# NTSB WPR18LA265: Schweizer 300CBi 269C1, N2128T, Granada Hills, CA, September 15, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: September 15, 2018, 12:33 local (19:33 UTC) - Place: Granada Hills, CA - Coordinates: 34.285831, -118.494445 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.2858&lon=-118.4944&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA-FSDO - NTSB case key (mKey): 98315 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR18LA265 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98315/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98315 - Page: https://openairdocs.org/ntsb/WPR18LA265 ## Probable cause A partial loss of engine power that was the result of a loss of compression in the No. 1 and 4 cylinders due to damage and material separation from the exhaust valve heads, which resulted in a subsequent forced, hard landing. Contributing to the accident was inadequate maintenance inspection. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Schweizer 269C-1, 2 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=8059504), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Schweizer 269C-1, 3 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=8059504), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/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: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Schweizer 269C-1, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=8059504), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Schweizer 269C-1, 4 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=8059504), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Schweizer 269C-1, 11 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=8059504), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis The flight instructor reported that during the instructional flight, when the helicopter was about 1,600 ft mean sea level (msl) and about 65 knots, the engine experienced “a significant and abrupt change in engine sound and power.” Shortly after, the engine rpm rose to 3,000. He immediately chose to initiate a partial-power, emergency landing on a nearby golf course instead of an autorotation because the engine was still producing partial power. He stated that it was difficult to control the throttle as he was lowering the collective and beginning the descent. He flared the helicopter when it was about 20 ft agl, and it subsequently landed hard on the level golf course fairway. During the examination of the wreckage, the tail rotor assembly, including the horizontal and vertical stabilizers, was found separated. The tail rotor blades were undamaged. The tailboom remained attached to the fuselage but had separated near the tail rotor assembly due to the upper tailboom support rod separating in overload near its midsection. All three main rotor blades remained attached to the hub assembly. Two of the blades exhibited impact damage, consistent with the blades contacting the tailboom. A section of the drive shaft had separated from the transmission and tailboom. During the engine examination, thumb compression tests, the Nos. 1 and 4 cylinders could not obtain compression. Examination of the No. 1 cylinder with a borescope revealed that the exhaust valve head exhibited thermal discoloration in three areas, consistent with combustion blowby. Cracking was visible near the valve head’s edge, and a small amount of material was missing from the head’s outer edges. Additionally, the No. 4 cylinder piston head and combustion chamber exhibited mechanical damage. The exhaust valve head was missing about one-third of its material. The last annual inspection was accomplished one month before the accident. The maintenance records indicated that a service bulletin that directed the inspection of the exhaust valves’ condition had been complied with. The bulletin indicated that failure to comply with the provisions of the bulletin could result in engine failure due to excessive carbon build up between the valve guide and valve stem resulting in sticking valves or broken exhaust valves that result from excessive wear (bell-mouthing) of the exhaust valve guide. Given the condition of the No. 1 and 4 exhaust valves, it is likely that the inspection that had been accomplished in accordance with the service bulletin was not adequate and that the damage and material loss from the valve heads resulted in the loss of compression in those cylinders and partial loss of engine power. ## Factual narrative On September 15, 2018, about 1233 Pacific daylight time, a Schweizer 300CBi helicopter, N2128T, sustained substantial damage when it was involved in an accident near Granada Hills, California. The flight instructor and the student pilot were uninjured. The helicopter was operated by Group 3 Aviation, Inc., as a 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor and pilot receiving instruction were conducting an instructional flight in the helicopter, which was primarily used for flight instruction. The instructor reported that, after departure from Van Nuys Airport (VNY), Van Nuys, California, when the helicopter was about 1,600 ft mean sea level (msl), it “experienced a significant and abrupt change in engine sound and power.” Shortly after, the engine rpm rose to 3,000. The instructor immediately chose to initiate a partial-power, emergency landing to a nearby golf course instead of an autorotation because the engine was still producing partial power. He stated that it was difficult to control the throttle as he was lowering the collective and began the descent. The instructor flared the helicopter when it was about 20 ft agl, and it subsequently landed hard on the golf course fairway. During examination of the accident site, the tail rotor assembly, including the horizontal and vertical stabilizers, was found forward of the main wreckage area. The tail rotor blades were undamaged. The tailboom remained attached to the fuselage but had separated near the tail rotor assembly. The upper tailboom support rod had separated in overload near its midsection. All three main rotor blades remained attached to the hub assembly. Two of the blades exhibited impact damage, and the third blade was buckled near the hub. A section of the drive shaft assembly had separated from the transmission and tailboom section. During the engine examination, thumb compression tests on the Nos.1 and 4 cylinders could not obtain compression. A boroscopic examination of the No. 1 cylinder combustion chamber revealed that the piston head and chamber exhibited normal deposits. The exhaust valve head exhibited thermal discoloration in three areas, consistent with combustion blowby. Cracking was visible near the valve head’s edge, and a small amount of material was missing from the head’s outer edges. A boroscopic examination of the No. 4 cylinder combustion chamber revealed that the surfaces of the piston head and chamber exhibited mechanical damage. The exhaust valve head was missing about one-third of its material. Review of the helicopter’s maintenance records revealed that the engine was installed on July 31, 2014. The last annual inspection was conducted on August 17, 2018, when the engine had 1,571 total flight hours. Service Bulletin No. 388C, “Exhaust Valve and Guide Inspection,” was complied with during the inspection. The bulletin describes the approved procedures for checking exhaust valve guide condition. Failure to comply with thebulletin could result in engine failure due to excessive carbon build up between the valve guide and valve stem resulting in sticking valves or broken exhaust valves which result from excessive wear (bel-mouthing) of the exhaust valve guide. The Nos. 1 through 4-cylinder compressions were reported as 76/80, 77/80, 76/80, 78/80, respectively. The helicopter was subsequently flown another 31 hours before the time of the accident. ## Aircraft - Registration: [N2128T](https://openairdocs.org/deregistered/N2128T-2019-03-04), registration cancelled 2019-03-04, S/N 0366, built 2009 (OpenAirDocs) - Reported make and model: Schweizer 300CBi 269C1 - Registry model: [Schweizer 269C-1](https://openairdocs.org/model/schweizer-269c-1) (registry code 8059504) (OpenAirDocs) - Registry engine: [Lycoming HIO-360-G1A](https://openairdocs.org/engine/lycoming-hio-360-g1a) (registry code 41898, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 0366 - Year built: 2009 - Airframe hours: 3899.7 - Engines: Lycoming HIO-360-G1A 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Group 3 Aviation, Inc - Registered owner: Charlie Papa LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 17, 2018, 32 hours before - Departed: KVNY, Van Nuys, CA - Destination: Piru, CA - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 45; injuries: none; commercial, flight instructor; instrument ratings: helicopter; medical: class 1, without waivers/limitations; last flight review April 17, 2018; seat: left; restraint: 4-point; flight hours: 1,549 total, 842 in this make and model, 1,515 as pilot in command, 180 in the last 90 days, 60 in the last 30 days, 8 in the last 24 hours - Student pilot; age 52; injuries: none; commercial, private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review March 28, 2018; seat: right; restraint: 4-point; flight hours: 459.2 total, 8.8 in this make and model, 205.3 as pilot in command, 11 in the last 90 days, 3 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 37 °F - Altimeter: 29.88 inHg - Observed at: KWHP, 4 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 20180915013709A](https://openairdocs.org/incident/20180915013709A), Sep 15, 2018: Schweizer 269C-1, Granada Hills, CM, Destroyed. On 09/15/18 N2128T helicopter lost partial power and performed an emergency landing on knollwood golf fine miles north of the van nuys airport. Due to the sink… ## Docket (5 files) The files NTSB released with the investigation on October 28, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98315. 13.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12078246&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - NTSB airframe and engine examination summary (item 2, PDF, 9 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12048903&FileExtension=pdf&FileName=WPR18LA265%20Engine%20and%20Airframe%20Examination%20Summary_Redacted-Rel.pdf - Maintenance logbook-excerpts (item 3, PDF, 2 pages, 822 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12048893&FileExtension=pdf&FileName=Maintenance%20Logbook%20Excerpts_Redacted-Rel.pdf - Photo array-accident site, courtesy of the FAA (item 4, PDF, 7 pages, 5.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12867076&FileExtension=pdf&FileName=Photo%20Array-Accident%20Site-Rel.pdf - Service bulletin no 388C (item 5, PDF, 13 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12827880&FileExtension=pdf&FileName=SB%20388C%20Procedure%20to%20Determine%20Exhaust%20Value%20and%20Guide%20Condition-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.