# NTSB WPR09LA069: Hughes 369, N104BN, Honiara, Solomon Islands, December 28, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: December 28, 2008, 05:45 local (05:45 UTC) - Place: Honiara, Solomon Islands - Coordinates: -9.243889, 154.845278 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=-9.2439&lon=154.8453&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report May 12, 2009 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 73157 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA069 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73157/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73157 - Page: https://openairdocs.org/ntsb/WPR09LA069 ## Probable cause The pilot's failure to remove the tail rotor pedal lock before attempting flight, resulting in a loss of control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Rotorcraft flight control: tail rotor control system](https://openairdocs.org/ntsb-findings/01046720): Aircraft › Aircraft propeller/rotor · Not specified (probable cause); cases with it: [Hughes 369A, 2 cases](https://openairdocs.org/ntsb-findings/01046720/cases.md?model=4470503), [All aircraft, 13 cases](https://openairdocs.org/ntsb-findings/01046720/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Hughes 369A, 3 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=4470503), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot; cases with it: [Hughes 369A, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=4470503), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Hughes 369A, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=4470503), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Hughes 369A, 2 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=4470503), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Hughes 369A, 3 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=4470503), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N104BN-2010-10-25), registration cancelled 2010-10-25, S/N 591148, built 1969 (OpenAirDocs) - Reported make and model: HUGHES 369 (A) - Registry model: [Hughes 369A](https://openairdocs.org/model/hughes-369a) (registry code 4470503) (OpenAirDocs) - Registry engine: [Allison 250 series](https://openairdocs.org/engine/allison-250-series) (registry code 03014, turbo-prop) (OpenAirDocs) - Category: Helicopter - Serial number: 591148 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: fatal; 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 files) The files NTSB released with the investigation on July 12, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73157. 941 KB in all. - Pilot-operator aircraft accident report NTSB form 61201 (item 1, PDF, 9 pages, 645 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=261203&FileExtension=pdf&FileName=Pilot-Operator%20Aircraft%20Accident%20Report%20NTSB%20Form%2061201-Rel.pdf - Witness statements (item 2, PDF, 5 pages, 296 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=261206&FileExtension=pdf&FileName=Witness%20Statements-Rel.pdf 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.