Aircraft Accident/Incident Report

Pacific Ocean
Monday, June 7, 1999 9:00

NTSB Narrative Summary Released at Completion of Accident

About 10 minutes into a fish spotting mission from a fishing vessel, the pilot felt an intense vibration through the tail rotor pedals and helicopter control became increasingly difficult. About 250 feet above the water, the 90-degree gear box and tail rotor assembly separated. The helicopter spiraled down toward the water, spinning to the right with an estimated 55- to 60-degree nose-down attitude. The pilot reported the last moments before contacting the water were 'uncontrollable.' The helicopter was recovered, except for the tail rotor system rotating components and gearbox. The operator reported that he had removed the tail rotor abrasion strips from the blades during an annual inspection about 73 hours before the accident. He reported that he applied 'direct and intense heat' to the blades to remove the strips. According to the manufacturer, the abrasion strips can be removed; however, it must be done by an approved blade overhaul facility and cannot be accomplished in the field. The manufacturer stated that the use of heat is unauthorized and likely induced a bond separation within the tip cap area. A review of the McDonnell Douglas maintenance manual revealed that tail rotor blade repairs are not specifically addressed. A McDonnell Douglas representative reported that if a repair is not addressed in the manual, it is not authorized. He stated that certified blade repair stations are authorized expanded repairs. The pilot/mechanic reported that he was aware that the operator had removed the tail rotor abrasion strips and had observed a small gap between one of the tail rotor blade tip caps and the blade during a routine inspection before the accident. He contacted the operator and requested a new blade. He then applied clear epoxy resin at the joining surfaces then test-flew the helicopter and noticed 'no change in the flight characteristics of the aircraft.' He stated that he felt the 'blade [was] airworthy and was as originally constructed.' McDonnell Douglas Service Bulletin HN-195 directs mechanics to visually inspect the tip cap-to-blade bonding for failure and states that 'if any evidence of debonding is noted, replace blade.'

NTSB Probable Cause Narrative

The removal of the tail rotor blade abrasion strips by the use of an unapproved method by the maintenance personnel which resulted in the imbalance of the tail rotor blade assembly and subsequent separation of the 90-degree gear box; the pilot/mechanic's unapproved repair to the tail rotor blade tip caps; and, his continued operation of the helicopter with known deficiencies.

Event Information

Type of Event Accident
Event Date 6/7/1999
Event Day of the Week Monday
Time of Event 900
Event Time Zone --
Event City PACIFIC OCEAN
Event State PACIFIC OCEAN
Event Country --
Zipcode of the event site
Event Date Year 1999
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 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) 10
Air Temperature at event time (in degrees celsius) 27
Dew Point at event time (in degress fahrenheit) --
Wind Direction (degrees magnetic) 120
Variable Wind Indicator Unknown
Wind Speed (knots) 18
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 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) 446
NTSB Notification Source --
NTSB Notification Date Jul 14 1999 12:00AM
NTSB Notification Time 1400
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Dec 12 2000 11:39AM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N4278M
NTSB Number LAX99LA253
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 230450S
Certified Max Gross Weight 2550
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 Apr 16 1999 12:00AM
Airframe hours since last inspection 73
Airframe Hours 8168
ELT Installed Unknown
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name HOFFMAN HELICOPTERS INC.
Aircraft Owner Street Address 111 KOLEPBLA COURT
Aircraft Owner City YONA
Aircraft Owner State GU
Aircraft Owner Country
Aircraft Owner Zipcode 96914
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) Aerial Observation
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code
Departure City FISHING VESSEL
Departure State
Departure Country
Departure Time 845
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 Maneuvering
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:35AM
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 --