Individually Owned: 150,657
Corporate Owned: 137,281
Gustine Airport
Aircraft Accident/Incident Report
Gustine, California 95322
Wednesday, May 11, 2005 9:45 PDT
NTSB Narrative Summary Released at Completion of Accident
The helicopter landed hard and rolled over after the nut/bolt assembly connecting the left cyclic push-pull tube to the swashplate came loose, causing a loss of roll control during takeoff. No mechanical anomalies were noted during the preflight. The certificated flight instructor (CFI) and student departed to do training at another airport. During takeoff to return to their home base, the CFI heard a clicking noise coming from the helicopter and decided to make a precautionary landing; however, the helicopter began a roll to the right. The CFI attempted to correct the roll to the right with the application of left cyclic, but there was no corresponding response. The right skid contacted the ground and the helicopter rolled over, coming to rest on its left side. Following the accident, the bolt, nut, and two spacers that connected the left cyclic push-pull tube to the swashplate were located on the runway. When the Federal Aviation Administration inspector arrived, he also walked the accident area and found the self-locking nut. A review of the aircraft logbook indicated that the left rib at the top of the mast fairing had been installed at the last 100-hour inspection, 2.5 hours before the accident. In order to remove the left rib (bulkhead), the bolt and nut assembly that attaches the left cyclic push-pull tube to the left lug of the non-rotating swashplate had to be disassembled, and then reassembled after the rib (bulkhead) replacement. According to the manufacturer's Illustrated Parts Catalog, left cyclic push-pull tube connection to the non-rotating swashplate assembly requires a bolt and self-locking nut, 3 spacers (2 of the 3 spacers were found at the accident site), a washer, and a locking palnut, were not found. A metallurgical examination of the swashplate assembly, left push-pull tube, left rib (bulkhead), nut and bolt and associated hardware was conducted. All of the fracture surfaces examined revealed no preexisting damage. The absence of the bolt between the left cyclic push-pull tube and the non-rotating swashplate after the accident and the thread imprints within the hole of the left lug of the non-rotating swashplate indicated that the bolt had been backing out of the hole over time. The bolt and nut that were recovered were in good condition, and the hole in the left lug of the non-rotating swashplate was not significantly ovalized, indicating that the bolted connection was not subjected to excessive loads of any kind. The loss of the nut (and subsequent backing out of the bolt) indicates that the connection was not properly assembled following the recent maintenance, which required the bolted connection to be disassembled.
NTSB Probable Cause Narrative
the improper installation of the nut/bolt assembly connecting the left cyclic push-pull tube to the non-rotating swashplate by maintenance personnel, which led to a loss of roll control during takeoff.
Event Information
| Type of Event | Accident |
| Event Date | 5/11/2005 |
| Event Day of the Week | Wednesday |
| Time of Event | 945 |
| Event Time Zone | Pacific Daylight Time |
| Event City | Gustine |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 95322 |
| Event Date Year | 2005 |
| Event Date Month | 5 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 371545N |
| Event Location Longitude | 1205747W |
| Event Location Airport | GUSTINE |
| Event Location Nearest Airport ID | 3O1 |
| 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 | 75 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 953 Pacific Daylight Time |
| Direction of event from weather observation facility (degrees) | 265 |
| Weather Observation Facility ID | MCE |
| Elevation of weather observation facility | 156 |
| Distance of event from weather observation facility (units?) | 22 |
| Time Zone of the weather observation | PDT |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | Clear |
| 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) | 18 |
| Dew Point at event time (in degress fahrenheit) | 8 |
| Wind Direction (degrees magnetic) | 330 |
| 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) | 30.03 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | None |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 2 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 20177 |
| NTSB Notification Source | FAA |
| NTSB Notification Date | May 11 2005 12:00AM |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | Aug 29 2006 3:49PM |
| User who most recently changed record | NTSB\JOHB |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | WP-FAT-FSDO |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N144SM |
| NTSB Number | LAX05LA164 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | No |
| Damage | Substantial |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Robinson |
| Aircraft Model | R44 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 1098 |
| Certified Max Gross Weight | 2400 |
| 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 | 4 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | 100 Hour |
| Date of Last Inspection | May 1 2005 12:00AM |
| Airframe hours since last inspection | 2.5 |
| Airframe Hours | 1601.8 |
| ELT Installed | Yes |
| ELT Activated | Yes |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | Helimark LLC |
| Aircraft Owner Street Address | 1002 Airport Rd., Suite B |
| Aircraft Owner City | Los Banos |
| Aircraft Owner State | CA |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 93635 |
| 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) | Instructional |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | LSN |
| Departure City | Los Banos |
| Departure State | CA |
| Departure Country | USA |
| Departure Time | 930 |
| Departure Time Zone | PDT |
| Destination Same as Local Flt | dest & departure same, accident can occur anywhere |
| Destination Airport Code | LSN |
| Destination City | -- |
| Destination State | -- |
| Destination Country | -- |
| Specific Phase of Flight | Takeoff - roll/run |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jun 12 2006 6:36PM |
| User who most recently changed record | COOS |
| Since inspection or accident | Last Inspection |
| Event Location Runway Number and Location | 36 |
| Runway Length | 3200 |
| Runway Width | 60 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |