WPR17LA158

NTSB accident investigation · Enstrom F 28C · Ontario, CA · July 19, 2017

Accident · Serious injuriesLimited investigationFinal report
Date
July 19, 2017, 10:10 local (17:10 UTC)
Place
Ontario, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N5697BEnstrom F 28C
Defining event
Approach-VFR pattern downwind: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report January 25, 2018
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Enstrom Helicopter Corporation, Lycoming Engines
FAA report
20170719009939A
Case key
95623

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 student pilot's mismanagement of the main rotor rpm, which resulted in low rotor rpm, a high descent rate, and a subsequent hard landing.

Findings · 5

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · Student/instructed pilotEnstrom F-28C: 5 casesAll aircraft: 9,295 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · Student/instructed pilotEnstrom F-28C: 2 casesAll aircraft: 1,391 casesProbable cause
Main rotor system: main rotor blade systemAircraft › Aircraft propeller/rotor · Incorrect use/operationEnstrom F-28C: 2 casesAll aircraft: 60 casesProbable cause
Performance/control parameters: descent rateAircraft › Aircraft oper/perf/capability · Not attained/maintainedEnstrom F-28C: 1 caseAll aircraft: 242 casesProbable cause
Performance/control parameters: prop/rotor parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedEnstrom F-28C: 3 casesAll aircraft: 182 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 solo student pilot reported that he entered the downwind leg to set up for the helicopter's first landing of the day. When abeam the touchdown location, he conducted the prelanding checks with no anomalies noted. Before turning onto the base leg, the pilot lowered the collective, reduced the throttle, and started to descend about 100 ft per minute. During the descent, he observed that the engine rpm was slightly above 2,900 rpm. He reduced the throttle, and the rpm reduced slightly; however, it again increased to 2,900 rpm, and the manifold pressure was about 10 inches of mercury. When the helicopter was about 400 ft above ground level, the pilot heard the engine sound increase, and he observed that the engine rpm had increased to between about 3,300 and 3,500 rpm. The helicopter was unable to reach the runway, so the pilot continued to descend it toward a pasture, and it landed hard in the dirt. A postaccident airframe and engine examination and subsequent engine run revealed no preimpact anomalies that would have precluded normal operation. The observed damage to the main rotor blades was consistent with blade coning, a condition indicative of low main rotor rpm. It is likely that the student pilot mismanaged the main rotor rpm during the descent, which resulted in a low rotor rpm and a high descent rate during landing.

Factual narrative

On July 19, 2017, about 1010 Pacific daylight time, an Enstrom F28-C rotorcraft, N5697B, descended rapidly and landed hard in a dirt pasture about 1/2-mile northeast of the Chino Airport (CNO), Ontario, California. The student pilot, sole occupant, was seriously injured and the helicopter sustained substantial damage to the tailboom and main rotor blades. The helicopter was registered to Dubois Aviation Inc and operated by the pilot as a 14 Code of Federal Regulations Part 91 solo instructional flight. Visual meteorological conditions prevailed and no flight plan was filed. The flight originated from CNO about 1005. The student pilot reported he entered the downwind leg to set up for the first landing of the day. When abeam his touchdown location, he conducted the prelanding checks with no anomalies noted. Prior to turning base he lowered the collective, reduced the throttle, and started to descend at about 100 feet per minute. During the descent, he observed the engine RPM to be slightly above 2,900 RPM, and he reduced the throttle. The RPMs reduced slightly, however, went back to 2,900 RPM, and the manifold pressure was about 10 inches of Hg. About 400 feet above the ground, he heard the engine sound increase and he observed 3,300-3,500 RPM. Unable to make the runway, he continued to descend towards a pasture and landed hard in the dirt. A postaccident airframe and engine examination revealed no preimpact anomalies that would have precluded normal operation. Flight control continuity was established from the cockpit controls to the main rotorhead. The tailrotor driveshaft was turned and rotation was observed from the tail rotor gear to the main rotor mast. The main rotor blades remained intact and exhibited signatures consistent with coning. The lower spark plugs were removed from the engine and the engine was rotated from the cooling fan. Thumb compression was obtained on all cylinders in proper firing order, and the impulse coupling was heard clicking from the left magneto. The spark plugs were reinstalled, and the engine was prepared for an engine run. The engine ran normally for several minutes at various RPMs. Normal operating pressures and temperatures were observed, and there were no fuel or oil leaks observed. The engine was shutdown normally with no anomalies noted.

Aircraft

Registration
N5697B
Reported as
Enstrom F 28C
Category
Helicopter
Serial number
505-2
Airframe hours
3,715
Engine
Lycoming HIO-360-E1AO, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 5, 2017 · 20 hours before
Departed
CNO · Ontario, CA
Destination
CNO · Ontario, CA
Airport
CNO · Chino Airport

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
37
Injuries
Serious
Certificate
Student
Medical
Class 2, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
33 total · 33 in this make and model · 1 as pilot in command · 30 in the last 90 days · 8 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 61 °F
Altimeter
30.01 inHg
Observed at
CNO, 1 nm away

Docket · 4

The files NTSB released with the investigation on November 2, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.