Pilot Debrief

MCDONNELL DOUGLAS 369E near Hilo, HI — 2008-02-08

Final reportSEA08FA071
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Date
2008-02-08
Location
Hilo, HI, USA
Airport
PHTO
Aircraft
MCDONNELL DOUGLAS 369E
Registration
N698DM
Category
Helicopter
Highest injury
Minor
Fatalities
0

Probable cause

A leak in the fuel filter pressure differential switch that resulted in a loss of engine power. Contributing to the accident was uneven terrain that hindered a successful emergency landing.

NTSB narrative

The flight was approximately five miles from the departure airport when the pilot turned back due to a fuel bypass caution light. The pilot heard 2-3 abnormal engine sounds, with simultaneous yawing, during the turn and entered an autorotation. During the final stages of the autorotation, the engine flamed out. The helicopter touched down on uneven terrain and rolled over resulting in substantial damage. Post accident examination of the engine assembly revealed a fuel leak from the fuel filter pressure differential switch. The differential switch was in place and the associated fuel lines, bushing and adapter fitting were not damaged. Examination of the system revealed that one of the three fuel filter pressure differential switch set screws, and associated safety wire segment, was missing. The two remaining screws were in place. One of the screws was fixed, the other finger tight. The corresponding safety wire was attached to the remaining set screws. The distal end of the safety wire leading to the missing set screw was severed. A post accident evaluation of the engine in a production test cell revealed a fuel leak at the pressure differential switch when the engine was motored to 16 percent N1 (compressor speed). The original fuel filter pressure differential switch was removed and replaced with an exemplar differential switch. A second engine start was successful and the engine ran, without leaks, and attained normal operating parameters. Maintenance records indicated that the helicopter's fuel system components were inspected during the 100-hour inspection completed 66 flight hours before the accident. The maintenance "check sheet" indicated that the engine's fuel system components, to include fuel lines and connections, were inspected for leaks or damage, and no anomalies were noted. No record was found in the maintenance records of any work done to the fuel filter pressure differential switch subsequent to the 100-hour inspection. It could not be determined when, or how, the fuel filter pressure differential switch set screws, and associated safety wire came loose. The approved maintenance manual for the helicopter contains multiple warnings indicating that air in the closed fuel system will cause a power reduction or flame out.

NTSB coding

View NTSB final report

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