Accident Details
Probable Cause and Findings
the decision of the pilot to fly at low altitude and low airspeed within a hazardous performance area published in the pilot operating handbook. Factors in the accident were tailwinds, lack of operator preventative maintenance impairing engine power, airworthiness of the restraint systems, and the pilot's use of prescription drugs that can impair human performance.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On April 23, 1996, at 1600 hours Pacific daylight time, a Hughes 269C, N9579F, collided with a fence between two residences in San Diego, California, after an in-flight loss of control while orbiting out of ground effect. The helicopter was destroyed. The certificated commercial pilot was fatally injured and one passenger was seriously injured. The helicopter was rented from Civic Helicopters, Carlsbad, California, by the pilot for a personal flight. The flight originated from Montgomery Field in San Diego at 1540, and was destined for Carlsbad after completing an aerial video shoot at a local hospital. Visual meteorological conditions prevailed at the time.
The pilot departed Carlsbad about 1000. Review of data downloaded from the pilot's global positioning system (GPS) receiver revealed the pilot had flown north from Carlsbad along the Pacific coast to Los Angeles. The GPS data indicated the pilot landed at the Fullerton Municipal Airport and then headed south along the coast to San Diego. The data revealed the helicopter made eight clockwise orbits around the Kaiser Permanente Hospital located across the street from the accident site. The accident occurred in the beginning of the ninth orbit as the helicopter was traveling east over Zion Avenue.
A videotape was recovered from the helicopter. The tape illustrated portions of the helicopter's flight, but did not record the helicopter's descent before impact. The tape did show that the helicopter was orbiting the hospital at a low altitude. The altitude was constant in relation to the elevation of the hospital roof. The terrain in the area around the hospital was sloping and the helicopter's elevation above the ground varied. At one point in the orbit, the helicopter's shadow was cast on Zion Avenue. The length of the shadow was about the same as the length of parked cars.
According to ground witnesses, the helicopter was orbiting the local hospital at a low altitude and at a slow airspeed. The helicopter yawed left followed by a uncontrolled descent while spinning to the right. Several witnesses reported the engine sputtered before the loss of control.
The surviving passenger told inspectors from the Federal Aviation Administration that the pilot indicated it was time to leave moments before the loss of control. The surviving passenger did not indicate that there was a loss of engine power.
OTHER DAMAGE
The helicopter struck a boundary wall between two residential homes damaging the wall, both homes, two wooden fences, and two campers parked at the residences.
PERSONNEL INFORMATION
The pilot held a commercial pilot certificate for single and multi-engine airplane and rotorcraft/helicopter. The certificate was issued on December 16, 1994, as the result of the pilot completing the commercial helicopter pilot practical exam. Prior to the most recent issue, the pilot held private pilot privileges for helicopters.
The most recent second-class medical certificate was issued to the pilot on May 19, 1995, and contained the limitation that correcting lenses be worn while exercising the privileges of his airman certificate. The pilot indicated on his application for medical certificate that there were no changes in his health since his last physical on May 2, 1994. He also indicated he was not taking medications at the time of his physical and had not visited a health professional in the past 3 years.
The pilot's total aeronautical experience consists of about 693 hours, of which 42 hours were accrued in the Hughes model 269 helicopter. In the preceding 90 days before the accident, the pilot's logbook listed a total of 16 hours flown in the Hughes 269C.
AIRCRAFT INFORMATION
The helicopter, a Hughes 269C, was manufactured on July 29, 1974, and had accumulated a total time of 6,000.9 hours. Examination of the maintenance records revealed that the most recent annual inspection was accomplished on November 11, 1995, 132.1 flight hours before the accident. In addition, a 100-hour inspection was completed on February 29, 1996, and a 50-hour inspection was completed on April 22, 1996, 6.7 flight hours before the accident.
A Lycoming HIO-360-D1A engine, serial number L14249-51A, was installed in the airframe on November 23, 1994, after a factory overhaul. The engine accrued a total time in service of 1,403 hours since new. The maintenance records note that a major overhaul was accomplished on May 27, 1994, about 428 operational hours before the accident. Annual and other hourly inspections were accomplished on the dates specified above for the airframe.
Fueling records at Aviation Facilities, Inc. Fullerton, California, established that the helicopter was last fueled on the day of the accident with the addition of 27.6 gallons of 100LL octane aviation fuel.
METEOROLOGICAL INFORMATION
The closest official weather observation station is at Montgomery Field which is located about 3 nautical miles from the accident site. The elevation of the weather observation station is 423 feet msl. At 1549, a record surface observation was reporting in part: sky condition clear; visibility 30 statute miles; temperature 81 degrees Fahrenheit; dew point 36 degrees Fahrenheit; winds 300 degrees at 9 knots; altimeter 30.02 inHg.
Review of the videotape recovered from the helicopter revealed an American Flag at the corner of Mission Gorge Road and Zion Avenue was being blown by a wind from the west at 8 to 12 miles per hour.
WRECKAGE AND IMPACT INFORMATION
The helicopter came to rest across the end of a block wall in the residential area. The block wall was found collapsed in the area under the helicopter's engine. The left side of the landing gear system was destroyed from contact with the wall. The right side of the landing gear system extended beyond the end of the wall and did not exhibit any damage from collision with the wall.
The cockpit came to rest in a nose down attitude. The area beneath the right and left seat structures was found displaced in a downward moment about 1.5 inches. The helicopter's windshield was shattered. The windshield and door jamb structure was broken. The left door was found open and was attached to the windshield frame at the hinges. The door frame was found broken along a vertical axis and was resting on the tongue of a trailer parked on the west side of the block wall.
The tail boom was displaced to the left of the helicopter's longitudinal axis. The tail boom struck a wooden fence that was perpendicular to the block wall. There was a black paint transfer that was found on the left side of tail boom at the vertical stabilizer. The color of the paint matched the color of the main rotor blades. The 90-degree gearbox remained attached to the tail boom. One of the tail rotor blades was broken off. The separated piece was found about 15 feet south of the gearbox under another trailer parked in a side yard. A small hole with a red paint transfer was found in the sheet metal siding of the trailer above the location of the separated piece. The color of the paint transfer and the shape of the hole conformed to a portion of the separated tail rotor blade.
Drive train continuity was traced from the engine to the transmission and to the tail rotor. The tail rotor drive shaft was found fractured at the forward end. The fracture area was near the bend in the tail boom which displaced it to the left. The fracture surfaces did not exhibit any rotational smearing. The forward end separated and was found about 5 feet south of the wreckage adjacent to the fuselage station where it is installed. All eight drive belts were found intact with no unusual wear patterns noted. There was no evidence of mechanical failure or malfunction found with the drive system that could have been attributed during the operation of the helicopter before impact with the ground.
Flight control system continuity was traced from the cockpit to the corresponding control surfaces on the rotor systems. A single cyclic and collective were installed on the left side of the helicopter. There was no evidence of mechanical failure or malfunction found with the helicopter's flight controls.
MEDICAL AND PATHOLOGICAL INFORMATION
A post mortem examination was conducted by San Diego County Medical Examiner's Office with specimens retained for toxicological examination. The specimens were sent to the Federal Aviation Administration Civil Aeromedical Institute for analysis. The results of the toxicological analysis revealed Desalkylflurazepam, Hydroxyethylflurazepam, Pseudoephedrine, Phenylpropanolamine, Ephedrine, and Salicylate were detected in the specimen samples.
According to the FAA, the Desalkylflurazepam, and Hydroxyethylflurazepam are metabolites of prescription medication used to induce sleep. The "Physicians' Desk Reference" states patients using such medications should be cautioned about engaging in hazardous occupations requiring complete medical alertness after ingesting the drug because of potential impairment of performance of such activities.
Also according to the FAA, Pseudoephedrine, Phenylpropanolamine, and Ephedrine are compounds commonly used in oral preparations for the relief of nasal and sinus congestion.
TESTS AND RESEARCH
Restraint Systems
The helicopter's occupant restraint system was examined on July 31, 1996, at Pacific Scientific facilities in Yorba Linda, California. There were three lap belts and two shoulder harnesses installed in the helicopter. The cloth data tags on the shoulder harnesses were missing. The origin or installation date of the shoulder harness was not determined. According to the FAA, the shoulder harness along with the seat belts are type certificated components and are required by federal regulations to be permanently and legibly marked (14 CFR Part 21.607(d).
The pilot's shoulder harness was found broken at a faded area in the webbing corresponding to a ...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# LAX96FA177