2 fatal · McDonnell Douglas 500N · 1999-10-25 · SAN JOSE, CA, USA
Event
NTSB number
LAX00GA025
Event ID
20001212X19976
Type
Accident
Date
1999-10-25
Location
SAN JOSE, CA, USA
Coordinates
37.339271, -121.899223
Injuries
Highest injury
FATL
Fatal
2
Serious
0
Minor
0
Uninjured
0
Total aboard
2
Aircraft
Make
McDonnell Douglas
Model
500N
Registration
N904PD
FAR Part
091
Engines
1
Damage
DEST
Conditions
Light
DAYL
Weather
VMC
Probable cause
The pilot's in-flight loss of control due to the failure and separation of the forward thruster control cable telescoping sleeve ball swivel fitting, which resulted in a stuck thruster and the entry into an uncontrollable yaw/spin. Also causal was the mechanics improper maintenance actions during diagnostics to determine the cause of a yaw control anomaly in that he failed to remove an access panel over the FS113 splitter to fully and completely examine the thruster control cable. Factors in the accident were: (1) the incomplete emergency procedures/system explanations in the RFM for a stuck thruster condition; (2) the pilot's negative transfer of emergency procedures from the HH-60, which likely induced him to make incorrect inputs to throttle, collective, and the anti-torque controls during the onset of the stuck thruster condition; and (3) MDHI and the cable manufacturer's failure to expeditiously diagnose and correct the stress corrosion cracking problem in the forward thruster cable ball swivel fitting.