Ontario Airport
Aircraft Accident/Incident Report

Ontario, California 91761
Tuesady, June 25, 2002 14:10 PDT

NTSB Narrative Summary Released at Completion of Accident

The helicopter landed hard during an autorotation following a catastrophic engine failure in the takeoff initial climb. The engine lost all power during the initial climb out on a test flight following the completion of a 100-hour inspection. The pilot initiated an autorotative descent. While he maneuvered to avoid automobile traffic and power lines, the main rotor rpm decayed. The helicopter touched down hard on a street and was destroyed by an intense fuel-fed ground fire. The accident occurred during the first flight following maintenance performed by the on-board passenger, a mechanic employed by the operator. The helicopter's airframe was examined and no evidence of preimpact anomalies were found. Upon splitting the engine's case halves, all of the compressor blades on stages 1 through 6 were found either damaged or missing. A piece of a wire tie wrap was noted adhering to one of the case halves in the 6th stage area. Additionally, metallic debris was found in the outer combustion case (OCC). The metallurgical examination of the OCC debris revealed it was composed of an aluminum-magnesium-silicon alloy, which was foreign to components used in the engine. Wire tie wraps, similar to the tie wrap found in the engine, were also found in the accident site debris field. Similar wire tie wraps were additionally observed in storage at the operator's maintenance facility. The air intake to the engine's compressor is enclosed in a plenum chamber on the top of the helicopter. Prior to the accident, the mechanic had been observed performing maintenance in this area.

NTSB Probable Cause Narrative

The mechanic's improper maintenance procedures (FOD prevention) during a 100-hour inspection, which resulted in foreign object damage (FOD) to the compressor section and catastrophic engine failure. Factors were the presence of vehicles and power lines partially obstructing the forced landing site that necessitated the pilot's use of rotor system energy to avoid, which resulted in a hard landing.

Event Information

Type of Event Accident
Event Date 6/25/2002
Event Day of the Week Tuesday
Time of Event 1410
Event Time Zone Pacific Daylight Time
Event City Ontario
Event State CALIFORNIA
Event Country --
Zipcode of the event site 91761
Event Date Year 2002
Event Date Month 6
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 340248N
Event Location Longitude 1173606W
Event Location Airport Ontario
Event Location Nearest Airport ID ONT
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 1
Degrees magnetic from airport 180
Airport Elevation 944
Weather Briefing Completeness Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 1409 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 180
Weather Observation Facility ID ONT
Elevation of weather observation facility 944
Distance of event from weather observation facility (units?) 1
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height 17000
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 32
Dew Point at event time (in degress fahrenheit) 15
Wind Direction (degrees magnetic) 230
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 15
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.94
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Serious
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None --
Injury Total Serious 2
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 17737
NTSB Notification Source
NTSB Notification Date Jun 25 2002 12:00AM
NTSB Notification Time 1430
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Jun 8 2005 12:51PM
User who most recently changed record NTSB\JOHB
Basic weather conditions Visual Meteorological Cond
FAA District Office WP-FSDO Riverside, CA

Aircraft Involved

Aircraft #1

Aircraft Registration Number N40NT
NTSB Number LAX02GA209
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? No
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name McDonnell Douglas
Aircraft Model 369E
Aircraft Series Identifier --
Aircraft Serial Number 0513E
Certified Max Gross Weight 3000
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 4
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Jun 25 2002 12:00AM
Airframe hours since last inspection 0
Airframe Hours 6856
ELT Installed No
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name City of Ontario Police Department
Aircraft Owner Street Address 200 N. Cherry Avenue
Aircraft Owner City Ontario
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 91764
Operator is an individual? No
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? --
Certified for Part 133 or 137 Operation --
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 ONT
Departure City Ontario
Departure State CA
Departure Country USA
Departure Time 1409
Departure Time Zone PDT
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code ONT
Destination City Ontario
Destination State CA
Destination Country USA
Specific Phase of Flight Emergency descent/landing
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Apr 7 2005 3:52PM
User who most recently changed record COOS
Since inspection or accident Time of Accident
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --