Aircraft Accident/Incident Report

Mancos, Colorado 81328
Thursday, June 30, 2005 13:57 MDT

NTSB Narrative Summary Released at Completion of Accident

The EMS helicopter had been dispatched to medivac a logger who had been injured in a trucking accident. The pilot made a low pass, then circled around to make his landing approach. A volunteer fireman, who was standing at the landing zone (LZ) and directing the helicopter, said the temperature was "about 80 degrees [F.]," and he advised the pilot that the winds were calm. The fireman said the helicopter was about 220 feet above tree level when "it dropped straight down." He heard no unusual engine sounds and did not see the impact. The on-scene examination revealed all four main rotor blades remained attached to the rotor hub and were drooped over the wreckage. Examination of the fuel control unit (FCU) revealed a 1/16-inch gap at the mating flange between the flow (fuel bypass passage, Po) and drive (air pressure passages, Px & Py) bodies. One of four retention-bolts was backed out and the packing was partially extruded. The bolt was too short, another bolt was too long, and the other two bolts were insufficiently torqued. Additionally, the flow and drive bodies were not perfectly flat. Further examination of the FCU revealed no functional anomalies.

NTSB Probable Cause Narrative

a loss of engine power for undetermined reasons and the pilot's inability to get into autorotation prior to impacting the ground. A factor contributing to the accident was the helicopter's low altitude when power was lost.

Event Information

Type of Event Accident
Event Date 6/30/2005
Event Day of the Week Thursday
Time of Event 1357
Event Time Zone Mountain Daylight Time
Event City Mancos
Event State COLORADO
Event Country --
Zipcode of the event site 81328
Event Date Year 2005
Event Date Month 6
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 372362N
Event Location Longitude 1080832W
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 1353 Mountain Daylight Time
Direction of event from weather observation facility (degrees) 240
Weather Observation Facility ID CEZ
Elevation of weather observation facility 5914
Distance of event from weather observation facility (units?) 30
Time Zone of the weather observation MDT
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) 30
Dew Point at event time (in degress fahrenheit) -4
Wind Direction (degrees magnetic) --
Variable Wind Indicator Variable
Wind Speed (knots) --
Wind Velocity Indicator Light and Variable
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.16
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 3
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 21070
NTSB Notification Source FAA Comm Ctr
NTSB Notification Date Jun 30 2005 12:00AM
NTSB Notification Time --
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 Salt Lake City, Utah

Aircraft Involved

Aircraft #1

Aircraft Registration Number N403CF
NTSB Number DEN05FA103
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed Company VFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Agusta
Aircraft Model A119
Aircraft Series Identifier --
Aircraft Serial Number 14009
Certified Max Gross Weight 5997
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 Annual
Date of Last Inspection May 1 2005 12:00AM
Airframe hours since last inspection 422
Airframe Hours 753
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Tri-State Care Flight LLC
Aircraft Owner Street Address 2755 Silver Creek Rd., Ste. 107
Aircraft Owner City Bullhead City
Aircraft Owner State AZ
Aircraft Owner Country USA
Aircraft Owner Zipcode 864428343
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 --
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) Positioning
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code 5CO0
Departure City Durango
Departure State CO
Departure Country USA
Departure Time 1242
Departure Time Zone MDT
Destination Same as Local Flt crash at destination city
Destination Airport Code --
Destination City Mancos
Destination State CO
Destination Country USA
Specific Phase of Flight Approach
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Dec 12 2006 3:22PM
User who most recently changed record BOWL
Since inspection or accident Last Inspection
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight Yes
Medical Flight --