WPR09LA069

NTSB accident investigation · Hughes 369 · Honiara, Solomon Islands · December 28, 2008

Accident · FatalLimited investigationFinal report
Date
December 28, 2008, 05:45 local (05:45 UTC)
Place
Honiara, Solomon Islands
Injuries
1 fatal, 1 serious
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N104BNHughes 369
Defining event
Takeoff: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report May 12, 2009
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
Case key
73157

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's failure to remove the tail rotor pedal lock before attempting flight, resulting in a loss of control.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Rotorcraft flight control: tail rotor control systemAircraft › Aircraft propeller/rotor · Not specifiedHughes 369A: 2 casesAll aircraft: 13 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotHughes 369A: 3 casesAll aircraft: 551 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The helicopter was being operated from a fishing vessel in open ocean waters. A witness, who was the mechanic for the helicopter, reported that the pilot forgot to remove the tail rotor pedal lock before takeoff. The helicopter lifted off and began to spin. The mechanic saw the pilot "trying to grab the pedal lock;" however, the pilot was unsuccessful. The helicopter impacted the water, the fixed floats separated, and the helicopter sank.

Factual narrative

On December 28, 2008, about 0545 Coordinated Universal Time, a Hughes 369A helicopter, N104BN, impacted ocean water and sank following a loss of control on takeoff from a fishing vessel in the Pacific Ocean's Solomon Sea, about 350 miles west of Honiara, Solomon Islands. The pilot, a Philippine national, was not found and is presumed dead, and the passenger, a Chinese national, sustained serious injuries. The helicopter, which was registered to Oceanside Helicopters, Inc., of Port Vila, Vanuatu, was not recovered and is presumed destroyed. Visual meteorological conditions prevailed, and no flight plan was filed for the 14 Code of Federal Regulations Part 91 local work use flight. According to a written statement provided by the helicopter's mechanic, who witnessed the accident, the pilot forgot to remove the tail rotor pedal lock before takeoff. The helicopter lifted off and began to spin. The mechanic saw the pilot "trying to grab the pedal lock;" however, the pilot was unsuccessful. The helicopter impacted the water, the fixed floats separated, and the helicopter sank.

Aircraft

Registration
N104BN
Reported as
Hughes 369 (A)
Category
Helicopter
Serial number
591148
Engine
Allison 250, 350 horsepower, turbo shaft
Damage
Destroyed
Flight
Other work use · Part 91
Operator
Oceanside Helicopters Inc.
Registered owner
Oceanside Helicopters Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · October 16, 2008
Departed
Honiara
Destination
Honiara

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
49
Injuries
Fatal
Certificate
Foreign
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Seat
Left
Flight hours
2,600 total · 600 in this make and model · 2,400 as pilot in command · 150 in the last 90 days · 50 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
90° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F
Altimeter
29.85 inHg

Docket · 2

The files NTSB released with the investigation on July 12, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 941 KB in all.