Individually Owned: 150,657
Corporate Owned: 137,281
Naples Municipal Airport
Aircraft Accident/Incident Report
Naples, Florida 34104
Thursday, June 18, 2009 10:30 EDT
NTSB Narrative Summary Released at Completion of Accident
The 19-hour helicopter student pilot departed on a cross county flight and shortly after takeoff the helicopter experienced a loss of engine power. While attempting to return, the pilot allowed the main rotor rpm to decay and while descending, the helicopter contacted a building, trellis, and then the ground. Inspection of the helicopter revealed no evidence of preimpact failure or malfunction of the flight controls, main rotor or tail rotor drive systems. The engine was removed from the helicopter and test run after proper timing of the right magneto; no discrepancies were noted. The engine had been overhauled approximately 124 hours earlier; overhauled magnetos were installed at that time. The engine had been inspected three times since the overhauled engine was installed; the last 100-Hour inspection was approximately 29 hours earlier. The mechanic who performed the last 100-Hour inspection reported using the engine manufacturer's inspection guide and 14 CFR Part 43 Appendix D as references. He did not check the magneto breaker points for pitting and minimum gap as specified in the engine manufacturer's 100-Hour inspection guide. Appendix D specified that the engine accessories are to be checked for apparent defects in security of mounting. There was no record that the magnetos had been removed since the overhauled engine was installed. The cause of the loss of engine power was determined to be caused by rotation (advance) of the right magneto which was due to an incorrect gasket and also by undetected fracture of the clamping flange. While there was no discrepancy with the left magneto, it also had an incorrect gasket installed.
NTSB Probable Cause Narrative
A loss of engine power due to the improper installation of the right magneto by maintenance personnel resulting in subsequent loss of engine power. Contributing to the accident was the inadequate 100-Hour inspection by the mechanic when he failed to note that improper hardware were installed at both magnetos, and his failure to detect fracture of the clamping flange of the right magneto.
Event Information
| Type of Event | Accident |
| Event Date | 6/18/2009 |
| Event Day of the Week | Thursday |
| Time of Event | 1030 |
| Event Time Zone | Eastern Daylight Time |
| Event City | Naples |
| Event State | FLORIDA |
| Event Country | -- |
| Zipcode of the event site | 34104 |
| Event Date Year | 2009 |
| Event Date Month | 6 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 260846N |
| Event Location Longitude | 0814553W |
| Event Location Airport | Naples Municipal Airport |
| Event Location Nearest Airport ID | APF |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | 1 |
| Degrees magnetic from airport | -- |
| Airport Elevation | 8 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1053 Eastern Daylight Time |
| Direction of event from weather observation facility (degrees) | 301 |
| Weather Observation Facility ID | APF |
| Elevation of weather observation facility | 8 |
| Distance of event from weather observation facility (units?) | -- |
| Time Zone of the weather observation | EDT |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | 4000 |
| Sky/Lowest/Cloud Conditions | Few |
| 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) | 33 |
| Dew Point at event time (in degress fahrenheit) | 22 |
| Wind Direction (degrees magnetic) | -- |
| Variable Wind Indicator | Variable |
| Wind Speed (knots) | 4 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 29.98 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | Serious |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | 1 |
| Injury Total All | 1 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 27254 |
| NTSB Notification Source | Naples Municipal Airport Opera |
| NTSB Notification Date | -- |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | -- |
| Date of most recent change to record | Sep 14 2010 12:22PM |
| User who most recently changed record | johb |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N9421K |
| NTSB Number | ERA09FA355 |
| 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 | SCHWEIZER |
| Aircraft Model | 269C-1 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 0153 |
| Certified Max Gross Weight | 1750 |
| 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 | 3 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | 100 Hour |
| Date of Last Inspection | Jun 2 2009 12:00AM |
| Airframe hours since last inspection | 29 |
| Airframe Hours | 2296 |
| ELT Installed | No |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | No |
| ELT Type | Unknown |
| Aircraft Owner Name | NORTH BAY ENTERPRISES INC |
| Aircraft Owner Street Address | 5400 OCCIDENTAL RD |
| Aircraft Owner City | SANTA ROSA |
| Aircraft Owner State | CA |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 95401-5530 |
| Operator is an individual? | No |
| Operator Name | Ocean Helicopters, Inc. |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | 11550 Aviation Blvd., Suite 1 |
| Operator City | West Palm Beach |
| Operator State | FL |
| Operator Country | USA |
| Operator Zip code | 33412 |
| Operator Code | -- |
| Owner has at least one certificate | None |
| 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 | -- |
| Indicates Domestic or International Flight | -- |
| Operator carrying Pax/Cargo/Mail | -- |
| Type of Flying (Per_Bus / Primary) | Instructional |
| Second Pilot on Board | No |
| Departure Point Same as Event | Yes |
| Departure Airport Code | APF |
| Departure City | Naples |
| Departure State | FL |
| Departure Country | USA |
| Departure Time | 1029 |
| Departure Time Zone | EDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | IMM |
| Destination City | Immokalee |
| Destination State | FL |
| Destination Country | USA |
| Specific Phase of Flight | -- |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jul 30 2010 2:51PM |
| User who most recently changed record | kenj |
| Since inspection or accident | Last Inspection |
| Event Location Runway Number and Location | N/A |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |