# NTSB WPR19LA111: MD Helicopter 369, N593C, Hauula, HI, April 16, 2019

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Class 3 · Limited · Final report
- Date: April 16, 2019, 11:26 local (21:26 UTC)
- Place: Hauula, HI
- Coordinates: 21.588333, -157.91194
- Nearby events: https://openairdocs.org/map.md?lat=21.5883&lon=-157.9119&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192)
- Highest injury: No injuries
- Injuries: 4 uninjured
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Western Pacific Region
- Parties: MD Helicopter, Federal Aviation Administration
- NTSB case key (mKey): 99271
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA111
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99271/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99271
- Page: https://openairdocs.org/ntsb/WPR19LA111

## Probable cause

Fuel exhaustion as a result of the pilot’s fuel burn miscalculation. Contributing to the accident was the inoperative caution light indicating low fuel level.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Mcdonnell Douglas Helicopter 369E, 2 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=3027369), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md)
- [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Mcdonnell Douglas Helicopter 369E, 2 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=3027369), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Mcdonnell Douglas Helicopter 369E, 2 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=3027369), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md)
- [Enroute: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Mcdonnell Douglas Helicopter 369E, 2 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=3027369), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md)
- [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Mcdonnell Douglas Helicopter 369E, 6 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=3027369), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)
- [Autorotation: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Mcdonnell Douglas Helicopter 369E, 9 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=3027369), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

During the fifth flight of the day, while flying about 1,700 ft mean sea level, the pilot noted the engine-out [warning] beeping, the engine-out light, as well as the re-ignition warning light on the caution warning panel. He noted the FUEL LEVEL LOW caution light did not illuminate during the flight. The pilot entered an autorotation and was able to descend to what looked like a more level area. He made a mayday call, flew toward the lowest and most uniform area of trees, and executed a “full down” autorotation. As the helicopter descended through the tree canopy, the helicopter rolled to the right before coming to rest upside down. All four occupants were able to evacuate the helicopter without assistance. The pilot reported he had 64 gallons of fuel onboard before beginning his flights for the day. He conducted four flights before the accident flight that involved transporting passengers and cargo to different landing zones. He noted he had about 200 lbs of fuel according to the fuel gauge before he lifted off for the fifth flight. He flew three passengers to three different landing zones to deploy equipment before starting toward a staging area to refuel. He stated the fuel gauge indicated 100 lbs of fuel remaining when he lifted off from the final landing zone to fly about 5 minutes to the staging area. The pilot stated that the engine failure was due to fuel exhaustion because he overestimated his shutdown time, underestimated his flight time, and relied solely on the fuel gauge. Examination of the fuel low warning system found that a wire to a resistor on the sending unit was corroded and separated, resulting in the FUEL LOW LEVEL light being inoperable. Had the pilot been provided information that a low fuel level condition existed, he would have had about 5 minutes to select an emergency landing site, if airborne, or had the opportunity to decide not to depart on the next flight segment.

## Factual narrative

On April 16, 2019, about 1126 Hawaii time, a McDonnell Douglas 369E helicopter, N593C, was substantially damaged when it was involved in an accident near Hauula, Hawaii. The pilot and three passengers were not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 135 flight. During the fifth flight of the day, while flying about 1,700 ft mean sea level over mountainous terrain, the pilot noted the engine-out [warning] beeping, the engine-out light, as well as the re-ignition warning light on the caution warning panel. He noted the FUEL LEVEL LOW caution light did not illuminate during the flight. The pilot entered an autorotation and was able to descend to what looked like a more level area. He made a mayday call, flew toward the lowest and most uniform area of trees, and executed a “full down” autorotation. As the helicopter descended through the tree canopy, the helicopter rolled to the right before coming to rest upside down. All four occupants were able to evacuate the helicopter without assistance. The pilot reported that after having arrived for the first flight of the day at the “Turtle Bay” staging area, he performed his preflight inspection, fueled the helicopter with 64 gallons of fuel, and configured the helicopter for five flights. The pilot conducted the first four flights between 0750 and 1045, which involved transporting passengers and cargo to different landing zones. He did not shut down the engine between the fourth and fifth flights, and he noted he had about 200 lbs of fuel according to the fuel gauge before he lifted off about 1050. He then flew three passengers to three different landing zones to deploy equipment before starting toward the staging area to refuel. He stated the fuel gauge indicated 100 lbs of fuel remaining when he lifted off from the final landing to fly about 5 minutes to the staging area. Based on the flight times and shutdown times provided by the pilot, the total flight time was calculated to be about 2 hours and 36 minutes. The total shutdown time was 30 minutes. The pilot told investigators “…it seems apparent to me that fuel exhaustion was the cause of the engine flaming out and this accident.” He further explained that he planned for enough fuel to complete the missions that morning prior to initial departure but didn’t keep a running track of actual flight time. He also said he knew better than to rely solely on the fuel gauge but had somehow done that. A Federal Aviation Administration (FAA) inspector examined the wreckage and examined the FUEL LEVEL LOW warning system. He noted the FUEL LOW LEVEL light illuminated when the PRESS TO TEST button was depressed, but it did not illuminate when the [fuel level sending unit] float arm was lowered to simulate a low fuel level. The fuel gauge responded appropriately when the float arm was raised and lowered. Examination of the circuit board that controls the FUEL LEVEL LOW light revealed a disconnected/broken and corrodedwire on one end of the resistor on the board. According to the helicopter manufacturer, the FUEL LEVEL LOW light illuminates based on the configuration of the helicopter. This normally occurs with about 35 pounds of fuel remaining, of which about 22.5 pounds is usable. This would equate to about 3.3 gallons of usable fuel remaining. Considering a fuel burn of about 35 gallons per hour, the engine would operate about 5 minutes until the engine flamed out after illumination of the FUEL LEVEL LOW light.

## Aircraft

- Registration: [N593C](https://openairdocs.org/aircraft/N593C), registered now, S/N 201E (OpenAirDocs)
- Reported make and model: MD HELICOPTER 369 (E)
- Registry model: [Mcdonnell Douglas Helicopter 369E](https://openairdocs.org/model/mcdonnell-douglas-helicopter-369e) (registry code 3027369) (OpenAirDocs)
- Category: Helicopter
- Serial number: 201E
- Year built: 1986
- Airframe hours: 3757.5
- Engines: Rolls-Royce 250-C20B 420 hp turbo shaft
- Damage: Substantial damage
- Flight: Business, Part 135
- Operator: K & S Helicopters Inc
- Registered owner: K & S Helicopters Inc
- Airworthiness certificate: Standard, Utility; Standard, Normal
- Last inspection: 100 hour, April 12, 2019, 31.5 hours before
- Departed: NA, Wiamano, HI
- Destination: HI58, Kahuku, HI
- Equipment: Satellite tracking device, ADS-B, Electronic primary flight display

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 42; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: helicopter; medical: class 2, with waivers/limitations; last flight review February 6, 2019; seat: left; restraint: 4-point; flight hours: 2,545 total, 1,350 in this make and model, 2,427 as pilot in command, 315 in the last 90 days, 82 in the last 30 days, 2 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 160° at 10 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 79 °F, dew point 60 °F
- Altimeter: 30.08 inHg
- Turbulence: Severe
- Observed at: HHI, 9 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 20190416002949A](https://openairdocs.org/incident/20190416002949A), Apr 16, 2019: Mcdonnell Douglas Helicopter 369E, Hauula, HI, Substantial damage. 4-16-19 Pilot arrived work at 0630 preflight and added 7 gallons to top off fuel. Hobbs meter indicated 751.4 hrs at departure. Pilot departed H158 heliport…

## Docket (7 files)

The files NTSB released with the investigation on March 22, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99271. 32.8 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 20.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12322896&FileExtension=pdf&FileName=Pilot%20accident%20report%20form_Redacted-Rel.pdf
- Record of conversation (item 2, PDF, 1 page, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12551034&FileExtension=pdf&FileName=Record%20of%20Conversation%20-%20MD%20Helicopters-Rel.pdf
- FAA inspector's interview statement with pilot (item 3, PDF, 2 pages, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13431020&FileExtension=pdf&FileName=FAA%20inspector%27s%20interview%20with%20pilot-Rel.pdf
- FAA inspector's fuel quantify sensor examination report (item 4, PDF, 8 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12417636&FileExtension=pdf&FileName=FAA%20inspector%27s%20fuel%20quantify%20sensor%20examination%20report%20-Rel.pdf
- Statement of party representatives to NTSB investigation (item 5, PDF, 2 pages, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12323157&FileExtension=pdf&FileName=NTSB%20party%20forms_Redacted-Rel.pdf
- Release of aircraft wreckage, NTSB form 6120.15 (item 6, PDF, 1 page, 709 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12416560&FileExtension=pdf&FileName=NTSB%20Release%20of%20Wreckage%20form_Redacted-Rel.pdf
- Onboard video of accident sequence (item 7, MP4, 8.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12418186&FileExtension=MP4&FileName=onboard%20video%20of%20accident%20sequence-Rel.MP4

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.

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