WPR18LA226

NTSB accident investigation · Hughes 369 · Riverside, CA · August 17, 2018

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
August 17, 2018, 10:50 local (17:50 UTC)
Place
Riverside, CA
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Emergency descent
Aircraft
N105JLHughes 369
Defining event
Autorotation: Hard landing
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
McDonnell Douglas Helicopters, Federal Aviation Administration, Western Helicopters Inc.
FAA report
20180817014409A
Case key
98093

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

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Probable cause

The instructor’s delayed remedial action to an excessive descent rate during a simulated autorotation, which resulted in a 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.

Performance/control parameters: descent rateAircraft › Aircraft oper/perf/capability · Incorrect use/operationHughes Helicopters HUGHES 369D: 5 casesAll aircraft: 242 casesProbable cause
Misc hardware: fastenersAircraft › Fluids/misc hardware · Not installed/availableHughes Helicopters HUGHES 369D: 1 caseAll aircraft: 58 cases
Attention/monitoring: monitoring other personPersonnel issues › Psychological · Instructor/check pilotHughes Helicopters HUGHES 369D: 1 caseAll aircraft: 200 casesProbable cause
Fuselage: seat/cargo attach fittingAircraft › Aircraft structures · Incorrect service/maintenanceHughes Helicopters HUGHES 369D: 1 caseAll aircraft: 27 cases
Action: delayed actionPersonnel issues › Action/decision · Instructor/check pilotHughes Helicopters HUGHES 369D: 1 caseAll aircraft: 894 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 pilot receiving instruction was performing a full-touchdown, 180° autorotation when the instructor noted that the helicopter was going to be short of the intended landing zone and advanced the throttle to initiate a power recovery. The helicopter continued to descend and landed hard and rolled over, resulting in substantial damage. The instructor reported no mechanical malfunctions with the helicopter or engine that would have precluded normal operation. It is likely that the instructor’s delayed response to the helicopter’s excessive rate of descent resulted in the hard landing. After egressing the helicopter, the instructor noted that the pilot receiving instruction had been ejected from the helicopter during the accident sequence. Examination of the restraint systems revealed that the cotter pins for the hook-end fitting that attached to the airframe seat belt fittings had not been installed. The centrifugal force generated by the rotation of the helicopter during the accident sequence was likely sufficient for the hook-end fitting, void of the cotter pin, to separate from the seat belt fitting, which then resulted in the student being ejected from the helicopter. As a result of the accident, the manufacturer issued a mandatory service bulletin requiring the installation of cotter pins in the seat belt assemblies.

Factual narrative

On August 17, 2018, about 1050 Pacific daylight time, a Hughes 369D helicopter, N105JL, was substantially damaged when it was involved in an accident near Riverside, California. The flight instructor sustained a minor injury, while the pilot receiving instruction was seriously injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The pilot performed several power recovery autorotations, then the instructor demonstrated a full-touchdown 180° autorotation. The pilot subsequently performed several power recovery 180° autorotations before the instructor asked him to perform a full-touchdown 180° autorotation. The instructor stated that, as the pilot turned the helicopter toward the runway, he saw that they were going to be short of the intended landing zone and advanced the throttle to perform a power recovery. The instructor then realized that the descent rate was greater than he anticipated, and he instructed the pilot to level the helicopter’s skids. The instructor reported that he “felt the absorbers on the skids collapsing” as the helicopter touched down, then he felt a large bump then rapid rotation of the airframe. After shutting off the fuel, the instructor egressed and saw that the pilot receiving instruction had been ejected from the helicopter during the accident sequence. Examination of the seat belts revealed that no cotter pins were installed in the hooked end fittings of each seat belt. The manufacturer reported that cotter pins were not delivered with the seat belts, nor were there any instructions from the manufacturer that cotter pins were required to be installed. Following the accident, on November 20, 2019, MD Helicopters issued Mandatory Service Bulletin SB369D-227, entitled “INSTALL COTTER PINS IN THE SEAT-BELT INSTALLATION.” In part, the Service Bulletin was issued “…to prevent the hook-ends from disengagement from the attachment points.” The bulletin further noted that, “Failure to comply with this bulletin can cause a pilot, copilot, or passenger to fall out of the helicopter in flight or on the ground.”

Aircraft

Registration
N105JL
Reported as
Hughes 369 (D)
Category
Helicopter
Serial number
900807D
Built
1980
Airframe hours
11,717.7
Engine
Allison 250-C20B, 450 horsepower, turbo shaft
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Western Helicopters Inc
Registered owner
Helicopters Unlimited LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 30, 2018 · 60 hours before
Departed
RAL · Riverside, CA
Airport
RAL · Riverside Municiapal Airport, runway 34, 2,850 × 50 ft, concrete
Equipment
None

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
62
Injuries
Minor
Certificate
Commercial
Medical
Class 2, With waivers/limitations
Last flight review
December 15, 2017
Seat
Right
Restraint
4-point
Flight hours
13,850 total · 13,000 in this make and model · 13,600 as pilot in command · 45 in the last 90 days · 27 in the last 30 days · 2 in the last 24 hours
Role
Pilot
Age
64
Injuries
Serious
Certificate
Private
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
4-point
Flight hours
2,500 total · 500 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 67 °F
Altimeter
30.06 inHg
Observed at
RAL, 1 nm away

Docket · 7

The files NTSB released with the investigation on June 17, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.2 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.