorcraft flight training on August 11, 1993, and had made 72 flights in various rotorcraft at the time of the accident.

Aircraft information

According to personnel at Medford Jet Center, the aircraft was topped off with 38 gallons of Jet A fuel shortly before its departure on the day of the accident.

Wreckage and impact information

The aircraft crashed at a location bearing 065 degrees magnetic and 12 nautical miles from the Medford Airport. The latitude and longitude of the site was 42 degrees 23.720 minutes north and 122 degrees 37.031 minutes west at an elevation of approximately 2,250 feet above mean sea level (msl). The terrain at the site was characteristic of gently rolling hills populated with occasional deciduous trees and the slope of the terrain was approximately -2 degrees toward the north. The wreckage was observed situated almost directly beneath transmission lines oriented along a 018/198 degree magnetic bearing line (refer to photographs 1 through 4). The poles carried three wires arranged vertically. The bottom-most line, a small telephone transmission line positioned 26 feet above ground, was observed to be separated (refer to photograph 5) while the two upper lines (32 and 40 feet above ground) remained intact. The rotorcraft was located near the midpoint between two of the poles separated by a distance of nearly 400 feet (refer to Supplement, I, page 3). There was no evidence of longitudinal/ lateral wreckage displacement across the terrain. All five main rotor blades were observed to have separated from the main rotor hub assembly (refer to photograph 6). Four of the blades were observed in close proximity to the fuselage. A fifth blade was located 280 feet due north of the fuselage. This blade was observed to have wire strike marks at the outboard end on the leading edge. The abrasions were observed to be super- imposed on top of mud and dirt adhering to the blade's surface (refer to photographs 07). The tail rotor 90 degree gearbox and rotor blades were observed lying on the ground a short distance north of the fuselage (refer to photograph 8). All major airframe components were located and found near the fuselage. The tail boom was observed to be severed along a production seam just forward of the vertical fin/horizontal stabilizer (refer to photograph 9). The stinger tube at the bottom of the lower vertical fin was observed to be absent. An area of scorched soil and burned grass was observed directly behind the aircraft engines exhaust (refer to photograph 10) and a section of the tail rotor drive shaft was observed to have been expelled from the tail boom (refer to photograph 11). The aft end of the drive shaft section was separated in bending and twisting, whereas the forward end had been separated in a cutting fashion consistent with extended rotation of the drive shaft against a bearing surface (refer to photographs 12). Two prominent gouges in the soil were observed a short distance west of the fuselage (refer to photograph 13). The gouges were observed to parallel one another and were oriented along an east/west bearing line. The northernmost gouge (the larger and deeper of the two) contained fragments of red paint (chips) matching the red paint on the tail rotor blades. The southernmost gouge was observed to be smaller and more clearly defined. Imbedded within this gouge was the "stinger" tube which protrudes from the bottom of the rotorcraft's lower vertical stabilizer (refer to photograph 14). Additionally, a longitudinal gouge oriented along a 092/272 degree magnetic bearing line was observed slightly north of the fuselage (refer to photograph 13). This gouge was found to be similar in length to the left skid. The soil south of the gouge was raked/smeared smooth, characteristic of the skid dragging south or rotating clockwise (from above). The helicopter's right skid was observed to have folded under the belly of the aircraft. An arc-shaped gouge was observed on the south side of the fuselage within the upsloping terrain (refer to photograph 15). The radius of the arc from the main rotor hub assembly was approximately consistent with the length of the separated main rotor blades.

Medical and pathological information

Post mortem examination was conducted by James N. Olson, M.D., at the facilities of Conger Morris Funeral Home, Medford, Oregon, on March 8, 1995. Toxicological evaluation of samples from the pilot was conducted by the FAA's Toxicology and Accident Research Laboratory. All tests were negative (refer to attached report).

Additional information

On site examination of the wreckage was accomplished on the afternoon of march 9, 1995, after which it was verbally released to the aircraft owner. Written wreckage release is documented on NTSB Form 6120.15 (attached).

Aircraft

Registration
N59HS
Reported as
McDonnell Douglas 369E
Category
Helicopter
Serial number
0221E
Airframe hours
680
Engine
Allison 250-C20B, 425 horsepower, turbo shaft
Damage
Destroyed
Flight
Instructional · Part 91
Operator
Weidman, Ronald, W.
Registered owner
Sutton, Herbert, W.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 1, 1995 · 8 hours before
Departed
MFR · Medford, OR

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
51
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
9,968 total · 44 in this make and model · 9,631 as pilot in command · 5 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
30 statute miles
Lowest ceiling
25,000 ft overcast
Temperature
52 °F, dew point 34 °F
Altimeter
29.00 inHg
Observed at
MFR, 12 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.