# NTSB WPR15LA257: Hughes 369HS, N9068F, Manra Island, Kiribati, September 3, 2015 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: September 3, 2015, 17:52 local (17:52 UTC) - Place: Manra Island, Kiribati - Coordinates: -5.716667, -166.11666 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=-5.7167&lon=-166.1167&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report October 23, 2017 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Federal Aviation Administration- LAX-IFO - NTSB case key (mKey): 91916 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR15LA257 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91916/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91916 - Page: https://openairdocs.org/ntsb/WPR15LA257 ## Probable cause A The loss of helicopter control for reasons that could not be determined asbecause the helicopter sank in the oceanwater and was not recovered. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Hughes 369HS, 2 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=4470728), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Equipment/furnishings: life jacket](https://openairdocs.org/ntsb-findings/01022561): Aircraft › Aircraft systems · Not specified; cases with it: [Hughes 369HS, 1 case](https://openairdocs.org/ntsb-findings/01022561/cases.md?model=4470728), [All aircraft, 3 cases](https://openairdocs.org/ntsb-findings/01022561/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) (defining event); cases with it: [Hughes 369HS, 3 cases](https://openairdocs.org/ntsb-events/220/sequence.md?model=4470728), [All aircraft, 780 cases](https://openairdocs.org/ntsb-events/220/sequence.md) - [Landing: Ditching](https://openairdocs.org/ntsb-events/441); cases with it: [Hughes 369HS, 1 case](https://openairdocs.org/ntsb-events/441/sequence.md?model=4470728), [All aircraft, 186 cases](https://openairdocs.org/ntsb-events/441/sequence.md) ## Analysis According to an operator representative, the commercial pilot and passenger/spotter were conducting fish-spotting duties. The operator reported that, about 16 minutes after the helicopter departed from the fishing vessel, the fishing vessel's radio operator reported losing contact with the helicopter. Vessel personnel then located the helicopter upside down in the water and initiated rescue operations. The passenger reported that "the helicopter went wrong in the air and started rolling over and fell into the water." The passenger evacuated the helicopter and was rescued shortly after. He reported that he saw that the pilot's life vest had inflated inside the helicopter and that the pilot was struggling to exit and then stopped moving. After the passenger was transported to a hospital, he was not available for further questioning. The pilot's personal life vest, which was equipped to self-inflate when submerged in water, likely prevented him from evacuating the helicopter as it rolled over. After the accident, the operator advised its pilots not to use this type of life vest and to use the company-issued flotation life vests. The helicopter sank and was not recovered. The reason for the loss of helicopter control could not be determined. ## Factual narrative On September 3, 2015, at 1752 Coordinated Universal Time (UTC), a Hughes 369HS helicopter, N9068F, was destroyed following a forced landing into the Pacific Ocean about 300 nautical miles east of Manra Island, Republic of Kiribati. The El Salvador certificated helicopter pilot was fatally injured, the passenger sustained serious injuries. The helicopter was operated by Whirlwide Helicopters Inc., of Port Vila, Vanuatu. The local aerial observation flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91, when the accident occurred. Visual meteorological conditions prevailed, and no flight plan had been filed for the flight, which originated from a tuna fishing vessel 35 minutes prior to the accident. In a written report to the NTSB, a representative from the operator stated that the pilot and passenger/spotter were conducting fish spotting duties when the accident occurred. He reported that the helicopter descended and impacted the water and rolled upside-down. The spotter was able to exit the helicopter when he observed that the pilot's life vest had deployed while inside the helicopter and the pilot was struggling to exit. He saw the pilot stop moving, but due to his injuries was unable to assist him. A nearby fishing vessel was able to recover the pilot and the passenger but the helicopter sank and was not recovered. Shortly after being rescued, the passenger, a Vietnamese national, reported to the fish master that "the helicopter went wrong in the air and started rolling over and fell into the water." After the passenger was transported to a hospital in Majuro, Marshall Islands, he was not available for further questioning. The operator reported that the flight crews are issued life vests, but that some pilots preferred to use their own vests. The accident pilot had acquired his own vest which was equipped with an auto-inflation activation system which would activate anytime the vest was submerged underwater. The pilot's body was transported to Majuro for further processing. The investigation was unable to obtain any results of any testing or examination of the pilot. The mechanism of his injuries, detailed postmortem information was not available. The pilot held a commercial helicopter pilot certificate issued by the Republic of El Salvador on May 20, 2004, and a first-class airman medical certificate issued on November 6, 2014, with the limitations that the pilot must wear corrective lenses. The pilot's logbook was not recovered for examination. The operator reported the pilot had 5,350 total flight hours with 355 hours in make and model. No personal flight records were located for the pilot. The pilot did not hold a pilot certificate issued by the United States Federal Aviation Administration, which is required to operate a US registered aircraft while in international airspace. ## Aircraft - Registration: [N9068F](https://openairdocs.org/deregistered/N9068F-2019-05-10), registration cancelled 2019-05-10, S/N 210293S, built 1971 (OpenAirDocs) - Reported make and model: HUGHES 369HS (HS) - Registry model: [Hughes 369HS](https://openairdocs.org/model/hughes-369hs) (registry code 4470728) (OpenAirDocs) - Registry engine: [Allison 250 SER 400HP](https://openairdocs.org/engine/allison-250-ser-400hp) (registry code 03013, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 210293S - Year built: 1971 - Airframe hours: 6871 - Engines: Allison 250-C18C 317 horsepower turbo shaft - Damage: Destroyed - Flight: Aerial observation, Part 91 - Operator: Whirlwide Helicopters Inc - Registered owner: Whirlwide Helicopters Inc - Airworthiness certificate: Special, Restricted (Special) - Last inspection: 100 hour, January 20, 2015 - Departed: Manra Island, POKR - Destination: Manra Island, POKR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: fatal; commercial; instrument ratings: helicopter; last flight review March 10, 2015; seat: left; restraint: 4-point; flight hours: 5,350 total, 355 in this make and model, 5,250 as pilot in command, 110 in the last 90 days, 35 in the last 30 days, 1 in the last 24 hours - Other flight crew; injuries: serious; seat: right; flight hours: 0 total, 0 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 85° at 17 knots, gusting 5 - Visibility: 20 statute miles - Lowest ceiling: none - Observed at: PCIS, 379 nm away ## Other investigations on N9068F (2) 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. - [NTSB LAX98LA053](https://openairdocs.org/ntsb/LAX98LA053), Dec 6, 1997: McDonnell Douglas 369HS (N9068F), Saipan, India, destroyed. Probable cause: The failure of the maintenance facility to comply with the service bulletins, which resulted in the development of a corrosion pit, subsequent leakage and failure of the acceleration bellows of the… - [NTSB SEA72DYE38](https://openairdocs.org/ntsb/SEA72DYE38), Jun 30, 1972: Hughes 500 (N9068F), Longmire, WA, substantial damage ## Docket (7 files) The files NTSB released with the investigation on October 6, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91916. 4.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456867&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Certificate (item 2, .PDF, 497 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456868&FileExtension=.PDF&FileName=Pilot%20Certificate%20-Master.PDF - FAA Interview of Operator (item 3, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456869&FileExtension=.PDF&FileName=FAA%20Interview%20of%20Operator-Master.PDF - Statement of Mechanic (item 4, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456870&FileExtension=.PDF&FileName=Statement%20of%20Mechanic-Master.PDF - Maritime Report (item 5, .PDF, 543 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456871&FileExtension=.PDF&FileName=Maritime%20Report-Master.PDF - Pilot Contract (item 6, .PDF, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456872&FileExtension=.PDF&FileName=Pilot%20Contract-Master.PDF - Email Reference Life Vest (item 7, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40456873&FileExtension=.PDF&FileName=Email%20Reference%20Life%20Vest-Master.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.