Grand Canyon West Airport
Aircraft Accident/Incident Report

Peach Springs, Arizona 86434
Wednesday, September 11, 2002 17:00 MST

NTSB Narrative Summary Released at Completion of Accident

The helicopter landed hard following a loss of directional control during a precautionary landing after a hydraulic system failure, with the main rotor blades cutting off the tail boom. This was a tour flight that was en route back to the departure airport when a complete hydraulic system failure occurred and the pilot decided to make a precautionary landing at a nearby airport. He had planned on conducting a run-on landing; however, during the approach the airspeed dropped to 30 knots. The helicopter's nose dropped and it started to spin to the left. The pilot pulled back on the cyclic enough to get the nose up; however, forward airspeed continued to decay and the rotation rate increased. The pilot said that the flight controls were not responding, and he believed the only way to stop or slow the rotation was to shutdown the engine. The helicopter completed two revolutions before it impacted the ground in a nose level attitude, 180 degrees from its original direction of travel. A witness to the accident reported the altitude of the helicopter as it began to spin was about 30-50 feet above the ground and he saw the main rotor blades cone upward as it fell to the ground. For a hydraulics failure, Federal Aviation Administration approved flight manual required the pilot to reduce the collective pitch and adjust the airspeed between 40 to 60 knots in level flight. The pilot was then instructed to cut off the hydraulic pressure by activating the collective lever pushbutton, and to make a flat approach over a clear landing area and land with forward speed. During examination of the hydraulic pump, investigators noted that the coupling sleeve splines were worn beyond serviceable limits. They also noted the general condition as rust colored, and no lubrication was found inside the pump housing or coupling sleeve splines. A company maintenance work order contained a serviceable tag for the hydraulic pump assembly. The serviceable tag that the operator's maintenance personnel wrote said that the hydraulic pump was "inspected, cleaned filter, new O rings installed on connections, inspected coupling, new pump assembled." The maintenance records also revealed that the assembled hydraulic pump was installed 15 days prior to the accident and had been in service for 74.6 hours when it failed. A metallurgical examination of the hydraulic pump revealed that it had failed due to the wearing away of the splines on the coupling sleeves. The wear was due to insufficient lubrication and soft splines on both coupling sleeves. The failure mode was assisted by an increase in internal rotational resistance at operating temperatures. The hardness testing indicated that the case hardened layer on the splines was not deep enough and the hardness, within the layer, was slightly below the specified range. The inner surfaces of the gear bearings displayed rubbed areas, consistent with hard contact, and areas of bluing, consistent with elevated temperatures. Examination of the coupling sleeves revealed a total loss of inwardly protruding spline material and hardness below the design requirements. The manufacturer's maintenance manual requires that the pump drive shaft, coupling sleeves, and bearing be packed with "abundant" grease during assembly. The examination found only a trace amount of grease in the coupling sleeves that did not satisfy the "abundant" requirement specified in the manufacturer's maintenance manual. There was rust on the front retaining rings and bearings, which indicated that there was insufficient grease in the splines to retain it or lubricate the splines.

NTSB Probable Cause Narrative

the pilot's failure to maintain an adequate airspeed and main rotor rpm during the landing approach as prescribed in the hydraulic pump failure emergency procedures found in the rotorcraft flight manual, thus resulting in a loss of control of the aircraft and the subsequent crash. Contributing to the accident was the failure of the hydraulic pump due to excessive coupling spline wear which was caused by the application of insufficient lubrication by the operator's maintenance personnel during pump installation and the improper manufacturing of the couple sleeve.

Event Information

Type of Event Accident
Event Date 9/11/2002
Event Day of the Week Wednesday
Time of Event 1700
Event Time Zone Mountain Standard Time
Event City Peach Springs
Event State ARIZONA
Event Country --
Zipcode of the event site 86434
Event Date Year 2002
Event Date Month 9
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 355970N
Event Location Longitude 1134800W
Event Location Airport Grand Canyon West Airport
Event Location Nearest Airport ID 1G4
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation 4825
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1756 Mountain Standard Time
Direction of event from weather observation facility (degrees) 275
Weather Observation Facility ID LAS
Elevation of weather observation facility 2181
Distance of event from weather observation facility (units?) 65
Time Zone of the weather observation MST
Lighting Conditions Day
Lowest Ceiling Height 15000
Lowest Non-Ceiling Height 4000
Sky/Lowest/Cloud Conditions Few
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 7
Air Temperature at event time (in degrees celsius) 24
Dew Point at event time (in degress fahrenheit) 15
Wind Direction (degrees magnetic) 290
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 9
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.9
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Minor
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor 1
Injury Total None 6
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 20831
NTSB Notification Source FAA
NTSB Notification Date Sep 11 2002 12:00AM
NTSB Notification Time 1850
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Jan 31 2007 9:40AM
User who most recently changed record NTSB\johb
Basic weather conditions Visual Meteorological Cond
FAA District Office WP-LAS-FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N357NT
NTSB Number LAX02FA281
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 135: Air Taxi & Commuter
Type of Flight Plan filed Company VFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name Aerospatiale
Aircraft Model AS350BA
Aircraft Series Identifier --
Aircraft Serial Number 1549
Certified Max Gross Weight 4630
Aircraft Category Helicopter
Aircraft Registration Class --
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 Aug 1 2002 12:00AM
Airframe hours since last inspection 74.6
Airframe Hours 8387.7
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Heli-USA Airways, Inc.
Aircraft Owner Street Address 245 E. Tropicana Ave. Suite 120
Aircraft Owner City Las Vegas
Aircraft Owner State NV
Aircraft Owner Country USA
Aircraft Owner Zipcode 89109
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 S9HA
Owner has at least one certificate --
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 Non-scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code LAS
Departure City Las Vegas
Departure State NV
Departure Country USA
Departure Time 1700
Departure Time Zone PDT
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code LAS
Destination City Las Vegas
Destination State NV
Destination Country USA
Specific Phase of Flight Emergency landing
Report sent to ICAO? Yes
Evacuation occurred Yes
Date of most recent change to record Nov 4 2006 1:51PM
User who most recently changed record COOS
Since inspection or accident Last Inspection
Event Location Runway Number and Location 17
Runway Length 5058
Runway Width 60
Sight Seeing flight Yes
Air Medical Flight No
Medical Flight --