Aircraft Accident/Incident Report

Burlington, Washington 98233
Sunday, September 24, 2000 12:45 PDT

NTSB Narrative Summary Released at Completion of Accident

The pilot aborted his landing in the Hughes 269B helicopter after encountering dust and reduced visibility at the landing site. During the climbout, and at 50-60 mph and approximately 140 feet above ground, the engine rapidly lost power. The pilot executed an autorotation landing from an airspeed/altitude condition slightly outside the limitations of the height-velocity diagram and landed hard. Post crash examination revealed that the #1 cylinder fuel injector line had separated approximately one inch outboard of the injector unit. Metallurgical examination revealed the separation as fatigue. The engine log showed this to be the second #1 cylinder fuel injector line separation in recent history. Further examination revealed that 3 of the hold down bolts for the #3 cylinder had separated and metallurgical examination revealed the separations as fatigue. The flange for the #3 cylinder was observed to be painted with primer paint measuring from about 0.0014 inch to 0.0028 inch in thickness. Both cylinder hold down plates were examined and showed fretting and rubbing damage. According to Textron Lycoming Service Bulletin 271A, the primer paint thickness on the flange should not exceed 0.0005 inch. According to the engine log the engine underwent a major overhaul on July 8, 1994, during which the '...engine was painted assembled and delivered to Cascade Airframe Repair....' The #3 cylinder was subsequently removed and honed on an unspecified date. The date when the #3 cylinder flange was painted was not determined.

NTSB Probable Cause Narrative

Mintenance personnel not following the mandatory service bulletin procedure of not exceeding 0.0005 inch paint thickness on the cylinder flange. Factors were the fatigue separation of multiple cylinder hold down bolts resulting in looseness of the cylinder; and the subsequent vibration and fatigue separation of the fuel injector line. An additional factor was the pilot's operation of the rotorcraft outside the height/velocity parameters for a successful autorotation.

Event Information

Type of Event Accident
Event Date 9/24/2000
Event Day of the Week Sunday
Time of Event 1245
Event Time Zone Pacific Daylight Time
Event City BURLINGTON
Event State WASHINGTON
Event Country --
Zipcode of the event site 98233
Event Date Year 2000
Event Date Month 9
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 Weather Observation Facility
Time of the weather observation 1253 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 323
Weather Observation Facility ID BLI
Elevation of weather observation facility 170
Distance of event from weather observation facility (units?) 20
Time Zone of the weather observation PDT
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) 66
Dew Point at event time (in degress fahrenheit) 43
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) 30
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 3
Injury Total None --
Injury Total Serious --
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 10046
NTSB Notification Source FAA SEA ROC
NTSB Notification Date Sep 24 2000 12:00AM
NTSB Notification Time 1313
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Jul 17 2001 8:35AM
User who most recently changed record MONR
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N9355F
NTSB Number SEA00LA188
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 Hughes
Aircraft Model 269B
Aircraft Series Identifier 269B
Aircraft Serial Number 44-0073
Certified Max Gross Weight 1670
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 3
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Apr 7 2000 12:00AM
Airframe hours since last inspection 65
Airframe Hours 2302
ELT Installed Unknown
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name JOHNSON, STEPHEN & CHARLOTTE
Aircraft Owner Street Address 18669 NE 106TH STREET
Aircraft Owner City REDMOND
Aircraft Owner State WA
Aircraft Owner Country
Aircraft Owner Zipcode 98052
Operator is an individual? --
Operator Name KELLY, DAVID M.
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 21028 SE 82ND STREET
Operator City ISSAQUAH
Operator State WA
Operator Country
Operator Zip code 98027
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) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code AWO
Departure City ARLINGTON
Departure State WA
Departure Country
Departure Time 1200
Departure Time Zone PDT
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 Oct 31 2002 4:13PM
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 --