Individually Owned: 151,845
Corporate Owned: 143,699
Sacramento Mather Airport
Aircraft Accident/Incident Report
Mather, California 95655
Friday, November 10, 1995 17:45 PST
NTSB Narrative Summary Released at Completion of Accident
The left seat pilot was practicing night autorotations to runway 22 to maintain his currency. After the left seat pilot completed six hovering autorotations to the ground and eight autorotations to a power recovery, the right seat pilot snapped the right collective throttle to the ground idle position at 250 feet in a climb, to simulate a loss of engine power and announced 'power failure.' The left seat pilot initiated an autorotation; neither pilot was aware of an actual loss of power. When the left seat pilot applied throttle to initiate a power recovery, the engine's compressor stalled and the 'engine out' and 'auto re-ignite' lights illuminated. The left seat pilot continued with the autorotation, landed on runway 22 with the tail-first, broke the skids, and the aircraft rolled over. The investigation revealed that the right seat pilot did not perform the throttle rigging check before departing on the accident flight as recommended by the 369D pilot handbook. Several postaccident ground runs of the engine were conducted. Based upon those, it was determined that rapid roll off of the right seat throttle could retard the throttle below ground idle and flameout the engine. The throttle misrigging had not been detected by maintenance personnel.
NTSB Probable Cause Narrative
Fuel starvation due to the right seat safety pilot's inadvertent engine shutdown when he closed the throttle to simulate an engine failure, and his failure to perform the throttle rigging check before takeoff. Contributing to the accident was the improper rigging of the throttle system coupled with the pilot's improper recovery from the autorotation.
Event Information
| Type of Event | Accident |
| Event Date | 11/10/1995 |
| Event Day of the Week | Friday |
| Time of Event | 1745 |
| Event Time Zone | Pacific Standard Time |
| Event City | MATHER |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 95655 |
| Event Date Year | 1995 |
| Event Date Month | 11 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | SACRAMENTO MATHER |
| Event Location Nearest Airport ID | MHR |
| Indicates whether the acc/inc occurred off or on an airport | On Airport |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | 96 |
| Weather Briefing Completeness | Not pertinent |
| Investigator's weather source | Pilot |
| Time of the weather observation | 0 |
| Direction of event from weather observation facility (degrees) | 0 |
| Weather Observation Facility ID | |
| Elevation of weather observation facility | 0 |
| Distance of event from weather observation facility (units?) | 0 |
| Time Zone of the weather observation | |
| Lighting Conditions | Night/Dark |
| Lowest Ceiling Height | 0 |
| Lowest Non-Ceiling Height | 0 |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 15 |
| Air Temperature at event time (in degrees celsius) | 19 |
| Dew Point at event time (in degress fahrenheit) | -- |
| Wind Direction (degrees magnetic) | 0 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 0 |
| Wind Velocity Indicator | Calm |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | -- |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | Minor |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | -- |
| Injury Total Minor | 2 |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 2 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 1938 |
| NTSB Notification Source | -- |
| NTSB Notification Date | Nov 10 1995 12:00AM |
| NTSB Notification Time | 1824 |
| Fiche Number and/or location -used to find docket information | IMAGE |
| Date of most recent change to record | Nov 6 2001 10:14AM |
| User who most recently changed record | NTSB\MONR |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N33CN |
| NTSB Number | LAX96TA044 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | -- |
| Damage | Substantial |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | McDonnell Douglas |
| Aircraft Model | 369D |
| Aircraft Series Identifier | 369D |
| Aircraft Serial Number | 670150D |
| Certified Max Gross Weight | 3000 |
| Aircraft Category | Helicopter |
| Aircraft Registration Class | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 4 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | 100 Hour |
| Date of Last Inspection | Oct 27 1995 12:00AM |
| Airframe hours since last inspection | 75 |
| Airframe Hours | 17075 |
| ELT Installed | No |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | -- |
| Aircraft Owner Name | SACRAMENTO SHERIFF'S DEPT |
| Aircraft Owner Street Address | 10056 MISSILE WAY |
| Aircraft Owner City | MATHER |
| Aircraft Owner State | CA |
| Aircraft Owner Country | |
| Aircraft Owner Zipcode | 95655 |
| Operator is an individual? | -- |
| Operator Name | |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | |
| Operator City | |
| Operator State | |
| Operator Country | |
| Operator Zip code | |
| Operator Code | |
| Owner has at least one certificate | None |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | Unknown |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | -- |
| Indicates Domestic or International Flight | -- |
| Operator carrying Pax/Cargo/Mail | -- |
| Type of Flying (Per_Bus / Primary) | Public Use |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | Yes |
| Departure Airport Code | MHR |
| Departure City | |
| Departure State | |
| Departure Country | |
| Departure Time | 1715 |
| Departure Time Zone | PST |
| Destination Same as Local Flt | dest & departure same, accident can occur anywhere |
| Destination Airport Code | |
| Destination City | |
| Destination State | |
| Destination Country | |
| Specific Phase of Flight | Maneuvering |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jan 2 2001 10:30AM |
| User who most recently changed record | dbo |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 22 |
| Runway Length | 11300 |
| Runway Width | 300 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |