Aircraft Accident/Incident Report

Waialae Falls, Hawaii 96796
Saturday, May 20, 1989 16:00 HST

NTSB Narrative Summary Released at Completion of Accident

THE ON-DEMAND AIR TAXI HELICOPTER WAS ON A LOCAL SIGHTSEEING FLT TO WAIALAE FALLS WITH SIX PAX ABOARD. ELEVATION OF THE FALLS WAS ABOUT 3000 FT. AFTER HOVERING AT LOW ALT NEAR THE FALLS, THE PLT BEGAN A PEDAL TURN & BEGAN FORWARD MOVEMENT FOR THE INITIAL CLIMB AWAY FROM THE FALLS. THE MAIN ROTOR RPM DECAYED & THE PLT TURNED BACK TOWARD THE UPPER FALLS, WHERE HE THOUGHT HE COULD LAND. HOWEVER, THE HELICOPTER SETTLED INTO A RAVINE, IMPACTED ROCKS & CAME TO REST. AN EXAM OF THE ENG FUEL CONTROL REVEALED THE MAXIMUM STOP WAS SET AT 93% VERSUS 99% AS SPECIFIED BY THE MANUFACTURER. ALSO, THE GOVERNOR BREAK WAS SET 400 RPM EARLY, THERE WAS NO SEAL ON THE METERING VALVE SLEEVE & THE SAFETY WIRE THRU THE GOVERNOR ADJUSTMENT HAD BEEN CUT & NOT REPLACED.

NTSB Probable Cause Narrative

IMPROPER MAINTENANCE/ADJUSTMENT OF THE ENGINE FUEL CONTROL UNIT BY COMPANY MAINTENANCE PERSONNEL, WHICH RESULTED IN A SLIGHT LOSS OF ENGINE POWER, AND FAILURE OF THE PILOT TO MAINTAIN ROTOR RPM, WHILE TURNING AND TAKING OFF FROM A HOVER WITH A RELATIVELY HEAVY GROSS WEIGHT. FACTORS RELATED TO THE ACCIDENT WERE: THE HIGH DENSITY ALTITUDE AND ROUGH/UNEVEN (ROCKY) TERRAIN IN THE EMERGENCY LANDING AREA.

Event Information

Type of Event Accident
Event Date 5/20/1989
Event Day of the Week Saturday
Time of Event 1600
Event Time Zone Hawaii Standard Time
Event City WAIALAE FALLS
Event State HAWAII
Event Country --
Zipcode of the event site 96796
Event Date Year 1989
Event Date Month 5
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 0
Degrees magnetic from airport 0
Airport Elevation 0
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 1355 Hawaii Standard Time
Direction of event from weather observation facility (degrees) 280
Weather Observation Facility ID KOKE
Elevation of weather observation facility 4200
Distance of event from weather observation facility (units?) 4
Time Zone of the weather observation HST
Lighting Conditions Day
Lowest Ceiling Height 0
Lowest Non-Ceiling Height 1800
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) 15
Air Temperature at event time (in degrees celsius) 18
Dew Point at event time (in degress fahrenheit) 13
Wind Direction (degrees magnetic) 90
Variable Wind Indicator Unknown
Wind Speed (knots) 5
Wind Velocity Indicator Unknown
Wind Gust Indicator Unknown
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 30
Density Altitude (feet) 3900
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 7
Injury Total None --
Injury Total Serious --
Injury Total All 7
Investigating Agency NTSB
NTSB Docket Number (internal use) 2060
NTSB Notification Source --
NTSB Notification Date May 20 1989 12:00AM
NTSB Notification Time 1735
Fiche Number and/or location -used to find docket information 41461
Date of most recent change to record Dec 13 2000 12:41PM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N6003S
NTSB Number LAX89LA197
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 135: Air Taxi & Commuter
Type of Flight Plan filed Company VFR
Flight plan Was Activated? --
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name AEROSPATIALE
Aircraft Model AS350D
Aircraft Series Identifier AS350D
Aircraft Serial Number 1552
Certified Max Gross Weight 4300
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 7
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection May 2 1989 12:00AM
Airframe hours since last inspection 64
Airframe Hours 2203
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name N. AMERICAN HELICOPTER AIRWAYS
Aircraft Owner Street Address 10628 NE 38TH PL.
Aircraft Owner City KIRKLAND
Aircraft Owner State WA
Aircraft Owner Country
Aircraft Owner Zipcode 98033
Operator is an individual? --
Operator Name PAPILLION HELICOPTERS
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address P.O. BOX 339
Operator City HANALEI
Operator State HI
Operator Country
Operator Zip code 96714
Operator Code ILNA
Owner has at least one certificate Yes - certificate holder
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 Non-scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) Unknown
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code HPV
Departure City PRINCEVILLE
Departure State HI
Departure Country
Departure Time 1524
Departure Time Zone HST
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 Landing
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 --