Princeville Airport
Aircraft Accident/Incident Report

Princeville, Hawaii 76722
Thursday, March 8, 2007 15:02 HST

NTSB Narrative Summary Released at Completion of Accident

The helicopter was returning from a sightseeing flight when the pilot contacted the dispatcher and announced, "I'm having hydraulic problems, and I'm probably going to have to do a run-on landing." The language he used to describe his situation changed from "hydraulic problem" to "hydraulic failure" as the flight proceeded. The pilot did not immediately land at the approach end of the runway; instead, he continued to the departure end, where the passenger terminal was located. The helicopter approached the mid-point of the runway, and as it neared the surface, the dispatcher heard the pilot state, "Okay we're done." Then, the sound of the rotor changed pitch and the helicopter impacted the ground. Postaccident examination of the helicopter revealed that the left lateral flight control servo became disconnected in flight at the transmission. Further examination revealed that the lower clevis of the left lateral servo was still attached to the transmission case, but was no longer attached to the servo. The threads on the clevis, as well as the threads on the inner diameter of the servo, appeared undamaged. The jam nut, lock nut washer, and safety wire were still attached to the clevis threads and rotated freely. The lock washer was severely worn and the locking tang was missing. Metallurgical testing and torque testing of the accident servos revealed that the jam nut, washer, and piston rod were able to easily rotate off of the clevis if no torque was applied and with the locking tang missing. Under normal loads, the main hydraulic flight control servos experience slight twisting that could contribute to the servo rotating off the clevis bolt (without an intact and functioning locking washer installed). Therefore, the investigation revealed that the servo attachment nut was not torqued during maintenance about one month prior to the accident, and the lack of torque, coupled with the installation of a severely worn lock washer, allowed the servo to rotate off of the clevis during the accident flight, resulting in a complete disengagement of the servo from its mounting clevis on the transmission. Examination of the company maintenance program revealed that none of the mechanics at the helicopter's base had received factory training, and that the maintenance manuals they used were three revisions out of date. Mandatory quality control inspections of maintenance actions, as well as post-maintenance test flights prescribed in the General Operator's Manual and the manufacturer's maintenance manuals (that included the replacement of the flight control servo), were not performed. (This report was modified on June 16, 2009)

NTSB Probable Cause Narrative

The failure of maintenance personnel to properly tighten (torque) the flight control servo lower attachment clevis, and reinstall a functioning lock washer, which resulted in a flight control disconnect and a complete loss of helicopter control. Contributing to the accident was the operator's failure to ensure its maintenance program was being executed in accordance with Federal regulations.

Event Information

Type of Event Accident
Event Date 3/8/2007
Event Day of the Week Thursday
Time of Event 1502
Event Time Zone Hawaii Standard Time
Event City Princeville
Event State HAWAII
Event Country --
Zipcode of the event site 76722
Event Date Year 2007
Event Date Month 3
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 221200N
Event Location Longitude 1592600W
Event Location Airport PRINCEVILLE
Event Location Nearest Airport ID HI01
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 344
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1453 Hawaii Standard Time
Direction of event from weather observation facility (degrees) 157
Weather Observation Facility ID PHLI
Elevation of weather observation facility 153
Distance of event from weather observation facility (units?) 15
Time Zone of the weather observation HST
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height 5500
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) 23
Dew Point at event time (in degress fahrenheit) 12
Wind Direction (degrees magnetic) 50
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 13
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.91
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 3
Injury Total All 7
Investigating Agency NTSB
NTSB Docket Number (internal use) 24876
NTSB Notification Source FAA
NTSB Notification Date Mar 8 2007 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Jun 17 2009 1:51PM
User who most recently changed record guzj
Basic weather conditions Visual Meteorological Cond
FAA District Office FAA AAI-100

Aircraft Involved

Aircraft #1

Aircraft Registration Number N354NT
NTSB Number NYC07MA073
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 Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name AEROSPATIALE
Aircraft Model AS350BA
Aircraft Series Identifier --
Aircraft Serial Number 1168
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 Feb 22 2007 12:00AM
Airframe hours since last inspection 64
Airframe Hours 21706
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Jan Leasing
Aircraft Owner Street Address --
Aircraft Owner City Las Vegas
Aircraft Owner State NV
Aircraft Owner Country USA
Aircraft Owner Zipcode 76722
Operator is an individual? No
Operator Name Heli-USA Airways, Inc.
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City Princeville
Operator State HI
Operator Country USA
Operator Zip code 76722
Operator Code --
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
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 Yes
Departure Airport Code HI01
Departure City Princeville
Departure State HI
Departure Country USA
Departure Time 1415
Departure Time Zone HST
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code HI01
Destination City --
Destination State --
Destination Country USA
Specific Phase of Flight Emergency landing
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 1 2009 12:47PM
User who most recently changed record muzd
Since inspection or accident Time of Accident
Event Location Runway Number and Location 05
Runway Length 3560
Runway Width 40
Sight Seeing flight Yes
Air Medical Flight No
Medical Flight --