Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Pacific Ocean
Friday, June 20, 1997 10:30
NTSB Narrative Summary Released at Completion of Accident
The pilot was spotting tuna off a ship and was approximately 10 minutes from the ship when the cyclic went full left travel. The pilot, who had not attended any factory training courses on this helicopter, said he tried to get the trim motor to reengage but to no avail. He was unable to get the cyclic to return to a neutral position. He stated that he came in to land on the boat and lost control of the helicopter because he could not hold the cyclic with one hand. The helicopter struck an antenna, rolled to the left, and landed upside down in the water. The pilot indicated to others he had problems with the trim switch on previous flights. The owner's manual states that the cyclic stick forces with a runaway cyclic would be approximately 30 pounds. It states that the helicopter will respond normally to all cyclic inputs by the pilot. The switch was returned and disassembled for detailed examination. The manufacturer could not find any identifiable markings on the switch during the examination and tool marks and other internal evidence disclosed that the switch had been disassembled and reassembled in the field. Non-standard parts were found on the inside of the switch. Boeing Helicopters sent out a mandatory service information notice dated March 10, 1994, which required all operators of the 369/500 helicopters to replace all four-way trim switches with the revision 'D' four-way trim switch. The switch is not a repairable item. No repair manual or spare parts programs exist for this switch.
NTSB Probable Cause Narrative
The unapproved field modification of the cyclic trim switch, including the use of non-standard parts, which resulted in a hard-over lateral trim failure, and the pilot's subsequent failure to maintain control of the helicopter during a landing approach. A factor in the accident was the operator's failure to comply with a factory service bulletin, which required replacement of the switch with a new version, and the pilot's continued operation with a known discrepancy.
Event Information
| Type of Event | Accident |
| Event Date | 6/20/1997 |
| Event Day of the Week | Friday |
| Time of Event | 1030 |
| Event Time Zone | -- |
| Event City | PACIFIC OCEAN |
| Event State | PACIFIC OCEAN |
| Event Country | -- |
| Zipcode of the event site | |
| Event Date Year | 1997 |
| Event Date Month | 6 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | |
| Event Location Nearest Airport ID | |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | -- |
| Weather Briefing Completeness | Unknown |
| 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 | Day |
| Lowest Ceiling Height | 0 |
| Lowest Non-Ceiling Height | 2500 |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 20 |
| Air Temperature at event time (in degrees celsius) | 29 |
| Dew Point at event time (in degress fahrenheit) | -- |
| Wind Direction (degrees magnetic) | 220 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 15 |
| Wind Velocity Indicator | Unknown |
| 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 | Fatal |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | 1 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | 1 |
| Injury Total All | 2 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 782 |
| NTSB Notification Source | -- |
| NTSB Notification Date | Jun 22 1997 12:00AM |
| NTSB Notification Time | 2330 |
| Fiche Number and/or location -used to find docket information | IMAGE |
| Date of most recent change to record | Dec 8 2000 12:21PM |
| User who most recently changed record | dbo |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N4250N |
| NTSB Number | LAX97LA218 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | -- |
| Damage | Destroyed |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Hughes |
| Aircraft Model | 369HS |
| Aircraft Series Identifier | 369HS |
| Aircraft Serial Number | 450734S |
| Certified Max Gross Weight | 2200 |
| 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 | 2 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | Annual |
| Date of Last Inspection | Feb 2 1997 12:00AM |
| Airframe hours since last inspection | 118 |
| Airframe Hours | 3908 |
| ELT Installed | Unknown |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | -- |
| Aircraft Owner Name | HANSEN HELICOPTERS |
| Aircraft Owner Street Address | P.O. BOX 9099 |
| Aircraft Owner City | TAMUNING |
| Aircraft Owner State | GU |
| Aircraft Owner Country | |
| Aircraft Owner Zipcode | 96931 |
| 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) | Other Work Use |
| Second Pilot on Board | No |
| Departure Point Same as Event | Yes |
| Departure Airport Code | |
| Departure City | |
| Departure State | |
| Departure Country | |
| Departure Time | 1330 |
| Departure Time Zone | |
| 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 | Approach |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jan 2 2001 10:34AM |
| User who most recently changed record | dbo |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 0 |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |