# NTSB WPR11LA462: Hughes 269C, N1088Y, Ramona, CA, September 22, 2011 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 22, 2011, 15:40 local (22:40 UTC) - Place: Ramona, CA - Coordinates: 33.123332, -116.916664 - Nearby events: https://openairdocs.org/map.md?lat=33.1233&lon=-116.9167&mi=10 - Phase of flight: [Emergency descent](https://openairdocs.org/ntsb-phases/600) (OpenAirDocs' grouping) - Defining event: [Autorotation: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report September 13, 2012 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - SAIBs cited in the narratives: [SAIB SW-12-12](https://openairdocs.org/saib/SW-12-12) (OpenAirDocs) - NTSB case key (mKey): 81872 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR11LA462 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/81872/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=81872 - Page: https://openairdocs.org/ntsb/WPR11LA462 ## Probable cause The flight instructor’s failure to follow the proper procedure while demonstrating a practice autorotation, which resulted in a total loss of engine power and subsequent hard landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Hughes 269C, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=4470504), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) - [Engine controls: power lever](https://openairdocs.org/ntsb-findings/01057603): Aircraft › Aircraft power plant · Incorrect use/operation (probable cause); cases with it: [Hughes 269C, 2 cases](https://openairdocs.org/ntsb-findings/01057603/cases.md?model=4470504), [All aircraft, 95 cases](https://openairdocs.org/ntsb-findings/01057603/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Autorotation: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Hughes 269C, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=4470504), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Autorotation: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Hughes 269C, 4 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=4470504), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis The flight instructor stated that he initiated the autorotation demonstration maneuver between 600 to 700 feet above ground level (agl) by rolling off the throttle and splitting the needles. About 300 feet agl, he initiated the recovery; however, he then noticed that the engine rpm was near zero and that the engine would not respond to throttle input. About 100 feet agl, the airspeed was about 40 knots, and the rotor rpm was on the low side of the green arc. The helicopter subsequently landed hard, slid forward, rolled over, and came to rest on its right side. A postaccident examination revealed no anomalies with the engine that would have precluded normal operation. The company chief pilot stated that, shortly after the instructor was hired, he showed the instructor the proper technique for teaching autorotations, which did not include rolling the throttle off in flight, a procedure that could result in engine stoppage. About 4 months after the accident, the Federal Aviation Administration issued Special Airworthiness Bulletin SW-12-12, “Conducting Engine-Failure Simulation in Helicopters with Reciprocating Engines.” The bulletin cautions owners and operators of Schweizer 269C and 269C-1 helicopters to avoid throttle chops to full idle in order to minimize the possibility of engine stoppage. ## Factual narrative On September 22, 2011, about 1540 Pacific daylight time, a Hughes 269C helicopter, N1088Y, was substantially damaged following a loss of power and a hard landing about five miles north of Ramona, California. The helicopter was registered to Civic Helicopters Inc., of Carlsbad, California. The certified flight instructor (CFI) and the student pilot were not injured. Visual meteorological conditions prevailed for the local instructional flight, which was being operated in accordance with Title 14 Code of Federal Regulations (CFR) Part 91, and a flight plan was not filed. The flight departed the McClellan-Palomar Airport (CRQ), about 1405. In a statement submitted to the National Transportation Safety Board investigator-in-charge (IIC), the CFI reported that he had demonstrated three straight-in autorotations for the student and what to expect if an actual engine failure occurred. The CFI stated that after the third autorotation the aircraft ascended to about 600 to 700 feet above ground level (agl); the plan was to demonstrate a simulated engine failure, enter the glide and recover by 200 feet agl. The CFI added that he had control of the helicopter with the student on the controls [following along], and that all engine indications were normal. The CFI reported that he then rolled the throttle to split the needles, verified that the needles were split and that the engine revolutions per minute (RPM) was bouncing between 1,500 and 2,000 RPM; he said that this was normal for this helicopter before [the needles] settled down. The CFI further stated that at about 300 feet agl when it came time to recover, he began to add throttle to join the needles but noticed that the engine RPM was at zero and that the engine would not respond to throttle input. He then instructed the student to remove his hands from the controls and told him that they had actually experienced an engine failure. The CFI reported that when he was about 100 feet agl his speed was 40 knots and rotor RPM was on the low side of green arc. As a result, he was unable to slow the descent and unable to build enough rotor RPM for a landing, which resulted in the helicopter landing hard and spreading the skids. The helicopter subsequently slid forward and rolled onto its right side. In a statement provided to the IIC, the chief pilot reported that while conducting an instructor proficiency check on the accident CFI shortly after being hired, the CFI initiated a practice autorotation in flight with a throttle chop and proceeded by lowering the collective. The chief pilot stated that when he detected the throttle rolling he immediately stopped the throttle from rolling off, returned the rotor RPM back to normal, and brought the collective back to straight and level flight. When the chief pilot asked the CFI what he was doing the CFI replied, “I am demonstrating an engine failure by rolling off the throttle then entering the autorotation. How else should I demonstrate the engine failureautorotation?” The chief pilot stated to the CFI that this is not how it is done at Civic. The chief pilot reported that after reviewing the procedures that the flight school used, he worked with the CFI for several autorotations in an effort to show him the proper way to conduct the maneuver. The chief pilot added that he advised the CFI to refer to the flight manual, which notes “Avoid rolling the throttle off in flight.” At the request of the IIC and under the supervision of a Federal Aviation Administration (FAA) airworthiness inspector assigned to the San Diego Flight Standards District Office, San Diego, California, an examination of the accident helicopter’s engine was performed on November 21, 2011. The inspector reported that all spark plugs were removed, each of which showed no visible damage or defects, and that each appeared normal. The inspector further reported that all cylinders exhibited [proper] compression; #1 cylinder exhibited compression but was leaking due to impact damage. The inspector revealed that a check of the magnetos was performed and that both magnetos tested normally. The inspector also revealed that the engine did rotate except for some binding of sheet metal, which had been bent due to the impact sequence. No attempt was made to operate (run) the engine due to the damage to the engine components as a result of the impact damage. The inspector concluded that with the exception of the damage received to the engine during the crash sequence, the engine was operating at the normal operating range prior to impact. On January 12, 2012, the FAA issued Special Airworthiness Information Bulletin (SAIB) SW-12-12, entitled “Conducting Engine Failure Simulation in Helicopters with Reciprocating Engines.” SAIB SW-12-12 specifically referenced owners and operators of Schweizer 269C and 269C-1 aircraft, which noted that Schweizer had updated the instructions and warnings in the approved Pilot Flight Manual (PFM) to avoid throttle chops to full idle, in order to minimize the possibility of engine stoppage. The FAA recommended that pilots and operators follow the updated PFM revision #18, which was approved on June 28, 2011, which clarified warnings for pilots that “rapid throttle reductions to full idle shall not be conducted.” On January 17, 2012, the Sikorsky Aircraft Corporation Lead Accident Investigator for light helicopters reported to the IIC that changes to their flight manual had been issued to address this issue. The investigator stated that most piston engine helicopters that have airplane piston engines installed don’t have the propeller associated rotational momentum it provides. As such, when the engine is rolled back rapidly from power on to idle [power] there is an acceleration of the RPM in a downward direction that can reduce RPM below the idle setting. This may result in the engine to unwind below idle and quit, or it may struggle along at idle and then quit when the throttle is rolled back on. As a directresult of the accident and in post accident conversations with the IIC, Civic Helicopters initiated remedial training for all qualified company certified flight instructors in accident make and model helicopter to verify that proper techniques are being followed relative to the demonstration of practice autorotations. Additionally, autorotation training was restricted to the company Chief Pilot and Assistant Chief Pilot until the remaining staff of flight instructors had accumulated 500 hours of instruction time given prior to being able to provide autorotation training, and only after the approval of the company Chief Flight Instructor. ## Aircraft - Registration: [N1088Y](https://openairdocs.org/deregistered/N1088Y-2018-10-24), registration cancelled 2018-10-24, S/N 611054 (OpenAirDocs) - Reported make and model: HUGHES 269C (UNDESIGNAT) - Registry model: [Hughes 269C](https://openairdocs.org/model/hughes-269c) (registry code 4470504) (OpenAirDocs) - Registry engine: [Lycoming HIO-360 series](https://openairdocs.org/engine/lycoming-hio-360-series) (registry code 41524, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 611054 - Airframe hours: 8761 - Engines: Lycoming HIO-360 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Allen D. Hopkins - Registered owner: Civic Helicopters INC. - Airworthiness certificate: Standard, Normal - Last inspection: Unknown, September 16, 2011, 9 hours before - Departed: CRQ, Carlsbad, CA - Destination: CRQ, Carlsbad, CA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 40; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: helicopter; medical: class 2, without waivers/limitations; last flight review May 31, 2011; seat: right; flight hours: 550 total, 282 in this make and model, 467 as pilot in command, 84 in the last 90 days, 40 in the last 30 days, 3 in the last 24 hours - Student pilot; age 24; injuries: none; student; medical: class 3, without waivers/limitations; seat: left; flight hours: 33 total, 15 in this make and model, 13 in the last 90 days, 2 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 59 °F - Altimeter: 29.94 inHg - Observed at: RNM, 5 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 20110922022609A](https://openairdocs.org/incident/20110922022609A), Sep 22, 2011: Hughes 269C, Ramona, CA, Substantial damage. During auto rotation landing for instruction pilot stated thate the engine quit causing aircraft to crash into a cow pasture ## Docket (9 files) The files NTSB released with the investigation on July 16, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=81872. 2.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 622 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370588&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Weather Data (item 2, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370589&FileExtension=.PDF&FileName=Weather%20Data-Master.PDF - FAA Inspector's Report of Engine Exam (item 3, .PDF, 308 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370591&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Report%20of%20Engine%20Exam-Redacted.PDF - FAA Special Airworthiness Information Bulletin (item 4, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40371676&FileExtension=.PDF&FileName=FAA%20Special%20Airworthiness%20Information%20Bulletin-Redacted.PDF - Statement - Sikorsky Aircraft Corp. (item 5, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40371671&FileExtension=.PDF&FileName=Statement%20-%20Sikorsky%20Aircraft%20Corp.-Redacted.PDF - Statement - Civic Helicopters' Chief Pilot (item 6, .PDF, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40371678&FileExtension=.PDF&FileName=Statement%20-%20Civic%20Helicopters%27%20Chief%20Pilot-Redacted.PDF - Excerpts from Maintenance Records (item 7, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370594&FileExtension=.PDF&FileName=Excerpts%20from%20Maintenance%20Records-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40370596&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40371670&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.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.