Aircraft Accident/Incident Report

Volcano, Hawaii 96785
Sunday, June 15, 2003 9:35 HST

NTSB Narrative Summary Released at Completion of Accident

The helicopter crashed onto a rugged hardened lava flow following a loss of engine power during cruise. The pilots of other helicopters heard the pilot make a mayday call with the clear "engine out" audio warning in the background. A post crash fire consumed the majority of the wreckage. An airframe examination revealed no evidence of a preimpact malfunction in what remained of the airframe. An engine inspection and a metallurgical examination revealed that the compressor-coupling adapter, a Parts Manufacturer Approval (PMA) part made by a company other than Rolls-Royce, had failed above the shear point due to fatigue cracking initiated by fretting on the pilot diameter, which had disconnected the compressor from the turbine section. The metallurgist noted that the damage was consistent with the rotation of the aft piece of the fractured compressor-coupling adapter within the stub shaft after it had separated. Fretting damage to the impeller corresponded to the fretting damage on the compressor-coupling adapter, and indicated relative movement between the parts. Rolls-Royce had records of 12 other compressor-coupling adapters that had fractured and failed, with all instances of the failure/fracture occurring in this specific new coupling design, which was significantly different than the previous design. The nature of the fretting and fractures indicated that the newly designed couplings have a small amount of longitudinal movement that is occurring between the outer diameter of the compressor-coupling adapter and the inner diameter of the impeller, which was not a factor in the previous design. If the spur adapter gear, compressor-coupling adapter, and compressor impeller (all coaxial spline joints) were in alignment, there would be no significant longitudinal movement of the pilot diameter. However, any axial misalignment of these components during engine buildup, for example, could induce a misalignment that would result in relative motion between the components with each engine rotation. The misalignment would also induce bending stresses into the compressor-coupling adapter in addition to torsion stresses that could result in fatigue. The combination of fretting damage and cyclic bending stresses are most likely the main factor in the failures of these couplings. One month prior to the accident, company maintenance personnel had changed out the engine gearbox due to finding a loose stud on the gearbox to turbine section mounting. Changing the gearbox would involve disturbing the coaxial spline joints between the spur adapter gear, compressor-coupling adapter, and compressor impeller.

NTSB Probable Cause Narrative

a loss of engine power due to the fatigue fracture and separation of the compressor coupling adapter. The fatigue fracture was initiated by fretting on the pilot diameter due to both the inadequate design of the coupling and the coaxial misalignment of the spur adapter gear, compressor-coupling adapter, and compressor impeller during recent engine maintenance where the gearbox was removed and replaced. A factor in the accident was the unsuitable nature of the terrain to make an emergency landing.

Event Information

Type of Event Accident
Event Date 6/15/2003
Event Day of the Week Sunday
Time of Event 935
Event Time Zone Hawaii Standard Time
Event City Volcano
Event State HAWAII
Event Country --
Zipcode of the event site 96785
Event Date Year 2003
Event Date Month 6
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 191900N
Event Location Longitude 1550400W
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 --
Investigator's weather source Weather Observation Facility
Time of the weather observation 953 Hawaii Standard Time
Direction of event from weather observation facility (degrees) 320
Weather Observation Facility ID ITO
Elevation of weather observation facility 38
Distance of event from weather observation facility (units?) 10
Time Zone of the weather observation HST
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height 8500
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) 27
Dew Point at event time (in degress fahrenheit) 20
Wind Direction (degrees magnetic) 20
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 8
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.06
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 4
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 4
Investigating Agency NTSB
NTSB Docket Number (internal use) 21535
NTSB Notification Source FAA
NTSB Notification Date Jun 15 2003 12:00AM
NTSB Notification Time 1316
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Jan 12 2009 12:38PM
User who most recently changed record broda
Basic weather conditions Visual Meteorological Cond
FAA District Office WP-HNL-FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N4493M
NTSB Number LAX03FA200
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 135: Air Taxi & Commuter
Type of Flight Plan filed Company VFR
Flight plan Was Activated? No
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name McDonnell Douglas
Aircraft Model 369D
Aircraft Series Identifier --
Aircraft Serial Number 570137D
Certified Max Gross Weight 3000
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 5
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Jun 1 2003 12:00AM
Airframe hours since last inspection 7836.1
Airframe Hours 7859.3
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name K & S Helicopters, Inc.
Aircraft Owner Street Address P.O. Box 5371
Aircraft Owner City Kailua-Kona
Aircraft Owner State HI
Aircraft Owner Country USA
Aircraft Owner Zipcode 96745
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 K2DA
Owner has at least one certificate --
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation External Load
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 ITO
Departure City Hilo
Departure State HI
Departure Country USA
Departure Time 915
Departure Time Zone HST
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code ITO
Destination City --
Destination State --
Destination Country --
Specific Phase of Flight Cruise
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record May 1 2007 1:58PM
User who most recently changed record RICJ
Since inspection or accident Last Inspection
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight Yes
Air Medical Flight No
Medical Flight --