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NTSB Final Report: Cahokia, IL

Location: Cahokia, Illinois

Accident Number: CEN23LA150

Date & Time:April 9, 2023, 08:45 Local

Registration: N372PA

Aircraft:HELICOPTERES GUIMBAL CABRI

Aircraft Damage: Substantial

Defining Event: Sys/Comp malf/fail (non-power) G2

 

Flight Conducted Under: S

Part 91: General aviation - Instructional

Injuries: 1 Minor, 1 None

Analysis

The flight instructor stated that during an instructional flight he lost left cyclic control during an approach for landing. The student pilot’s right cyclic controls continued to function, and the flight instructor coached him on cyclic control inputs to maintain control of the helicopter. The student’s cyclic control became unresponsive to control inputs during the attempted landing and the helicopter impacted the ground resulting in substantial damage to the main rotor blades. Postaccident examination of the flight control system revealed that retaining hardware for the pins used to attach the left cyclic control were not installed. Maintenance personnel were unable to provided information regarding previous maintenance performed on the cyclic controls. The left cyclic control did not have any deformation/damage.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be: The lack of proper attachment of the cyclic control that resulted in a loss of control during a landing approach and impact with terrain. Contributing to the accident was the improper maintenance performed.

Findings

Aircraft (general) - Not specified

Factual Information

History of Flight

Landing-flare/touchdown Sys/Comp malf/fail (non-power) (Defining event)

Landing-flare/touchdown Loss of control in flight

Landing-flare/touchdown Attempted remediation/recovery

Landing-flare/touchdown Collision with terr/obj (non-CFIT)

On April 9, 2023, at 0845 central daylight time, a Helicopteres Guimbal Cabri G2, N372PA, was involved in an accident near Cahokia, Illinois. The helicopter sustained substantial damage. The flight instructor received minor injuries and the student pilot was uninjured. The helicopter was operated under Title 14 Code of Federal Regulations Part 91 as an instructional flight.

The flight instructor stated that during the approach for landing at the departure airport, his left cyclic had “a little bit of play,” and the helicopter was not responding fully to his control inputs. He then completely lost cyclic control upon lining up with the taxiway of intended landing site. He stated that he still had collective and rudder control. The student pilot’s cyclic controls continued to function, and the flight instructor coached him on cyclic control inputs to maintain control of the helicopter, but the student pilot’s cyclic control then ceased to function. The helicopter impacted the ground during the attempted landing and sustained substantial damage to the main rotor blades.

Postaccident examination of the flight control system revealed that the helicopter’s Illustrated Parts Catalog part #34 (Reference HG17-0545) - Pin and part #36 (Reference HG21-0803) – Safety Pin were found not inplace on the left cyclic control. Part #43.0 (Reference G41-41-300)

– Pin Locker, part # 44 (Reference HG20-2036) – Bolt and part #7 (Reference HG12-0332) – Nut were not installed. Ideal Aviation was unable to a date when these parts were removed. There was no evidence indicating these parts were impacted by the crash. The left cyclic control did not have any deformation/damage.

Flight instructor Information

Certificate: Commercial; Flight instructor;

Age:

27,Male

 

Private

 

 

Airplane Rating(s):

 

Seat Occupied:

Left

Other Aircraft Rating(s):

Helicopter

Restraint Used:

4-point

Instrument Rating(s):

Helicopter

Second Pilot Present:

Yes

Instructor Rating(s):

Helicopter; Instrument helicopter

Toxicology Performed:

 

Medical Certification:

Class 2 Without

Last FAA Medical Exam:

January 2, 2023

 

waivers/limitations

 

 

Occupational Pilot:

Yes

Last Flight Review or Equivalent:

June 5, 2022

Flight Time:

545 hours (Total, all aircraft), 542 hours (Total, this make and model), 483 hours (Pilot In

 

Command, all aircraft), 87 hours (Last 90 days, all aircraft), 40 hours (Last 30 days, all aircraft),

 

3 hours (Last 24 hours, all aircraft)

 

 

Student pilot Information

Certificate:

Private

Age:

41,Male

Airplane Rating(s):

Single-engine land

Seat Occupied:

Right

Other Aircraft Rating(s):

None

Restraint Used:

4-point

Instrument Rating(s):

None

Second Pilot Present:

Yes

Instructor Rating(s):

None

Toxicology Performed:

 

Medical Certification:

Class 2 Without

Last FAA Medical Exam:

June 7, 2021

 

waivers/limitations

 

 

Occupational Pilot:

No

Last Flight Review or Equivalent:

July 2, 2010

Flight Time:

131 hours (Total, all aircraft), 17 hours (Total, this make and model), 34 hours (Pilot In

 

Command, all aircraft), 17 hours (Last 90 days, all aircraft), 9 hours (Last 30 days, all aircraft), 0

 

hours (Last 24 hours, all aircraft)

 

 

Aircraft and Owner/Operator Information

Aircraft Make: HELICOPTERES GUIMBAL

Registration:

N372PA

Model/Series:

CABRI G2

Aircraft Category:

Helicopter

Year of Manufacture:

2016

Amateur Built:

 

Airworthiness Certificate:

Normal

Serial Number:

1150

Landing Gear Type:

Skid

Seats:

2

Date/Type of Last

April 7, 2023 Annual

Certified Max Gross Wt.:

1543 lbs

Inspection:

 

 

 

Time Since Last Inspection:

 

Engines:

1 Reciprocating

Airframe Total Time:

 

Engine Manufacturer:

Lycoming

ELT:

C126 installed, activated, did

Engine Model/Series:

O-360

 

not aid in locating accident

 

 

Registered Owner:

Rotor Leasing LLC

Rated Power:

145 Horsepower

Operator:

Ideal Aviation

Operating Certificate(s)

Pilot school (141)

 

 

Held:

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Visual (VMC)

Condition of Light:

Day

Observation Facility, Elevation:

CPS,413 ft msl

Distance from Accident Site:

0 Nautical Miles

Observation Time:

08:45 Local

Direction from Accident Site:

 

Lowest Cloud Condition:

 

Visibility

10 miles

Lowest Ceiling:

None

Visibility (RVR):

 

Wind Speed/Gusts:

8 knots /

Turbulence Type

/

 

 

Forecast/Actual:

 

Wind Direction:

130°

Turbulence Severity

/

 

 

Forecast/Actual:

 

Altimeter Setting:

30.4 inches Hg

Temperature/Dew Point:

11°C / -1°C

Precipitation and Obscuration:

No Obscuration; No Precipitation

 

Departure Point:

Cahokia, IL

Type of Flight Plan Filed:

None

Destination:

Cahokia, IL

Type of Clearance:

VFR

Departure Time:

 

Type of Airspace:

Class D

Airport Information

Airport:

St Louis Downtown Airport CPS

Runway Surface Type:

Concrete

Airport Elevation:

413 ft msl

Runway Surface Condition:

Dry

Runway Used:

Taxiway A

IFR Approach:

None

Runway Length/Width:

2000 ft / 50 ft

VFR Approach/Landing:

Straight-in;Traffic pattern

Wreckage and Impact Information 

Crew Injuries:

1 Minor, 1 None

Aircraft Damage:

Substantial

Passenger

N/A

Aircraft Fire:

None

Injuries:

 

 

 

Ground Injuries:

 

Aircraft Explosion:

None

Total Injuries:

1 Minor, 1 None

Latitude,

38.570361,-90.155083(est)

 

 

Longitude:

 

Administrative Information

Investigator In Charge (IIC): Gallo, Mitchell

Additional Participating

Robert Prenger; Federal Aviation Administration, St. Louis FSDO; St. Ann, MO

Persons:

Bernard Boudaille; Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile

 

Dennis Mueller; Federal Aviation Administration, St. Louis FSDO; St. Ann, MO

Original Publish Date:

July 10, 2024

Last Revision Date:

 

 

Investigation Class:

Class 3

Note:

The NTSB did not travel to the scene of this accident.

Investigation Docket:

https://data.ntsb.gov/Docket?ProjectID=107038

 

 

 

The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in other modes of transportation— railroad, transit, highway, marine, pipeline, and commercial space. We determine the probable causes of the accidents and events we investigate, and issue safety recommendations aimed at preventing future occurrences. In addition, we conduct transportation safety research studies and offer information and other assistance to family members and survivors for each accident or event we investigate. We also serve as the appellate authority for enforcement actions involving aviation and mariner certificates issued by the Federal Aviation Administration (FAA) and US Coast Guard, and we adjudicate appeals of civil penalty actions taken by the FAA.

The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and are not conducted for the purpose of determining the rights or liabilities of any person” (Title 49 Code of Federal Regulations section 831.4). Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report (Title 49 United States Code section 1154(b)). A factual report that may be admissible under 49 United States Code section 1154(b) is available here.

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Created 164 days ago
by Admin

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