N4493M

HISTORY OF FLIGHT

On June 15, 2003, at 0935 Hawaiian standard time, a McDonnell Douglas Helicopter, Inc., (MDHI) 369D, N4493M, impacted a lava field on the Pulama Pali in the Volcanoes National Park, Volcano, Hawaii. K & S Helicopters, d.b.a. Tropical Tour Helicopters, operated the helicopter under the provisions of 14 CFR Part 135. A post impact fire destroyed the helicopter. The commercial rotorcraft-helicopter certified pilot and three passengers were fatally injured. The local area flight to the volcanoes departed the Hilo International Airport (ITO), Hilo, Hawaii, at 0915. Day visual meteorological conditions prevailed, and a company visual flight rules (VFR) flight plan had been filed.

The tour was scheduled as a 45-minute flight that would have entailed flying over the Pu'u O'o Vents, down towards the shoreline to see molten lava flowing into the ocean, and then back to ITO. For this tour, the helicopter was configured for the pilot side door to be removed, and with the passenger side door to remain in place.

In an interview with the National Transportation Safety Board investigator-in-charge (IIC), the helicopter loader and manager for Tropical Tour Helicopters stated that on the morning of the accident he had conducted a visual inspection of the helicopter before the pilot arrived. Part of the inspection was to wash the belly of the helicopter off; the manager noted a normal condition with no stains or leaks. The pilot showed up at 0800, in good spirits. He saw the pilot conduct a preflight inspection of the helicopter before repositioning it to the ramp where the passengers were to be loaded. The manager reported that the women were loaded into the backseat first, and were assisted with their seatbelts and headsets. He then went to the front of the helicopter, opened up the pilot's side door, and handed him the flight manifest. The manager then loaded the male into the front seat of the helicopter and secured his seatbelt and the pilot assisted the passenger with the headset. The Tropical Tour Helicopters' manager stated that the flight departed at 0915.

A company pilot departed at the same time as the accident pilot. She noted a scattered to broken cloud layer about 4,000 feet and light winds. Upon reaching Pahoa NDB (non-directional beacon), she turned toward the shoreline and noted that the accident pilot headed towards Pu'u O'o Vent. She recalled hearing occasional calls from the accident pilot reporting his location. As her tour continued, she turned uphill and heard a pilot flying for the Volcanoes National Park asking if anyone had heard a 'mayday' call, and that he thought he had heard a "500's audio warning in the background." She had not heard anything, and attempted to contact the accident pilot via radio. She received no reply.

A pilot from Windward Aviation, and a crew of National Park Service (NPS) rangers, were searching for a lost hiker when they heard a mayday call over the common area traffic frequency. The pilot and flight crew stated that they heard the accident pilot call "Mayday, Mayday, Mayday," and could hear the "engine out" audio tone in the background. No further transmissions were made. At that point, the crew broke off the search for the hiker, and flew around the lava field until they found the accident site.

The pilot and NPS rangers stated that the helicopter was fully engulfed in flames. The NPS rangers dropped 12 buckets of water on the accident site to put out the fire.

PERSONNEL INFORMATION

A review of Federal Aviation Administration (FAA) airman records revealed the pilot held a commercial certificate with a rotorcraft-helicopter rating, issued on June 7, 1997. The pilot also held a mechanic certificate with a rating for airframe.

The pilot held a second-class medical certificate that was issued on April 16, 2002, and had no limitations or waivers. At that time the pilot reported a total pilot time of 3,000 hours, with 150 hours in the past 6 months.

The pilot's most recent Part 135 Airman Competency/Proficiency Check was successfully completed on May 30, 2003, and was administered by an FAA inspector from the Honolulu, Hawaii, Flight Standards District Office (FSDO).

According to the operator's new hire information, the pilot completed his indoctrination training on May 30, 2003. His official hire date at the company was May 21, 2003. Prior to the pilot's Part 135 check ride, the director of operations (DO) for the company conducted the SFAR 71 flight check. The DO reported no problems with the flight check. At that time the pilot reported 3,300 hours of total flight time, with 2,800 hours in the accident make and model, 500 hours in the last 12 months, and 30 hours in the last 30 days.

AIRCRAFT INFORMATION

The helicopter was a McDonnell Douglas (Hughes) 369D, serial number 570137D. A review of the airplane's logbooks revealed a total airframe time of 7,859.3 hours. The last annual was completed on July 10, 2002; total time recorded at the last 300-hour inspection was 7,780.0 hours; and a total time recorded at the last 100-hour inspection was 7.856.5 hours.

The helicopter was equipped with an Allison 250-C20B engine, serial number CAE 835428. A review of the maintenance records revealed that the compressor section was changed out on the following dates: December 20, 2000 (CAC80158); February 26, 2001 (CAC 33946); September 07, 2002 (CAC33946). At the time of installation in September 2002, the total time since new was reported as 2,343.7 hours at an airframe total time of 6,812.0 hours. The last logged entry in the rotorcraft log was at a total time of 7,850.8 hours. A Safety Board IIC estimated that the compressor section CAC33946 had at least 3,377.9 hours as of June 6, 2003.

Fueling records from Air Service Hawaii - Hilo Station, Hilo, established that the helicopter had last fueled on June 14, 2003, with the addition of 42.2 gallons of Jet A fuel at 0930, and again at 1700, with the addition of 10.6 gallons. There was no fuel service provided to the accident helicopter on the morning of the accident. According to the weight and balance sheet, the flight would have departed with 219 pounds of fuel (50.8 percent).

The Safety Board IIC reviewed the Daily Aircraft Flight Logs from May 1, 2004, to June 6, 2003. There were no unresolved maintenance discrepancies for the helicopter prior to departure on the accident flight. A 25-hour inspection was completed on June 3, 2003, at an aircraft total time of 7,836.1 hours, and 7,926.9 hours total engine time.

During the 100-hour inspection conducted on May 13, 2003, at an aircraft total time of 7,781.3 hours, and engine total time of 7,870.6 hours, maintenance personnel noted in the DISCREPANCIES/MALFUNCTIONS section "loose stud on engine gearbox turbine attach." The CORRECTIVE ACTION was to remove the engine gearbox part number 6894171, serial number CAG 33861, time since new (TSN) 10,895.3 hours, time since overhaul (TSO) 5,791.2 hours. Gearbox serial number CAG 33731, TSN 7,902.1 hours, "TSO is TSN. Loaner ground run aircraft 30 minutes removed [and] cleaned chip plugs no chips."

The operator reported that the Daily Aircraft Flight Logs were kept in the helicopter until the next inspection, or discrepancy was encountered. The logs from June 7 to the date of the accident were destroyed in the post-impact fire.

A Safety Board investigator, along with FAA inspectors, interviewed a mechanic from K & S Helicopters. He reported that his job was to perform the 25- and 100-hour inspections every Tuesday, Thursday, and Saturday. He was also to work on any maintenance discrepancies reported by the pilots. The mechanic did not perform an aircraft inspection on Saturday June 14th or the day of the accident. He further indicated that on the 14th, the helicopter had been used for firefighting.

The mechanic stated that he performed a 100-hour inspection on June 13, 2003, and noted no discrepancies. This mechanic indicated that he normally did not perform engine maintenance for the company, but would routinely assist when requested for on the job training. He reported having replaced engine components on company aircraft. The mechanic could not recall what components had been overhauled recently, but remembered replacing a gearbox for loose studs about 4 to 6 weeks prior to the accident, and the starter generator had been replaced for overhaul purposes.

The mechanic reported that while he was never provided with a training manual, he and other mechanics were not left alone while working on helicopter without first being trained for that particular job. He also reported that at all times the manufacturer's maintenance manuals were always available and used while working on the helicopters. He noted that the director of maintenance was responsible for updating the revisions to the manuals.

WRECKAGE AND IMPACT INFORMATION

The Safety Board IIC, and inspectors from the FAA Honolulu FSDO examined the wreckage at the accident scene on June 16, 2003.

The accident site was located on the Pulama Pali at an active lava flow, approximately 2 miles north of the Chain of Craters road, and about 5 miles south of the Pu'u O'o Vents. The elevation at the accident site was 620 feet mean sea level (msl), with upsloping terrain; about 10 degrees. The primary wreckage was at 19 degrees 19.80 minutes north latitude and 155 degrees 04.97 minutes west longitude.

The helicopter came to rest on a 270-degree magnetic heading, and a 320-degree magnetic bearing to ITO. The fuselage of the helicopter, the main wreckage, was in a small hole (made by the lava). The majority of the helicopter was in a 10-foot radius of the main wreckage. Portions of the landing gear skids and cross tubes were located northeast and upslope of the main wreckage, about 5 feet away. Pieces of Plexiglass windshield, and the passenger side door, were also found upslope of the main wreckage...