Aircraft Accident/Incident Report

Baltimore, Maryland 21223
Wednesday, November 4, 1998 14:28 EST

NTSB Narrative Summary Released at Completion of Accident

The police helicopter was performing a police mission less than 500 above ground level when the engine lost power. The pilot was unable to reach a suitable landing area and maintain rotor rpm. The helicopter struck trees and a light pole, landed hard on a road, and slid into a fence. Examination revealed the #2 connecting rod had separated from the crankshaft. A torque check on the remaining connecting rod bolts found all below the minimum specified. A work action (strike) had been in effect at the engine manufacturer at the time of engine assembly, and production continued with management and replacement workers. During assembly the crankshaft had been replaced for an unknown reason. After the crankshaft was replaced, new connecting rods were attached, but not properly tightened. Replacement workers manned the two assembly stations identified as most probable for replacement of the crankshaft and failure to tighten the connecting rod bolts. Although long time employees knew the correct procedures for documentation of a replaced crankshaft, no specific written instructions were available for the replacement employees. The engine failed at 45.7 hours total time.

NTSB Probable Cause Narrative

inadequate assembly instructions from the engine manufacturer which resulted in improper engine assembly, and subsequent power loss over unsuitable terrain, with insufficient altitude for a successful autorotation.

Event Information

Type of Event Accident
Event Date 11/4/1998
Event Day of the Week Wednesday
Time of Event 1428
Event Time Zone Eastern Standard Time
Event City BALTIMORE
Event State MARYLAND
Event Country --
Zipcode of the event site 21223
Event Date Year 1998
Event Date Month 11
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 Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 1354 Eastern Standard Time
Direction of event from weather observation facility (degrees) 21
Weather Observation Facility ID BWI
Elevation of weather observation facility 146
Distance of event from weather observation facility (units?) 7
Time Zone of the weather observation EST
Lighting Conditions Day
Lowest Ceiling Height 0
Lowest Non-Ceiling Height 25000
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) 10
Air Temperature at event time (in degrees celsius) 11
Dew Point at event time (in degress fahrenheit) -7
Wind Direction (degrees magnetic) 360
Variable Wind Indicator Unknown
Wind Speed (knots) 9
Wind Velocity Indicator Unknown
Wind Gust Indicator Not Gusting
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 29
Density Altitude (feet) 0
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) 1932
NTSB Notification Source --
NTSB Notification Date Nov 4 1998 12:00AM
NTSB Notification Time 1505
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Dec 11 2000 11:53AM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N2100B
NTSB Number IAD99GA013
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 Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name Schweizer
Aircraft Model 269C
Aircraft Series Identifier 269C
Aircraft Serial Number S1726
Certified Max Gross Weight 2050
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 100 Hour
Date of Last Inspection Oct 23 1998 12:00AM
Airframe hours since last inspection 46
Airframe Hours 680
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name U.S. LEASECO INC
Aircraft Owner Street Address 701 WILSON POINT ROAD
Aircraft Owner City BALTIMORE
Aircraft Owner State MD
Aircraft Owner Country
Aircraft Owner Zipcode 21220
Operator is an individual? --
Operator Name BALTIMORE POLICE DEPARTMENT
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 601 EAST FAYETTE STREET
Operator City BALTIMORE
Operator State MD
Operator Country
Operator Zip code 21202
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 No
Departure Point Same as Event Yes
Departure Airport Code MTN
Departure City
Departure State MD
Departure Country
Departure Time 1310
Departure Time Zone EST
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 Climb
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 --