SA-404 FILE NO.

1-0005

AIRCRAFT ACCIDENT REPORT

LOS ANGLES AIRWAYS, INC.
SIKORSKY S-61L, N303Y
PARAMOUNT, CALIFORNIA
MAY 22,1968
ADOPTED: DECEMBER 18, 1969
i

NATIONAL TRANSPORTATION SAFETY BOARD

Bureau of Aviation Safety
Washington, 0. C. 20591

by ClearinghouBe for Federal Scientific and Technical Information, W.S. Degartment 01

P O T Bale
Commerce. Springfield, Ya. 22151. Annual subscription price $12.00 Domestic: $15.00 Foreign;
Single Copy $3.00; Microfiche $0.85.
Order Number: NTSB-AAR-70-1
 NATIONAL TRANSPORTATION SAFETY BOARD
DEPARTMENT OF TRANSPORTATION

AIRCRAFT ACCIDENT
LOS ANGELES AIRWAYS. I N C .
SIKORSKY S.61L. N303Y
PARAMOUNT. CALIFORNIA
MAY 22. 1968

TABLE OF CONTENTS

Synopsis ..................................... 1
Probable Cause ............................... 2
1 . Investigation ................................ 3
1.1 History of the F l i g h t ........................ 3
1.2 ..........................
I n j u r i e s t o Persons 4
1.3 ...........................
Damage t o A i r c r a f t
.................................
4
4
1.4 Other Damage
I 1.5 .............................
Crew I n f o r m a t i o n 4
1.6 A i r c r a f t Information ......................... 4
1.7
1.8
Meteorological Information ...................
...........................
Aids t o N a v i g a t i o n
5
5
1
~

1.9 Communications ............................... 5

.............. 5
i
i
1.10
1.11
1.12
Aerodrome and Ground F a c i l i t i e s
F l i g h t Recorders
Wf,eckage
.............................
.....................................
5
5
1.13 Fire ......................................... 14
1.14 S u r v i v a l Aspects............................. 15
1.15
. T e s t s and Research ........................... 15
2 A n a l y s i s and Conclusions ..................... 20
2.1 Analysis ..................................... 20
I 2.2 Conclusions .................................. 27

i 3 .
.............................
(a) F i n d i n g s
(b) Probable Cause .......................
..........................
C o r r e c t i v e Measures
Attachment
Appendix A
27
28
29

.. Appendix B
Appendix C
 SA-404 F i l e No. 1-0005

NATIONAL TRANSPORTATION SAFETY BOARD

Department of T r a n s p o r t a t i o n
AIRCRAFT ACCIDENT REPORT

Adopted: December 1'8, 1969 -

LOS ANGELES AIRWAYS, I N C .

SIKORSKY S-61L, N303Y
PARAMOUNT, CALIFORNIA
MAY 2 2 , 1968

SYNOPSIS

About 1 7 5 1 P . d . t . , May 2 2 , 1968, Los Angeles Airways F l i g h t 841, a

Sikorsky
-~ S-61L, N303Y, c r a s h e d and burned a t P~aramount,C a l i f o r n i a . The
! f l i g h t was en r o u t e from t h e Anaheim, C a l i f o r n i a , H e l i p o r t , which s e r v e s
Disneyland, t o t h e Los Angeles I n t e r n a t i o n a l A i r p o r t , A l l 2 3 persons
aboard the a i r c r a f t were f a t a l l y i n j u r e d and t h e a i r c r a f t was d e s t r o y e d by
impact and f i r e a f t e r impact.

The o v e r a l l evidence, coupled w i t h numerous t e s t s and f a i l u r e a n a l y s e s ,

i n d i c a t e s t h a t t h e a c c i d e n t sequence began w h i l e t h e a i r c r a f t was i n
c r u i s i n g f l i g h t about 2,000 f e e t above t h e ground and about 2 m i l e s e a s t
of t h e a c c i d e n t s i t e . The b l a c k , y e l l o w , and b l u e main r o t o r b l a d e s ,
followed by t h e r e d and w h i t e b l a d e s , underwent a s e r i e s of extreme over-
t r a v e l excursions i n t h e i r l e a d / l a g axis.

During t h e extreme e x c u r s i o n s , t h e y e l l o w main r o t o r b l a d e over-

t r a v e l e d i n t h e lead d i r e c t i o n and, a s a r e s u l t , i t s p i t c h change c o n t r o l
road w a s s u b j e c t e d t o downward and rearward loading many times i t s d e s i g n
o p e r a t i n g s t r e n g t h . Under t h e s e f o r c e s , t h e r o d became detached a t i t s
lower trunnion end where i t i s normally secured t o t h e attachment l u g s of
the main r o t o r r o t a t i n g swashplate. With t h i s s e p a r a t i o n , t h e b l a d e went
out of c o n t r o l and s t r u c k t h e r i g h t s i d e of t h e a i r c r a f t d i a g o n a l l y a c r o s s
t h e baggage l o a d i n g door. The o t h e r f o u r main r o t o r b l a d e s then s t r u c k and
p e n e t r a t e d both t h e a f t and forward p o r t i o n s of t h e a i r c r a f t . The b l a d e
s t r i k e s d e s t r o y e d t h e main r o t o r b l a d e s and s e p a r a t e d major p o r t i o n s of t h e
f u s e l a g e , i n c l u d i n g t h e t a i l r o t o r pylon and t a i l r o t o r assemblies. The
a i r c r a f t , completely u n c o n t r o l l a b l e , crashed i n a n e a r - v e r t i c a l d e s c e n t .

The i n i t i a l m a l f u n c t i o n , f a i l u r e , o r c o n d i t i o n which p r e c i p i t a t e d t h e
a c c i d e n t sequence was probably a l o s s of main r o t o r b l a d e damper i n t e g r i t y
caused by e i t h e r f a i l u r e of t h e b l a c k main r o t o r b l a d e damper, o r a l o s s of
e f f e c t i v e damper a c t i o n by t h e w h i t e main r o t o r b l a d e damper. An i m p o r t a n t
p o r t i o n of t h e b l a c k damper and a p o r t i o n of t h e b l a c k b l a d e h o r i z o n t a l
hinge p i n t o which t h e damper a t t a c h e s were n o t recovered.
 - 2 -

The S a f e t y Board determines t h a t t h e p r o b a b l e c a u s e of t h i s a c c i d e n t

was t h e l o s s , o f main r o t o r b l a d e damper i n t e g r i t y due t o e i t h e r a f a i l u r e - o f 1.1
t h e b l a c k b l a d e damper o r a .-
~~ ~~
~
l o s s of effective~_d.amping.action by t h e white
~

b l a d e damper. T h i s r e s u l t e d i n u n c o n t r o l l e d e x c u r s i o n s of the main r o t o r

b l a d e s i n t h e i r l e a d / l a g a x i s , an overload detachment of t h e yellow main can
r o t o r b l a d e p i t c h change c o n t r o l rod and d e s t r u c t i o n of t h e s t r u c t u r a l Dim
i n t e g r i t y of t h e a i r c r a f t by b l a d e s t r i k e s . The p r e c i s e r e a s o n f o r e i t h e r 25
of t h e p o s s i b i l i t i e s f o r t h e l o s s of damper i n t e g r i t y is undetermined. mati

und
wh e
Pas
was
thf
ren
20

a 1
CO
a

in
mi
th
3
2,
W(
6(
F:
t l
tl
 - 3 -

1. INVESTIGATION
lent
~ u r e0; 1.1 H i s t o r y of t h e F l i g h t
ite
tor Los Angeles Airways F l i g h t 841 of May 22, 1968, was a scheduled a i r
in c a r r i e r passenger f l i g h t from t h e Anaheim, C a l i f o r n i a , H e l i p o r t , s e r v i n g
Disneyland, t o t h e Los Angeles I n t e r n a t i o n a l A i r p o r t , a d i s t a n c e of about
ther 25 m i l e s . I t was t h e r e t u r n p o r t i o n of F l i g h t 441/841, one of approxi-
mately 30 f l i g h t s made d a i l y by t h e a i r l i n e between t h e two p o i n t s .

F l i g h t 441 d e p a r t e d t h e Los Angeles I n t e r n a t i o n a l A i r p o r t a t 1723 -11

under v i s u a l f l i g h t r u l e s i n c l e a r weather and proceeded t o Anaheim,
where i t landed about 1737. The crew made normal r a d i o c o n t a c t s and t h e
passengers noted n o t h i n g unusual about t h e f l i g h t . A t Anaheim, t h e a i r c r a f t
was n o t s e r v i c e d and t h e crew gave no i n d i c a t i o n of any d i f f i c u l t i e s w i t h
the h e l i c o p t e r . Because of t h e s h o r t turnaround, 3 m i n u t e s , t h e p i l o t s
remained i n t h e c o c k p i t and only t h e No. 2 engine was s h u t down w h i l e t h e
20 passengers boarded for F l i g h t 841.

F l i g h t 841 d e p a r t e d Anaheim a t 1740 and gave i t s d e p a r t u r e time and

a wind a d v i s o r y f o r o t h e r company p i l o t s t o Los Angeles Airways F l i g h t
Control. A t 1742, i t gave F u l l e r t o n Tower i t s r o u t e of f l i g h t and, a t 1747,
a p o s i t i o n r e p o r t . Both r e p o r t s were r o u t i n e .

About 1750, t h e p i l o t s of Los Angeles Airways F l i g h t 7 4 2 , which was

inbound to Anaheim, saw F l i g h t 841 as t h e two a i r c r a f t passed about one- half
mile a p a r t , f l y i n g i n o p p o s i t e d i r e c t i o n s . The p i l o t s of F l i g h t 742 r e p o r t e d
the f l i g h t s passed approximately over P i o n e e r I n t e r s e c t i o n , l o c a t e d about
3 miles e a s t of t h e c r a s h s i t e and F l i g h t 841 was a t a n a l t i t u d e of about
2,000 f e e t . They r e p o r t e d t h a t a t t h i s time F l i g h t 841 was on a n o m a 1
westerly heading, on c o u r s e , and appeared completely normal. Within 30 t o
60 seconds l a t e r , a t h i r d p i l o t aboard F l i g h t 742 and Los Angeles Airways
F l i g h t C o n t r o l heard a r a d i o t r a n s m i s s i o n which was subsequently determined
t o be, "LA, w e ' r e c r a s h i n g , h e l p US." F l i g h t 841 could n o t b e c o n t a c t e d
thereafter.

Witness o b s e r v a t i o n s i n d i c a t e t h a t d u r i n g t h e f i n a l 2 t o 2- 1/2 miles

of f l i g h t , F l i g h t 841 descended from i t s c r u i s i n g a l t i t u d e o f about 2,000
f e e t , as observed by F l i g h t 742, t o between 600 and 800 f e e t above t h e
ground. They i n d i c a t e t h a t d u r i n g t h i s d e s c e n t , t h e a i r c r a f t slowed and
t h e r e seemed t o be an e r r a t i c a c t i o n of t h e main r o t o r b l a d e s . S e v e r a l
witnesses then saw t h e a i r c r a f t t u r n l e f t from a w e s t e r l y t o a south-
westerly heading. One w i t n e s s , w i t h a h e l i c o p t e r maintenance background,
s t a t e d t h a t t h i s t u r n was a v i o l e n t yaw t o t h e l e f t o f n e a r l y 90 , and when
0

i t occurred, h e saw one main r o t o r b l a d e extremely o u t of tract on t h e

high s i d e .

-1/ A l l times h e r e i n a r e P a c i f i c d a y l i g h t , based on the.24- hour c l o c k .

f
i

- 4 -

Immediately t h e r e a f t e r , t h e r e were s e v e r a l s h a r p sounds from t h e a i r -

hc
c r a f t and two w i t n e s s e s saw t h e main r o t o r b l a d e s s t r i k i n g t h e f r o n t and
back a r e a s o f t h e a i r c r a f t f u s e l a g e . P a r t s i d e n t i f i e d a s p i e c e s of main a(
Wi
r o t o r b l a d e s , f u s e l a g e , and t h e t a i l r o t o r were s e e n t o s e p a r a t e from t h e
a i r c r a f t and t h e h e l i c o p t e r immediately f e l l i n a n e a r - v e r t i c a l t r a j e c t o r y
and c r a s h e d . F i r e followed t h e ground impact.
1‘
Ground w i t n e s s e s saw no l a r g e a i r c r a f t i n t h e a r e a of t h e a c c i d e n t g’
when i t occurred. Two h e l i c o p t e r s , one a p p a r e n t l y F l i g h t 742 and t h e o t h e r 1
a s m a l l Bell, were seen b u t n e i t h e r was c l o s e t o F l i g h t 841. Witnesses 1
s a i d t h e weather2yas c l e a r w i t h u n l i m i t e d v i s i b i l i t y a t t h e time and p l a c e 1
of t h e accident.- 1
t
1.2 I n j u r i e s t o Persons P
0

There were t h r e e crewmembers and 20 p a s s e n g e r s aboard t h e a i r c r a f t . B

A l l received f a t a l i n j u r i e s .

1.3 Damage t o A i r c r a f t f

The a i r c r a f t was d e s t r o y e d by impact and t h e e n s u i n g ground f i r e . 3

1.4 Other Damage

F a l l i n g p i e c e s of t h e a i r c r a f t damaged s e v e r a l b u i l d i n g s and a t r u c k .
There were no i n j u r i e s t o p e r s o n s on t h e ground.

1.5 Crew Information

The c a p t a i n , c o p i l o t , and f l i g h t a t t e n d a n t were p r o p e r l y c e r t i f i c a t e d

and q u a l i f i e d f o r t h e o p e r a t i o n involved. (For d e t a i l e d i n f o r m a t i o n s e e
Appendix A.)

1.6 A i r c r a f t Information

The a i r c r a f t was a Sikorsky S-61L, N303Y, w i t h s e r i a 1 , N o . 61060 and

company No. 44. I t was manuf c t u r e d by t h e Sikorsky A i r c r a f t D i v i s i o n of
United A i r c r a f t Corporation i n June 1962 and a n A i r w o r t h i n e s s C e r t i f i c a t e
f o r t h e h e l i c o p t e r was i s s u e d t o Los Angeles Airways on August 18, 1962.
(For o t h e r a i r c r a f t i n f o r m a t i o n see Appendix B . )

The main r or head i n s t a l l e d on t h e a i r c r a f t had accumulated a t o t a l

o f 9,102 hours,z’of which 1 , 1 7 5 were logged s i n c e o v e r h a u l . The o v e r h a u l
p e r i o d f o r t h e head was 2,400 hours.

-2/ The a c c i d e n t o c c u r r e d i n f u l l d a y l i g h t .
-31 Present corporate designation.
-4 / Nearest f u l l h o u r s a r e used i n t h i s r e p o r t .
 - 5 -

.e a i r - The b l a c k main r o t o r b l a d e damper assembly was i n s t a l l e d on t h e r o t o r

: and head on May 17, 1968, w i t h 6,680 t o t a l h o u r s , of which 430 hours were
,main accumulated s i n c e overhaul. The p i s t o n component of t h e assembly, which
m the
was l i f e l i m i t e d t o 3,400 hours, had accumulated 3,342 hours.
ec tory
The maximum a l l o w a b l e g r o s s takeoff weight f o r h e l i c o p t e r N303Y was
19,000 pounds. Computations i n d i c a t e t h a t , a t d e p a r t u r e from Anaheim, i t s
en t gross weight was 16,809 pounds and a t t h e time of t h e a c c i d e n t , about
e other 16,700 pounds. A t 16,500 pounds g r o s s weight, t h e foxward c e n t e r o f g r a v i t y
ses l i m i t a t i o n was 255.0 i n c h e s a f t of t h e r e f e r e n c e datum 51 and t h e a f t
place l i m i t a t i o n was 273.3 i n c h e s , A t 17,000 pounds g r o s s weight, t h e forward
l i m i t a t i o n was 256.0 i n c h e s a f t of t h e r e f e r e n c e datum and t h e a f t l i m i t a -
t i o n 278.7 inches. Based on t h i s i n f o r m a t i o n , and depending on t h e seat
p o s i t i o n of an i n f a n t passenger who was e i t h e r i n s e a t 5 o r 24, t h e c e n t e r
of g r a v i t y was 264.83 o r 263.63 a f t of t h e r e f e r e n c e datum, r e s p e c t i v e l y .
aft. Both were well w i t h i n l i m i t a t i o n s .

The a i r c r a f t was s e r v i c e d t o a t o t a l f u e l l o a d of 1,000 pounds of JP-4

f u e l p r i o r t o d e p a r t u r e f o r Anaheim and i t was n o t s e r v i c e d a t Anaheim.

3. 1.7 Meteorological I n f o r m a t i o n

A t t h e time and p l a c e of t h e a c c i d e n t , t h e weather c o n d i t i o n s were

c l e a r , w i t h v i s i b i l i t y more than 15 miles. F u l l d a y l i g h t e x i s t e d .
:ruck.
1.8 Aids t o Navigation

Not involved.

cated 1.9 Canrmunications

see
Communications w i t h F l i g h t 841 were normal u n t i l t h e f i n a l emergency
transmission from t h e f l i g h t i n d i c a t i n g t h a t i t was c r a s h i n g .

1.10 Aerodrome and Ground F a c i l i t i e s

and
n of Not involved.
ificate
62. 1.11 F l i g h t Recorders

The a i r c r a f t was n o t equipped w i t h e i t h e r a f l i g h t r e c o r d e r o r a

total cockpit v o i c e r e c o r d e r . N e i t h e r i s r e q u i r e d on t r a n s p o r t h e l i c o p t e r s by
7aul current Federal Aviation Regulations.

1.12 Wreckage
- The main body of t h e a i r c r a f t , i n c l u d i n g b o t h e n g i n e s , t h e main r o t o r
head, p i e c e s of main r o t o r b l a d e s , and most of t h e f u s e l a g e s t r u c k t h e

-51 Reference datum i s 267.4 i n c h e s forward of t h e c e n t e r l i n e of t h e

main r o t o r hub.
 ..

. . .-

- 6 -

ground i n a n e a r - v e r t i c a l f a l l . It s t r u c k t h e ground i n a n o s e d m a t t i -
tude on i t s l e f t s i d e . A t impact, t h e main r o t o r was t u r n i n g v e r y s l o w l y ,
if a t a l l , and t h e r e was l i t t l e power development from e i t h e r engine. F i r e
followed t h e ground impact and caused e x t e n s i v e a d d i t i o n a l damage t o t h i s
wreckage.

The o t h e r major p o r t i o n s of t h e a i r c r a f t f e l l a l o n g a groundpath

approximately 1,100 f e e t wide and 2,100 f e e t long t o t h e e a s t , o r back
along t h e f i n a l f l i g h t p a t h of t h e a i r c r a f t . These p o r t i o n s i n c l u d e d t h e
a f t p a r t of t h e f u s e l a g e , t a i l r o t o r d r i v e s h a f t , t h e pylon assembly i n c l u d i n g
t h e i n t e r m e d i a t e gearbox, t a i l r o t o r assembly, p i e c e s of main r o t o r b l a d e s ,
and p i e c e s of c o c k p i t and f u s e l a g e s t r u c t u r e . These p i e c e s and components
showed no evidence of f i r e . By v i r t u e of t h e i r d i s t a n c e s from t h e main
wreckage, i t was e v i d e n t t h a t they had s e p a r a t e d i n f l i g h t a l o n g t h e f i n a l
f l i g h t p a t h of t h e a i r c r a f t .

The main r o t o r system o f t h e S-61L h e l i c o p t e r h a s f i v e main r o t o r

b l a d e s ( s e e Attachment 1, Explanatory Diagram, Main Rotor Head). Looking
down on t h e head, they t u r n counterclockwise. Clockwise they a r e c o l o r
coded f o r i d e n t i f i c a t i o n , as t h e r e d , b l a c k , w h i t e , yellow, and b l u e b l a d e s .
The b l a d e s a r e i d e n t i c a l and, i n consonance w i t h t h e f u l l y a r t i c u l a t e d
design concept of t h e r o t o r head, a r e f r e e t o move i n d i v i d u a l l y and i n d e -
pendently, w i t h i n c o n t r o l l e d limits, about t h r e e a x e s , l e a d / l a g , f l a p ,
and p i t c h .

A v e r t i c a l h i n g e p i n f o r each b l a d e p e r m i t s t h e l e a d and l a g motion

and a damper and bumper assembly cusions and limits t h e motion. A h o r i z o n t a l
hinge p i n f o r each b l a d e a l l o w s ' i t s b l a d e t o f l a p o r move up and down about
t h e h i n g e p o i n t i n a d d i t i o n t o t h e normal f l e x i b i l i t y of t h e b l a d e i t s e l f .
A t h i r d h i n g e , t h e p i t c h h i n g e , p e r m i t s each b l a d e t o change p i t c h from
c o n t r o l i n p u t s . A p i t c h change c o n t r o l rod f o r each b l a d e i s t h e medium
through which b l a d e p i t c h changes a r e made. I t a t t a c h e s a t i t s lower end
t o t h e r o t a t i n g swashplate t o which c o n t r o l i n p u t s a r e a p p l i e d from t h e
s t a t i o n a r y swashplate. A t i t s upper end, t h e p i t c h c o n t r o l rod a t t a c h e s
t o t h e p i t c h change horn of i t s r e s p e c t i v e b l a d e .

The r o t a t i n g swashplate i s coupled t o t h e s t a t i o n a r y s w a s h p l a t e by a

b e a r i n g on a b a l l . This d e s i g n a l l o w s t h e r o t a t i n g swashplate t o r o t a t e ,
t i l t , and move up and down. The r o t a t i n g swashplate i s a t t a c h e d t o t h e
r o t o r hub by a s c i s s o r s and r o t a t e s w i t h t h e r o t o r hub. The hub i s d r i v e n
by engine power through t h e main gearbox. The r o t o r head can a l s o c o n t i n u e
t o r o t a t e i n t h e e v e n t of a loss of engine power e n a b l i n g an a u t o r o t a t i o n a l
l a n d i n g . The s t a t i o n a r y swashplate i s k e p t from r o t a t i n g by a n o t h e r s c i s s o r s
a t t a c h e d t o t h e main gearbox.

Control inputs f o r the r o t o r blades a r e applied t o the s t a t i o n a r y

swashplate by a h y d r a u l i c a l l y o p e r a t e d d u a l s e r v o system. I n p u t s t o t h e
s t a t i o n a r y swashplate c a u s e t h e r o t a t i n g swashplate t o move up and down,
o r t i l t , thereby changing t h e p i t c h of t h e r o t o r b l a d e s c o l l e c t i v e l y , o r
i n t i l t w i t h each r o t a t i o n of t h e r o t o r hub. S i n c e p i t c h changes of t h e
r o t o r b l a d e s a r e made through t h e medium of t h e p i t c h change c o n t r o l r o d s ,
 - 7 -
i f a p i t c h change rod were t o become detached f o r any r e a s o n , i t s b l a d e
Y, would become u n c o n t r o l l a b l e i n i t s p i t c h a x i s and, i n d i r e c t l y , i n i t s f l a p
ire a x i s about i t s h o r i z o n t a l hinge p i n . Normal o p e r a t i n g l o a d s on t h e p i t c h
s c o n t r o l rods a r e 250 t o 300 pounds.

Wreckage examination r e v e a l e d t h a t a l l f i v e main r o t o r b l a d e s were

broken i n t o two or more p i e c e s . S e c t i o n s from each c o n s i s t i n g of e i t h e r
blade and cuff o r o f t h e c u f f a l o n e remained a t t a c h e d t o t h e r o t o r head.
Numerous p i e c e s of t h e r e d , b l a c k , w h i t e , and b l u e b l a d e s were found w e l l
loding back along t h e wreckage p a t h among p i e c e s from t h e c o c k p i t , a f t f u s e l a g e ,
ee, and pylon assembly s t r u c t u r e . However, t h e p i e c e s found f a r t h e s t back
tS along t h e wreckage p a t h were p i e c e s of t h e yellow b l a d e . These were a
13-foot s e c t i o n inboard of t h e t i p and s e v e r a l b l a d e p o c k e t s . P i e c e s of
31 the yellow b l a d e were found some 2,100 f e e t from t h e main wreckage and
some 800 f e e t f a r t h e r than o t h e r dense p i e c e s of a i r c r a f t s t r u c t u r e .

The n a t u r e of t h e damage t o t h e r e d , b l a c k , w h i t e , and b l u e b l a d e s was

3 s i m i l a r . :';owever, w i t h r e s p e c t t o t h e yellow b l a d e , t h e damage was d i s -
tinctively different.
3es.
Examination of t h e r e d , b l a c k , w h i t e , and b l u e b l a d e s r e v e a l e d t h a t
a l l f o u r had s t r u c k and p e n e t r a t e d t h e c o c k p i t and t h e a f t f u s e l a g e o f t h e
a i r c r a f t . By matching of b l a d e w i t h c o c k p i t and f u s e l a g e s t r u c t u r a l damage,
i t was determined t h a t , except f o r t h e red and b l a c k b l a d e s t r i k e s i n t h e
cockpit a r e a , which were r e v e r s e d , a l l of t h e o t h e r b l a d e s t r i k e s on t h e
a i r c r a f t were i n t h e o r d e r of b l a d e r o t a t i o n and t h e p e n e t r a t i o n s were pro-
mtal
g r e s s i v e l y deeper i n t o t h e a i r c r a f t s t r u c t u r e . S t r i k e s by t h e w h i t e and
)Ut blue b l a d e s s e p a r a t e d t h e a f t f u s e l a g e and t a i l r o t o r pylon. One s t r i k e
E. i n the c o c k p i t was i n t h e a r e a of t h e r a d i o c o n t r o l p a n e l and a n o t h e r pene-
t r a t e d the a r e a of t h e e n g i n e c o n t r o l s .
1 Of p a r t i c u l a r importance, t h e r e was no evidence found t o i n d i c a t e t h a t
the yellow b l a d e i n f l i c t e d arty of t h e s t r i k e s i n e i t h e r the c o c k p i t o r a f t
fuselage a r e a s of t h e a i r c r a f t . T h i s , t h e r e f o r e , i n d i c a t e d t h a t t h e y e l l o w
blade was n e i t h e r i n i t s r o t a t i o n a l sequence p o s i t i o n between t h e w h i t e and
blue b l a d e s nor i n t h e r o t o r d i s c a t t h e time t h e b l a d e s t r i k e s were made.
I
The yellow b l a d e was broken i n t o f i v e major p i e c e s . I n one p i e c e from
the middle p o r t i o n o f t h e b l a d e , t h e r e was a n upward curved bend and, near
!n
we
i t s c u f f end, t h e r e was a s h a r p upward bend of about 10
0
.
On t h e upper
s u r f a c e of a s e c t i o n from n e a r t h e middle p a r t of t h e b l a d e , t h e r e were
la1 p a i n t marks. There were a l s o numerous wavy l o n g i t u d i n a l s c r a t c h e s found
mors on the top s u r f a c e of a n o t h e r b l a d e s e c t i o n from n e a r t h e hub end. On a n
outboard s e c t i o n was a d i s t i n c t r i v e t p a t t e r n impressed i n t h e upper
surface of t h e b l a d e .

The above- described marking and damage were matched w i t h a n impres-

sion made by an extremely heavy b l a d e h i t which r a n d i a g o n a l l y forward
and downward a c r o s s t h e a i r c r a f t baggage door. The door was l o c a t e d on
the r i g h t s i d e of t h e f u s e l a g e below and forward of t h e main r o t o r head and
f
I

- 8 -

j u s t behind t h e p i l o t compartment. The curved bend i n t h e m i d - p o r t i o n of

t h e y e l l o w b l a d e matched t h e c u r v a t u r e of t h e c h i n e o r bottom f u s e l a g e l i n e ear
of t h e a i r c r a f t . The r i v e t p a t t e r n found on t h e b l a d e matched t h e r i v e t cap
p a t t e r n where a r e p a i r p a t c h had been r i v e t e d t o t h e bottom of t h e f u s e l a g e . mar
A l s o , p a i n t found on some p i e c e s of b l a d e matched t h e p a i n t scheme on t h e wer
f u s e l a g e , and p a i n t i n t h e h i t impression on t h e baggage door matched bea
p a i n t used on t h e b l a d e . Thus, t h i s o v e r a l l evidence showed t h a t t h e yellow
b l a d e had h i t t h e baggage door and f u s e l a g e a r e a f l a t w i t h i t s upper s u r f a c e .
Also, t h e v a r i o u s d i s t a n c e s of t h e marks on t h e p i e c e s of t h e b l a d e from chz
i t s attachment p o i n t t o t h e r o t o r head showed t h a t t h e b l a d e was a t t a c h e d to
t o t h e head when t h e major b l a d e h i t o c c u r r e d . The l o n g i t u d i n a l s c r a t c h e s to1
and gouges on t h e b l a d e and matching marks on t h e f r o n t of t h e c o c k p i t a r e a
and r o t o r head components r e v e a l e d t h a t , a f t e r t h e major s t r i k e , t h e remain-
i n g i n b o a r d p a r t of t h e b l a d e w a s dragged around t h e f r o n t of t h e c o c k p i t no
and p a r t i a l l y wrapped around t h e r o t o r head. ti 1
me:
The numerous f r a c t u r e s o f a l l main r o r b l a d e s were determined t o
-
have been t h e r e s u l t of g r o s s o v e r l o a d s . '2)
la
I n s p e c t i o n of t h e y e l l o w main r o t o r b l a d e p i t c h change c o n t r o l rod St
d i s c l o s e d i t was detached a t i t s lower o r t r u n n i o n end where i t normally ro
a t t a c h e s t o the r o t a t i n g swashplate attachment lugs o r e a r s . A t t h i s co
a t t a c h m e n t , each end of t h e t r u n n i o n f i t s i n t o a b e a r i n g which i s p r e s s cl
f i t t e d i n t o a t r u n n i o n b e a r i n g cap. The t r u n n i o n b e a r i n g caps a r e i n s t a l l e d
i n t h e l e a d i n g and t r a i l i n g e a r s of t h e s w a s h p l a t e and s e c u r e d by a n upper
and a lower b o l t i n s t a l l e d through each cap and e a r . The b o l t s used a r e ca
made of s t e e l and t h e c a p s and e a r s a r e made of aluminum. or
fr
The y e l l o w b l a d e p i t c h change c o n t r o l rod was a l s o broken o f f n e a r ac
i t s upper end. The f r a c t u r e was i n t h e c l e v i s a r e a , j u s t below t h e c l e v i s
which a t t a c h e s t o t h e yellow b l a d e p i t c h c o n t r o l horn e y e b o l t . The s h a f t
p o r t i o n of t h e rod r e v e a l e d no deformation. tt
ar
I n v e s t i g a t i o n and t e s t s '/ r e v e a l e d t h e y e l l o w b l a d e p i t c h change mt
c o n t r o l rod was detached a t t h e r o t a t i n g s w a s h p l a t e end a s t h e r e s u l t of ar
extremely h i g h l o a d i n g imposed downward and rearward through t h e c o n t r o l
rod i n a manner which b r o k e o f f t h e s w a s h p l a t e t r a i l i n g a t t a c h m e n t e a r .
The f r a c t u r e o c c u r r e d through t h e lower b e a r i n g cap b o l t h o l e i n t h e e a r . tl
The b e a r i n g cap remained w i t h t h e e a r . Both p a r t s had been s u b j e c t e d t o 01
ground f i r e and t h e e a r was p a r t i a l l y consumed. The b e a r i n g cap was 0 7

a t t a c h e d t o t h e remaining p o r t i o n of t h e e a r by t h e upper of t h e two 01

s e c u r i n g t r u n n i o n b e a r i n g cap b o l t s . The lower b o l t was m i s s i n g , a l t h o u g h i l
i t s h o l e i n t h e cap was i n t a c t b u t e l o n g a t e d and narrowed by h e a t t o t h e CI
e x t e n t t h a t a p r o p e r b o l t f o r t h e h o l e would n o t f i t through i t . W,

-6/ See S e c t i o n 1.15, Tests and Research, f o r b l a d e examinations and

-
m a t e r i a l tests.
-7 / S e e S e c t i o n 1.15, T e s t s and Research, f o r f a i l u r e l o a d i n g a n a l y s i s .
 - 9 -

Examination of t h e b e a r i n g cap r e v e a l e d i t had been pushed o u t of t h e

line ear. The major deformation was i n bending i n t h e a r e a of t h e upper b e a r i n g
let cap b o l t . The b e a r i n g was m i s s i n g from t h e cap; however, curved s t r i k e
jelage. marks were found on t h e i n s i d e r i m a r e a of t h e b e a r i n g cap. These marks
were found t o match t h e r a d i i and a r c s of t h e i n n e r an o u t e r races of a
I the bearing of t h e type used i n t h e t r u n n i o n b e a r i n g cap. dl -
On t h e l e a d i n g s i d e of t h e s h a f t p o r t i o n of t h e yellow b l a d e p i t c h
change c o n t r o l rod t h e r e was an i n t e r f e r e n c e mark. With t h e rod p o s i t i o n e d
to an extreme o v e r t r a v e l l e a d p o s i t i o n , t h i s mark mated w i t h a n o t h e r on t h e
top s i d e of i t s l e a d i n g attachment e a r of t h e r o t a t i n g s w a s h p l a t e .

Examination of t h e s t a t i o n a r y swashplate r e v e a l e d no major damage and

no evidence was found of b i n d i n g o r i n t e r f e r e n c e between i t and t h e r o t a -
t i n g swashplate. The s c i s s o r s a t t a c h i n g t h e s t a t i o n a r y swashplate t o t h e
main gearbox was i n t a c t , b u t i t s lower l i n k was b e n t forward.

On the s u r f a c e between t h e l e a d i n g and t r a i l i n g e a r s of t h e l e f t

l a t e r a l arm, where one o f t h e c o n t r o l i n p u t primary s e r v o s a t t a c s t o t h e
s t a t i o n a r y swashplate, t h e r e were s e v e r a l s c r a t c h e s and gouges. jp
During
r o t a t i o n of t h e r o t o r head, t h e lower a t t a c h p o i n t f o r t h e p i t c h change
c o n t r o l rods p a s s e s d i r e c t l y o v e r t h e primary s e r v o attachment p o i n t s , w i t h
c l o s e t o l e r a n c e s between t h e components of t h e two a t t a c h m e n t s .

A number of b e a r i n g s , such a s t h e one m i s s i n g from t h e t r u n n i o n b e a r i n g

cap, a r e used throughout t h e a i r c r a f t , and, w h i l e a number o f t h e s e b e a r i n g s
o r p o r t i o n s of them were found, i t was i m p o s s i b l e t o determine i f one was
from the yellow b e a r i n g cap. A l l o t h e r similar b e a r i n g cap b o l t s were
accounted f o r .

Following examination of t h e r o t o r head and a s s o c i a t e d components a t

the a c c i d e n t scene, t h e head was moved t o t h e m a n u f a c t u r e r ' s f a c i l i t i e s
and mocked up. This was done t o s t u d y t h e wreckage i n a n a t t e m p t t o docu-
ment t h e e n t i r e damage i n minute d e t a i l and t o e s t a b l i s h a f a i l u r e sequence
a n a l y s i s . This work took s e v e r a l months.

One of t h e most s i g n i f i c a n t r e s u l t s of t h e f a i l u r e a n a l y s i s was t h a t

the damage i n d i c a t e d t h a t t h e b l a c k , yellow, and b l u e , followed by t h e
other main r o t o r b l a d e s , had i n i t i a l l y undergone extremely large l e a d / l a g
o v e r t r a v e l e x c u r s i o n s . The e x c u r s i o n s were so s e v e r e t h a t i n some i n s t a n c e s
one blade had overlapped t h e one n e x t t o i t , The work a l s o r e v e a l e d t h a t
i n a d d i t i o n t o a c t i o n s a l r e a d y d e s c r i b e d , t h e yellow b l a d e experienced h i g h
coning and extreme l e a d i n g and l a g g i n g . Some of t h e s i g n i f i c a n t damage
was a s follows:

-8 / See S e c t i o n 1.15, Tests and Research.

-9 / See S e c t i o n 1.15,
v a r i o u s markings.
T e s t s and Research, f o r i d e n t i f i c a t i o n of t h e s e
 - 10 -
1. H o r i z o n t a l Hinge P i n s

The r e d , b l a c k , w h i t e , and yellow b l a d e h o r i z o n t a l h i n g e p i n s

were broken o f f , A l l of t h e s e h i n g e p i n s were recovered w i t h t h e excep-
t i o n of a major p o r t i o n of t h e one f o r t h e b l a c k b l a d e . M e t a l l u r g i c a l
examination r e v e a l e d no evidence of f a t i g u e i n any o f f a i l u r e s of t h e s e
p i n s . A l l f a i l u r e s were i n g r o s s o v e r l o a d i n t h e b l a d e l a g d i r e c t i o n , o r
i n the d i r e c t i o n opposite t o r o t o r rotation.

2. Dampers

The damper p i s t o n threaded s h a f t s were broken from t h e b l a c k ,

yellow, and b l u e b l a d e s . The yellow and b l u e s h a f t s were r e c o v e r e d and
a l l of t h e r e d , yellow, w h i t e and b l u e damper a s s e m b l i e s were recovered
f o r m e t a l l u r g i c a l examination.

I n t h e c a s e of t h e b l a c k damper assembly, t h e damper p i s t o n -

threaded s h a f t p o r t i o n was missing. A l s o m i s s i n g were t h e c l e v i s end of
the damper assembly, which c o n s i s t s of two t r u n n i o n b e a r i n g s and b e a r i n g
c a p s , t h e damper t r u n n i o n , which i s h e l d i n p l a c e by t h e b e a r i n g s and c a p s ,
and a s m a l l p o r t i o n of t h e h o r i z o n t a l h i n g e p i n t o which the t r u n n i o n a t t a c h e ,
Also m i s s i n g was t h e n u t which s e c u r e s t h e t r u n i o n t o t h e h o r i z o n t a l h i n g e
p i n . The b l a c k damper body was recovered b u t e x t e n s i v e e f f o r t s made t o
f i n d t h e m i s s i n g p o r t i o n and components o f t h e b l a c k damper were u n s u c c e s s f u l

The a v a i l a b l e f r a c t u r e d end of t h e b l a c k damper p i s t o n and t h e

f r a c t u r e d end of t h e h o r i z o n t a l h i n g e p i n were given m e t a l l u r g i c a l l a b o r a -
t o r y examination. Also, t h e a v a i l a b l e body p o r t i o n o f t h e b l a c k damper
and a l l f o u r o t h e r dampers were examined and given v a r i o u s t e s t s . g/

A l l damper c y l i n d e r housings e x h i b i t e d v a r i o u s d e g r e e s of damage.

The a f t outboard s i d e s of t h e r e d and w h i t e damper c y l i n d e r h o u s i n g s were
p e n e t r a t e d , exposing t h e p i s t o n s . These dampers had been p e n e t r a t e d by
t h e b l a c k and yellow b l a d e h o r i z o n t a l h i n g e p i n s t u b s when these b l a d e s
were i n an extreme l a g p o s i t i o n . The b l u e b l a d e damper e x h i b i t e d a deep
gouge i n i t s a f t outboard s i d e , and t h i s gouge mated w i t h t h e h o r i z o n t a l
hinge p i n of t h e r e d b l a d e i n an extreme l a g p o s i t i o n .

The f r o n t end p l a t e s of t h e damper c y l i n d e r heads f o r t h e r e d ,

white, and b l u e b l a d e s e x h i b i t e d gouge marks. Marks on t h e outboard s i d e
were a s s o c i a t e d w i t h damage on t h e r e d b l a d e s p i n d l e ear, and on t h e i n s i d e
w i t h t h e f a i l e d b l u e b l a d e t r u n n i o n end. F o r t h e s e c o n t a c t s t o have o c c u r r e d
t h e r e d b l a d e had t o be i n t h e extreme l e a d p o s i t i o n and t h e b l u e b l a d e i n
an extreme l a g p o s i t i o n . The w h i t e damper f r o n t end marks were matched t o
damage on t h e b l u e b l a d e s p i n d l e e a r , w i t h t h e b l u e b l a d e i n t h e extreme
lead position. The r e d damper had been s t r u c k by t h e b l a c k b l a d e horn
when t h e l a t t e r was i n i t s extreme l e a d p o s i t i o n .

-
l.O/ See S e c t i o n 1.15, T e s t s and Research, f o r d e t a i l of damper
examination and t e s t i n g .

I
 - 11 -
3. P i t c h Change C o n t r o l Rod Horns

P h y s i c a l evidence i n d i c a t e d t h a t t h e b l a c k b l a d e horn p i t c h change

c o n t r o l rod e y e b o l t b o s s had c o n t a c t e d t h e r e d damper t r u n n i o n assembly,
causing s e p a r a t i o n of t h e b l a c k b l a d e horn from t h e b l a c k b l a d e s l e e v e
assembly. Deep gouge marks on t h e t o p of t h e w h i t e b l a d e horn i n t h e a r e a
of the p i t c h change c o n t r o l rod e y e b o l t b o s s were matched w i t h damage on
the black b l a d e t r u n n i o n assembly, w i t h t h e b l a c k b l a d e i n a n o v e r t r a v e l
position.

Examination of damage observed on t h e y e l l o w b l a d e p i t c h change

c o n t r o l rod horn e y e b o l t showed i t was s t r u c k by t h e w h i t e b l a d e damper
assembly, c a u s i n g s p r e a d i n g of t h e w h i t e damper t r u n n i o n c l e v i s . In o r d e r
f o r t h i s c o n t a c t t o have o c c u r r e d , t h e w h i t e b l a d e would have had t o move
from a l a g t o a l e a d p o s i t i o n and t h e n t o a l a g p o s i t i o n of between Oo t o 7
0
.
Damage i n d i c a t e d t h a t t h e y e l l o w b l a d e had reached a n g l e s of 24O i n upward
f l a p , 20' t o 68 i n l e a d , and minus 'f i n p i t c h .

Damage on t h e b l u e b l a d e p i t c h change c o n t r o l r o d h o r n i n t h e e y e b o l t
boss a r e a showed t h a t i t had c o n t a c t e d t h e y e l l o w b l a d e h o r i z o n t a l h i n g e
pin a f t e r t h e h i n g e p i n had been broken. This c o n t a c t r e q u i r e d t h e y e l l o w
blade t o be a t a h i g h f l a p a n g l e and a n e a r - n e u t r a l l e a d / l a g a n g l e , and
f o r the b l u e b l a d e t o b e i n a l e a d p o s i t i o n . Damage showed t h a t subsequent
lag motion of t h e yellow b l a d e w i t h t h e h i g h f l a p and low p i t c h a n g l e s and
lead p o s i t i o n of t h e b l u e b l a d e r e s u l t e d i n c o n t a c t between t h e broken
yellow b l a d e h o r i z o n t a l h i n g e p i n and outboard f l a n g e of t h e b l u e b l a d e
p i t c h change c o n t r o l rod horn. This c o n t a c t r e s u l t e d i n s h e a r i n g o f f t h e
inboard f l a n g e of t h e b l u e b l a d e horn i n a n outboard d i r e c t i o n . S h e a r i n g
of the horn then allowed t h e b l u e b l a d e s l e e v e assembly t o o v e r l a p and rest
on the back s i d e of t h e y e l l o w b l a d e v e r t i c a l h i n g e p i n and on t h e t o p of
the yellow b l a d e h o r i z o n t a l h i n g e p i n .

Evidence i n d i c a t e s t h a t t h e r e d b l a d e went i n t o a l e a d d i r e c t i o n a t
low p i t c h a n g l e and i t s p i t c h change c o n t r o l rod horn e y e b o l t c o n t a c t e d
the c r o t c h of t h e lower p l a t e . T h i s t o r e o u t t h e r e d b l a d e horn from i t s
sleeve assembly.

The i n p u t s of t h e manual and a u t o m a t i c f l i g h t c o n t r o l systems (AFCS)

are a p p l i e d t o t h e s t a t i o n a r y s w a s h p l a t e which can move up and down and
through a n g l e s of p i t c h and l a t e r a l d e f l e c t i o n s . Movement of t h e
s t a t i o n a r y s w a s h p l a t e i s accomplished by t h e o p e r a t i o n of t h r e e primary
servos connected t o t h e s w a s h p l a t e a t t h r e e p o s i t i o n s around i t s circum-
ference. Each primary s e r v o i s f i x e d a t t h e lower end t o t h e main gearbox.

The primary s e r v o s a r e h y d r a u l i c a c t u a t o r s c o n t r o l l e d by mechanical

i n p u t s which a t t a c h t o t h e p i l o t s ' c o n t r o l s . A redundant h y d r a u l i c con-
t r o l f o r t h e s t a t i o n a r y s w a s h p l a t e i s provided by t h e a u x i l i a r y s e r v o s ,
which a r e mechanically i n series between t h e primary s e r v o s and p i l o t
c o n t r o l s . Each s e r v o system, primary and a u x i l i a r y , i s c a p a b l e of o p e r a t i n g
the s t a t i o n a r y s w a s h p l a t e i n response t o p i l o t i n p u t s . Each s e r v o system
i s independent h y d r a u l i c a l l y , each having i t s own f l u i d r e s e r v o i r , pump,
and plumbing. In normal o p e r a t i o n , b o t h s e r v o systems a r e i n o p e r a t i o n and
each responds t o t h e p i l o t i n p u t which p a s s e s through the a u x i l i a r y s e r v o
t o and through t h e primary s e r v o t o t h e s t a t i o n a r y swashplate.

The APCS i n p u t i s p a r a l l e l t o , b u t s e p a r a t e from, t h e p i l o t s ' i n p u t .

I t enters t h e system through the a u x i l i a r y servo. The c o n t r o l v a l v e o f
each a u x i l i a r y s e r v o ( e x c e p t a l t i t u d e ) can be m a g n e t i c a l l y p o s i t i o n e d i n
e i t h e r d i r e c t i o n by e l e c t r i c a l s i g n a l s from t h e AFCS. I t i s a t t h i s v a l v e
t h a t t h e p i l o t s ' i n p u t i s combined w i t h t h e AFCS i n p u t . However, the AFCS
i n p u t i s r e s t r i c t e d t o approximately 7 . 5 p e r c e n t o f t h e p i l o t s ' i n p u r
c a p a b i l i t y i n p i t c h , 10 p e r c e n t i n r o l l , and 5 p e r c e n t i n yaw. 11/ The
p i l o t s ' c o n t r o l i s mechanically a t t a c h e d t o t h e v a l v e , b u t t h e XFCS moves
a component of the same v a l v e m a g n e t i c a l l y .

C o n t r o l 1 of t h e r o t o r head i s accomplished through e i t h e r o r b o t h t h e

a u x i l i a r y s e r v o system o r t h e primary s e r v o system. A complex l i n k a g e
system around t h e a u x i l i a r y s e r v o s t r a n s f e r s p i l o t c o n t r o l movements t o the
primary s e r v o s whether o r n o t t h e a u x i l i a r y s e r v o s a r e i n o p e r a t i o n . When
o p e r a t i o n of t h e s t a t i o n a r y swashplate i s only c o n t r o l l e d by the a u x i l i a r y
s e r v o , t h e primary s e r v o s become mechanical l i n k s t o t h e swashplate. An
i n t e r l o c k i n g p r e s s u r e s e n s i n g system p r e v e n t s t h e s h u t t i n g o f f o f e i t h e r
system when t h e o t h e r has no h y d r a u l i c p r e s s u r e .

The above- described f l i g h t c o n t r o l system p o s i t i o n s t h e s t a t i o n a r y

swashplate, which i n t u r n , through t h e r o t a t i n g swashplate, p o s i t i o n s the
main r o t o r b l a d e s s o they f u n c t i o n as a d i s c . There i s no i n d i v i d u a l b l a d e
i n p u t from t h e p i l o t o r AFCS through e i t h e r o r both s e r v o systems. The
AFCS can be disconnected by e i t h e r p i l o t by d e p r e s s i n g a d i s c o n n e c t c u t o f f
b u t t o n s w i t c h on h i s c o l l e c t i v e c o n t r o l .

Examination of t h e f l i g h t c o n t r o l systems of t h e a i r c r a f t accounted

f o r a l l major components o f the systems. A s h o r t p i e c e of c o n t r o l rod,
about 2 i n c h e s i n l e n g t h , and about 40 inches of c o n t r o l c a b l e were n o t
recovered; however, t h e b r e a k s on each s i d e of the m i s s i n g p o r t i o n s were
overload f a i l u r e s .

A l l h y d r a u l i c l i n e s of the primary s e r v o f l i g h t c o n t r o l system were

recovered. The h y d r a u l i c r e s e r v o i r , although empty, showed evidence t h a t
f l u i d had been i n i t b e f o r e i t was s u b j e c t e d t o ground f i r e . The h y d r a u l i c
pump was f u n c t i o n a l and t h e p r e s s u r e s e n s i n g s w i t c h was o p e r a b l e and i n
t h e "on" p o s i t i o n . The f u n c t i o n of t h i s swi'tch i s t o p r e v e n t shutdown o f t h e
a u x i l i a r y c o n t r o l system i f t h e primary system l o s e s h y d r a u l i c p r e s s u r e .
X-ray of t h e c o n t r o l manifold showed t h a t i t s v a l v e was i n the "on"
position.

-
11/ The c i v i l v e r s i o n of t h e S-61L h e l i c o p t e r does n o t have AFCS
control input t o the c o l l e c t i v e c o n t r o l valve.
 - 13 -
Each of the t h r e e primary s e r v o s which p r o v i d e c o n t r o l i n p u t s t o t h e
s t a t i o n a r y swashplate was X-rayed and t h e i r i n t e r n a l components were
found i n p l a c e and s a f t i e d . Two of t h e primary s e r v o s f u n c t i o n e d normally
i n checks, w i t h o u t a l t e r a t i o n o r r e p a i r . The t h i r d f u n c t i o n e d p r o p e r l y
a f t e r c l e a r l y d e f i n e d c r a s h damage was r e p a i r e d .

The a u x i l i a r y s e r v o f l i g h t c o n t r o l system had r e c e i v e d g r e a t e r impact

and f i r e damage than t h e primary system. flowever, a l l h y d r a u l i c l i n e s
were accounted f o r , t h e r e was f l u i d i n t h e a u x i l i a r y h y d r a u l i c r e s e r v o i r ,
and the h y d r a u l i c pump was f u n c t i o n a l . The a u x i l i a r y s e r v o f l i g h t c o n t r o l
manifold would n o t f u n c t i o n because a l l s e a l s were blown due t o impact
and f i r e . I t s p r e s s u r e s e n s i n g s w i t c h was s o s e v e r e l y damaged t h a t no
functional t e s t i n g could be performed. The c o n t r o l manifold v a l v e was found
i n the "on" p o s i t i o n .

Study of t h e c o c k p i t c o n t r o l switch f o r b o t h t h e primary and a u x i -

l i a r y systems, which is l o c a t e d on t h e C a p t a i n ' s c o l l e c t i v e c o n t r o l ,
indicated i t was i n t h e " both on" p o s i t i o n . This would b e t h e p o s i t i o n
f o r normal f l i g h t .

Because of t h e b u l k of t h e a u x i l i a r y s e r v o housing, t h e f o u r a u x i -
l i a r y c o n t r o l v a l v e s 12/ f o r r o l l , p i t c h , yaw, and c o l l e c t i v e had t o b e
removed from t h e s e r v o housing t o b e X-rayed. The X-rays showed t h e i n -
t e r n a l c o n d i t i o n o f a l l of t h e c o n t r o l v a l v e s was good, w i t h t h e i r compo-
nents i n proper p o s i t i o n and s e c u r e d . The valves were t h e n p u t back on
the servo housing f o r f u n c t i o n a l t e s t i n g . Each of t h e v a l v e s proved func-
t i o n a l ; however, t h e mechanical c e n t e r i n g r e q u i r e d of t h e v a l v e a f t e r
c o n t r o l i n p u t appeared t o be i n c o r r e c t . Also, when c o n t r o l i n p u t from
the AFCS was a p p l i e d t o t h e r o l l c o n t r o l v a l v e , a " f o r c i b l e hardover" 131 -
occurred This meant t h e r e was i n s u f f i c i e n t motion i n t h e feedback
-
linkage 14' t o permit t h e r e q u i r e d r e c e n t e r i n g of t h e r o l l channel con-
t r o l . The o t h e r c o n t r o l v a l v e s responded t o t h e AFCS i n p u t s w i t h o u t
f o r c i b l e hardovers, b u t mechanical r e c e n t e r i n g c o n t i n u e d t o appear o f f i n
a l l of t h e c o n t r o l v a l v e s . T h i s improper c o n d i t i o n meant one o f t h r e e
things: t h a t t h e c o n t r o l v a l v e s had n o t been r e i n s t a l l e d on t h e a u x i l i a r y
servo housing i n p r e c i s e l y t h e same p o s i t i o n they had been i n b e f o r e
removal f o r X- raying; t h a t t h e s e r v o housing was d i s t o r t e d by impact; or
t h a t , p r i o r t o t h e c r a s h , there was improper adjustment i n t h e feedback

1 2 1 These v a l v e s a r e a l s o c a l l e d MOOG v a l v e s and d u a l i n p u t v a l v e s .

-
I

13/ This i s a c o n t r o l f o r c e t o t h e p i l o t ' s c y c l i c c o n t r o l which t h e

p i l o t would b e unable t o overcome. A hardover i s a c o n t r o l f o r c e
w i t h i n t h e l i m i t s of t h e AFCS which can be overcome w i t h no d i f f i c u l t y .
A hardover i s used i n p i l o t t r a i n i n g and i s induced through a hard-
over panel i n t h e a i r c r a f t f o r t h i s purpose.
-
14/ T h i s i s a l s o r e f e r r e d t o a s t h e sloppy l i n k a g e .
l i n k a g e which prevented p r o p e r r e c e n t e r i n g of t h e r o l l c o n t r o l v a l v e . The
f i r s t reaso a s subsequently determined t o b e t h e c a u s e of t h e improper
-
c o n d i t i o n . P5Y

During t h e examination of t h e AFCS, a second e l e c t r i c a l f a u l t was d i s -

covered. This was an e l e c t r i c a l s h o r t i n t h e c o n t r o l v a l v e f o r p i t c h
c o n t r o l i n p u t t o t h e a u x i l i a r y servo. More s p e c i f i c a l l y , t h e s h o r t was
caused by t h e flow of s o l d e r from t h e "A" p i n j o i n t t o t h e frame of t h e
c o n t r o l u n i t . The u n i t had been s u b j e c t e d to t h e postimpact ground f i r e
thereby p o s i n g t h e q u e s t i o n of whether t h e s o l d e r flow was caused by h e a t
g e n e r a t e d by t h e ground f i r e o r was t h e r e s u l t of a p r e a c c i d e n t manufac-
t u r i n g f a u l t , I t was subsequently concluded t h a t t h e most p r o b a b l e r e a s o n
f o r t h e s h o r t was t h e p o s t c r a s h exposure to f i r e . 161

Examination of t h e engines from N303Y r e v e a l e d both were developing

l i t t l e o r no power a t impact. The l a c k of f r i c t i o n a l d i s c o l o r a t i o n on
b e n t compressor b l a d e s and t h e l a c k of o v e r a l l damage t o t h e e n g i n e s
i n d i c a t e d they were a t o r n e a r i d l e r.p.m. a t impact. Examination of t h e
engines, however, showed no evidence of o p e r a t i o n a l d i s t r e s s , m a l f u n c t i o n ,
o r f a i l u r e p r i o r to impact. A l a c k of m e t a l f u s i o n on t h e t u r b i n e n o z z l e s
and t u r b i n e showed t h e s e p a r t s had cooled f o r s e v e r a l seconds and, a t impact,
were below o p e r a t i n g temperatures. According t o t h e manusacturer, t h e
engines w i l l c o o l i n a windmilling c o n d i t i o n t o about 750 F. i n about 3 t o 4
seconds. The engines w i l l slow t o i d l e from normal c r u i s i n g power i n 10
t o 1 5 seconds.

The engine i n l e t guide vanes a r e c o n t r o l l e d by an a c t u a t o r which i s

scheduled by t h e f u e l c o n t r o l . These guide vanes and t h e a c t u a t o r , i n t h e
i n s t a n c e of both e n g i n e s , were c l o s e d .

The t h r o t t l e connection a t t h e f u e l c o n t r o l s h a f t c o n s i s t s of a r a c k
and g e a r . Movement of t h e t h r o t t l e c a b l e r e p o s i t i o n s t h e r a c k which r o t a t e s
t h e g e a r t o open o r c l o s e t h e t h r o t t l e . I n t h e c a s e of b o t h e n g i n e s , each
t h r o t t l e c a b l e was found i n t h e engine s h u t o f f p o s i t i o n .

Examination of t h e main gearbox showed no evidence of o p e r a t i o n a l

d i s t r e s s , malfunction, o r f a i l u r e .

1.13 Fire
There was no evidence t o i n d i c a t e i n - f l i g h t f i r e was involved i n t h i s
a c c i d e n t ; however, an i n t e n s e ground f i r e o c c u r r e d a s t h e r e s u l t of ground
impact. The Paramount, C a l i f o r n i a , F i r e Department was n o t i f i e d and responded
t o t h e c r a s h about 1801.

-
151 See S e c t i o n 1.15,
d e t e r m i n a t i o n was
Tests and Research, f o r t h e manner i n which t h i s
made.
-
161 S e e S e c t i o n 1.15, Tests and Research, f o r t h e manner i n which t h i s
d e t e r m i n a t i o n was made.
 - 15 -
1.14 S u r v i v a l Aspects

This a c c i d e n t was n o t s u r v i v a b l e .

1.15 Tests and Research

Due t o t h e complex n a t u r e of t h i s a c c i d e n t and t h e numerous unexplained

f a c t o r s , a f t e r t h e p u b l i c h e a r i n g t h e e n t i r e r o t o r head, main r o t o r b l a d e s ,
and t h e s t a t i o n a r y and r o t a t i n g swashplates were taken t o t h e f a c i l i t i e s
of the a i r c r a f t manufacturer f o r f u r t h e r examination and f a i l u r e a n a l y s i s .
The work involved numerous t e s t s and r e s e a r c h r e q u i r i n g o v e r 1 y e a r .

Through m e t a l l u r g i c a l examination and Barcol hardness t e s t s , i t was

determined t h a t a l l c r i t i c a l f r a c t u r e s of t h e main r o t o r b l a d e s were
caused by overload. No evidence of f a t i g u e was found i n any of t h e f a i l -
ures, and metal hardness of t h e b l a d e s was e q u a l t o O K i n excess of s p e c i -
f i c a t i o n s . I n a d d i t i o n , i t was determined t h a t t h e yellow main r o t o r
blade was s u b j e c t e d t o extreme upward bending n e a r i t s inboard end and
downward bending over i t s mid and outboard a r e a s . M e t a l l u r g i c a l examina-
t i o n of t h e s e a r e a s r e v e a l e d no evidence of f a t i g u e OK m a t e r i a l d e f i c i e n c i e s .
The work d u r i n g t h i s phase a l s o served t o f u r t h e r v e r i f y t h a t t h e y e l l o w
blade s t r u c k t h e s i d e of t h e a i r c r a f t a s p r e v i o u s l y d e s c r i b e d . I t f u r t h e r
v e r i f i e d t h a t t h e b l a d e was dragged around t h e f r o n t of t h e a i r c r a f t and
r o t o r head, and t h a t t h e b l a d e d i d n o t p a r t i c i p a t e i n t h e b l a d e s t r i k e s
e i t h e r i n t h e f r o n t o r r e a r a r e a s .of t h e a i r c r a f t .

Because t h e b o l t which s e c u r e s t h e b e a r i n g cap t o t h e t r a i l i n g e a r

of the r o t a t i n g swashplate where t h e t r u n n i o n end of t h e yellow p i t c h
change c o n t r o l rod a t t a c h e s , was m i s s i n g and t h e e a r broken o f f , e x t e n s i v e
t e s t i n g was made t o determine i f t h e absence of t h i s b o l t under normal
loading on t h e c o n t r o l rod allowed t h e b e a r i n g cap t o be pushed o u t ,
thereby f a i l i n g t h e t r a i l i n g e a r and r e l e a s i n g t h e p i t c h c o n t r o l r o d .

Tile t e s t s e t u p simulated a p i t c h change c o n t r o l rod i n i t s p r o p e r

p o s i t i o n , w i t h t h e b e a r i n g cap a t t h e t r u n n i o n end secured by t h e upper
b o l t i n a normal manner and w i t h the lower b o l t i n s t a l l e d , b u t w i t h i t s
n u t only f i n g e r t i g h t .

Under t h e f i r s t t e s t u s i n g t h i s s e t u p , t h e c o n t r o l rod s h a f t was n o t

attached and l o a d i n g was a p p l i e d d i r e c t l y t o t h e t r u n n i o n end. Under a
loading of 2,000 pounds, t h e t r u n n i o n s u p p o r t p l a t e deformed b u t d i d n o t
f a i l . The deformation of t h e b e a r i n g cap was n o t enough t o e l i m i n a t e t h e
looseness o f t h e lower b o l t i n s t a l l a t i o n .

Under a second t e s t , w i t h &he c o n t r o l rod s h a f t i n s t a l l e d on t h e

trunnion end and t h e rod in a 4 lead p o s i t i o n , compression l o a d i n g of

-
171 As p r e v i o u s l y s t a t e d , normal l o a d i n g i s about 250 t o 300 pounds.
 - 16 -
7,800 pounds was a p p l i e d . Under t h e downward and rearward l o a d i n g imposed
i n t h i s manner, t h e r e were no f a i l u r e s and t h e b e a r i n g c a p , where the l o o s e
b o l t was i n s t a l l e d , was only d i s p l a c e d about 1 / 8 of an i n c h .

The f r a c t u r e a t the upper end of the yellow b l a d e p i t c h change

c o n t r o l rod i n t h e a r e a of upper c l e v i s was examined f o r evidence of f a t i g u e
and f o r p r o p e r metal composition and metal h a r d n e s s . I t was determined
t h a t t h e f r a c t u r e was caused by bending o v e r l o a d , and t h e m a t e r i a l i n t h e
f r a c t u r e a r e a met o r exceeded t h e s p e c i f i c a t i o n s f o r h a r d n e s s , c a s e d e p t h ,
and m a t e r i a l composition.

Laboratory examination of t h e b e a r i n g cap from t h e broken t r a i l i n g

e a r of t h e y e l l o w p i t c h change c o n t r o l rod swashplate attachment r e v e a l e d
i t was deformed away from t h e t r a i l i n g e a r i n t h e a r e a where t h e b e a r i n g
cap b o l t was missing and t h e r e was bending i n the same d i r e c t i o n i n the
a r e a of t h e b o l t , which remained s e c u r i n g i t t o t h e t r a i l i n g e a r . On t h e
i n s i d e rim a r e a of t h e cap, t h e r e were s e v e r a l s t r i k e marks. One was
i d e n t i f i e d a s having been made by the t r u n n i o n end o f t h e c o n t r o l rod which
normally f i t s i n t o t h e b e a r i n g of t h e b e a r i n g cap. The o t h e r s t r i k e marks
were matched w i t h t h e r a d i i and a r c s of t h e i n n e r and o u t e r r a c e s of t h e
b e a r i n g i t s e l f . This i n d i c a t e d t h e b e a r i n g was i n t a c t when t h e s t r i k e s
o c c u r r e d , t h e b e a r i n g i n f a c t came o u t o f t h e c a p , and t h e t r u n n i o n came
o u t of t h e b e a r i n g .

T h e remaining b o l t which s t i l l secured the b e a r i n g cap t o the t r a i l i n g

e a r was examined. I t was found t o have been b e n t under l o a d s i n t h e same
d i r e c t i o n a s t h o s e which deformed the cap outward from t h e e a r . The x a s h e r
i n s t a l l e d under t h e n u t was a l s o deformed from t h e same l o a d s .

The b o l t h o l e i n t h e b e a r i n g cap f o r t h e missing b o l t was examined.

The h o l e was i n t a c t b u t e l o n g a t e d by h e a t from t h e ground f i r e t o a n
e x t e n t t h a t a p r o p e r s i z e b o l t f o r t h e h o l e would n o t go through i t ,
showing t h a t a b o l t was n o t i n p l a c e when t h e b e a r i n g cap was exposed t o
the f i r e .

Laboratory examination of t h e t r a i l i n g e a r broken from t h e y e l l o w

b l a d e r o t a t i n g swashplate p i t c h change c o n t r o l rod attachment showed i t had
been s u b j e c t e d t o i n t e n s e ground f i r e . An approximate 120' segment was
missing. This p o r t i o n had been most probably burned away, a s b o t h s i d e s
of the missing p o r t i o n showed they were exposed t o h e a t which caused t h e
aluminum t o b e g i n t o flow. The f r a c t u r e of t h e e a r through t h e lower
b e a r i n g cap b o l t h o l e r e v e a l e d no evidence of f a t i g u e o r m a t e r i a l d e f i c i e n c y .
Also, a s e c t i o n c u t o u t o f t h e e a r f o r t e s t i n g r e v e a l e d no f a t i g u e o r
m a t e r i a l d e f i c i e n c y . M e t a l l u r g i c a l examination confirmed t h a t t h e l o a d i n g
which f a i l e d t h e e a r was i n a t r a i l i n g o r rearward d i r e c t i o n . I t was a l s o
a p p l i e d t o the lower a r e a of t h e e a r . The f a i l u r e l o a d i n g was s i m i l a r t o
t h a t which a c t e d on t h e b e a r i n g cap.

A s p r e v i o u s l y i n d i c a t e d , there were s e v e r a l s c r a t c h e s and heavy gouge

marks found on t h e s u r f a c e a r e a between t h e e a r s of t h e l e f t l a t e r a l
 - 17 -
primary s e r v o attachment p o i n t of t h e s t a t i o n a r y swashplate. I d e n t i f i c a -
t i o n of t h e s e marks was i m p o r t a n t because i t was c o n s i d e r e d p o s s i b l e they
i n d i c a t e d t h a t t h e m i s s i n g b e a r i n g cap b o l t had come o u t and jammed between
the r o t a t i n g swashplate t r a i l i n g e a r of t h e yellow b l a d e c o n t r o l rod a t t a c h -
ment, and t h e forward o r t r a i l i n g e a r of t h e s t a t i o n a r y swashplate l e f t
l a t e r a l primary s e r v o attachment and, i n t h i s manner, caused t h e f a i l u r e
of the t r a i l i n g e a r .

To i d e n t i f y t h e marks, a p l a s t i c c a s t was made of them. I t was found

t h a t the marks matched t h e trunnion end of t h e yellow b l a d e p i t c h c o n t r o l
rod with t h e rod a t an a n g l e i n an o v e r t r a v e l p o s i t i o n i n t h e yellow b l a d e
lead d i r e c t i o n . With t h e c o n t r o l rod i n t h i s p o s i t i o n , marks on t h e l e a d i n g
e a r of t h e c o n t r o l rod r o t a t i n g swashplate attachment matched marks on t h e
s h a f t p o r t i o n of t h e p i t c h c o n t r o l rod. I n a d d i t i o n , a b o l t of t h e m i s s i n g
kind could n o t b e p o s i t i o n e d i n any manner where i t could jam between t h e
aforementioned components and could make t h e s c r a t c h e s and gouges where they
were l o c a t e d . L a s t l y , t h e r e was no heavy t e a r - o u t on t h e aluminum compo-
nents which would be expected i f a steel b o l t , b e i n g much h a r d e r , j a m e d
between them.

The f o u r complete main r o t o r b l a d e damper a s s e m b l i e s and t h e a v a i l -

able p i s t o n and c y l i n d e r body of t h e b l a c k damper were given l a b o r a t o r y
examination and t e s t i n g . X-rays of t h e p i s t o n a s s e m b l i e s , which c o n t a i n
a l l the a d j u s t a b l e components a f f e c t i n g t h e i r performance w i t h e x c e p t i o n
of the d i f f e r e n t i a l check v a l v e package, d i s c l o s e d no s e r i o u s d e f e c t s .
The o r i f i c e flow f o r each p i s t o n was measured w i t h i n limits a t 250 p . s . i . g .
(pounds p e r s q u a r e i n . gage) d i f f e r e n t i a l p r e s s u r e . The i n s t r o k e and
o u t s t r o k e relief v a l v e s r e v e a l e d no s i g n i f i c a n t d i s c r e p a n c i e s i n a d j u s t m e n t ,
no excessive leakage, and t h e v a l v e s were p r o p e r l y s e a t e d . A l l damper l i n e s ,
passages, quick d i s c o n n e c t s , and o r i f i c e s were c l e a r of any blockages.

Examinations of t h e d i f f e r e n t i a l check v a l v e packages were made and

each was t e s t e d f o r flow and leakage. The r e s u l t s r e v e a l e d no d i s c r e p a n -
c i e s which would cause any problems t o normal f l i g h t .

The f a i l u r e of t h e b l a c k main r o t o r b l a d e damper p i s t o n rod was given

c a r e f u l m e t a l l u r g i c a l examination t o a s c e r t a i n t h e n a t u r e o f t h e f a i l u r e
and whether i t was of t h e p r o p e r m e t a l composition and h a r d n e s s . I n a d d i -
tion, f i v e o t h e r damper p i s t o n rods were i n t e n t i o n a l l y f a i l e d t o f i n d t h e
approximate l o a d i n g under which t h e rod from t h e a c c i d e n t a i r c r a f t should
have f a i l e d .

Examination of t h e f a i l u r e showed t h e m i s s i n g threaded end of t h e

damper p i s t o n had been t o r n o u t by l o a d s a p p l i e d a t a s l i g h t a n g l e o f f t h e
rod a x i s . The f r a c t u r e f a c t evidenced c o n s i d e r a b l e t e a r i n g and s h e a r i n g
from n e a r a x i a l t e n s i o n f o r c e s . m e r e was some secondary damage i n t h e
form of impressions and gouges on t h e f a c e of t h e f r a c t u r e . Using s t e r e o -
microscopic m a g n i f i c a t i o n s and e l e c t r o n m i c r o f r a c t o g r a p h y examinations, i t
was determined t h a t t h e r e was no f a t i g u e c o n d i t i o n i n t h e f r a c t u r e .
 - 18 -
Examination was made f o r p r o p e r m e t a l composition of t h e remaining
p o r t i o n of t h e p i s t o n r o d . Of t h e s i x elements composing t h e r o d , a l l
were w i t h i n p e r c e n t a g e s p e c i f i c a t i o n s . The h a r d n e s s of the rod i n t h e
f r a c t u r e a r e a was e q u a l t o t h e requirement f o r t h e r o d , Rockwell v a l u e C 4 2 .

The t e n s i l e f a i l u r e t e s t s performed on t h e f i v e damper p i s t o n s r e v e a l e d

an average b r e a k i n g load of over 53,000 pounds.

The quick d i s c o n n e c t a t t h e damper f l u i d r e s e r v o i r f o r t h e hose t o t h e

w h i t e b l a d e damper assembly was found d i s c o n n e c t e d and i t could n o t b e
e s t a b l i s h e d i f t h i s occurred a t impact, d u r i n g t h e wreckage movement and
examination, o r whether i t was a c o n d i t i o n which e x i s t e d p r i o r t o t h e
a c c i d e n t . Because of t h i s , a t e s t was run t o determine i f damper f l u i d
would d r a i n o u t of t h e damper assembly i f the quick d i s c o n n e c t became d i s -
connected i n f l i g h t p r i o r t o t h e a c c i d e n t . The s u s p e c t quick d i s c o n n e c t
was i n s t a l l e d on a r o t o r head w i t h o u t b l a d e s and t h e r o t o r head was r u n
f o r 1 hour a t 100 p e r c e n t normal r o t a t i o n w i t h t h e quick d i s c o n n e c t
d i s c o n n e c t e d . The leakage of f l u i d from t h e quick d i s c o n n e c t was found t o
be i n s i g n i f i c a n t a t 6 C C .

Another t e s t was run t o determine i f , under t h e most a d v e r s e f l i g h t

c o n d i t i o n which would r e s u l t i n t h e main r o t o r b l a d e s going t o the g r e a t e s t
lead p o s i t i o n , t h e p i t c h change c o n t r o l r o d s could be made t o c o n t a c t t h e
forward e a r of t h e r o t a t i n g swashplate p i t c h c o n t r o l rod a t t a c h m e n t . To
e f f e c t t h i s t e s t , .062 diameter s o l d e r i n g w i r e was taped t o t h e forward o r
l e a d s i d e of a p i t c h change c o n t r o l rod of a t e s t a i r c r a f t . The a i r c r a f t
was then flown i n t o one- engine- out a u t o r o t a t i o n a t 120 k n o t s t o produce
t h e maximum r o t o r b l a d e l e a d p o s i t i o n . The t e s t r e s u l t was t h a t t h e p i t c h
c o n t r o l rod d i d n o t go i n t o a l e a d p o s i t i o n s u f f i c i e n t t o c a u s e t h e s o l d e r
t o touch t h e forward e a r .
1
A s p r e v i o u s l y i n d i c a t e d , a f o r c i b l e hardover o c c u r r e d when AFCS c o n t r o l
i n p u t was a p p l i e d t o t h e r o l l c o n t r o l v a l v e of t h e f l i g h t c o n t r o l system.
This was a t t r i b u t e d t o t h r e e p o s s i b l e c a u s e s : improper r e p o s i t i o n i n g of
the v a l v e on a u x i l i a r y s e r v o housing a f t e r i t and t h e o t h e r c o n t r o l v a l v e s
were X-rayed, d i s t o r t i o n damage t o t h e a u x i l i a r y s e r v o h o u s i n g , o r an
1
improper adjustment of t h e v a l v e p r i o r t o t h e a c c i d e n t . To r e s o l v e t h e
p o s s i b i l i t i e s , t h e s e r v o housing was s u b j e c t e d t o u l t r a v i o l e t ( b l a c k l i g h t )
t o d i s c l o s e t h e s i g n a t u r e i m p r i n t of t h e v a l v e p o s i t i o n p r i o r t o i t s removal.
When t h i s was done, i t was shown t h a t t h e v a l v e had been p o s i t i o n e d
s l i g h t l y o f f when i t was p u t back on the s e r v o housing. When t h e v a l v e was
p o s i t i o n e d on t h e housing a c c o r d i n g t o t h e s i g n a t u r e i m p r i n t r e v e a l e d by
the u l t r a v i o l e t l i g h t , t h e f o r c i b l e h a r d o v e r -c o n d i t i o n was e l i m i n a t e d ,
although t h e v a l v e c e n t e r i n g was s l i g h t l y o u t of p r o p e r a d j u s t m e n t . The
s e r v o housing was n o t d i s t o r t e d .

T e s t s were r u n t o determine i f t h e s h o r t e d AFCS p i t c h c o n t r o l i n p u t

v a l v e t o the a u x i l i a r y s e r v o was the r e s u l t of t h e postimpact f i r e o r a
p r e a c c i d e n t manufacturing f a u l t . I n t h e t e s t s , new v a l v e s were h e a t e d
u n t i l components of t h e v a l v e s became d i s c o l o r e d t o approximately t h e same
I
- 19 -
d i s c o l o r a t i o n of t h e s u s p e c t u n i t . A t t h i s temperature, 350%. , t o 400°F.,
the s o l d e r flowed i n a s i m i l a r manner a s i t d i d i n t h e s u s p e c t u n i t . Exami-
nation of new u n i t s a l s o showed t h a t v o i d s d i d n o t e x i s t i n t h e p o t t i n g
compound around the s o l d e r e d j o i n t s a s t h o s e found i n t h e s u s p e c t u n i t .
42.
Additional t e s t s a l s o i n d i c a t e d t h a t i f t h e s h o r t e d v a l v e e x i s t e d p r i o r t o
the a c c i d e n t , i t would have been a p p a r e n t d u r i n g p r e f l i g h t checks and
aled
normal f l y i n g . The v a l v e had been on t h e a i r c r a f t f o r s e v e r a l hundred h o u r s .
I n view of t h e s e f a c t o r s and t e s t s , i t was concluded t h a t t h e s h o r t e d v a l v e
ihe r e s u l t e d from the f i r e a f t e r impact.

A t the r e q u e s t of t h e S a f e t y Board, Sikorsky A i r c r a f t conducted an

a n a l y t i c a l study t o determine t h e e f f e c t on t h e S- 61L main r o t o r b l a d e
motion from a l o s s of damping. The a n a l y s i s recognized t h a t f o r e and a f t
3-
(lead and l a g ) t r a v e l of a h e l i c o p t e r r o t o r b l a d e can sometimes b e induced
because of the r e l a t i o n s h i p of t h e r i g i d body l a g and f l a p p i n g modes of an
a r t i c u l a t e d r o t o r when k i n e m a t i c c o u p l i n g i n t h e c o n t r o l system produces
a decrease i n b I a d e p i t c h a s t h e b l a d e l a g s back ( p o s i t i v e b l a d e a n g l e ) .
IO
I f i n s u f f i c i e n t damping i s a v a i l a b l e due t o some f a i l u r e i n t h e l a g damper,
excessive b l a d e t r a v e l can b u i l d up.

The p i t c h - l a g k i n e m a t i c c o u p l i n g of t h e S- 61L main r o t o r b l a d e was

3s t found t o be such t h a t l a g damping i s n e c e s s a r y t o p r e v e n t e x c e s s i v e p i t c h -
?
lag blade t r a v e l . F o r t h o s e r o t o r systems i n which an i n c r e a s e i n l a g
angle (blade l a g g i n g hack) c a u s e s a d e c r e a s e i n b l a d e p i t c h , t h e c o u p l i n g
)r produces a n e g a t i v e damping f o r c e a s a r e s u l t of l a g motions a t t h e l a g
n a t u r a l frequency. This phenomenon i n v o l v e s C o r i o l i s c o u p l i n g between
pitch and l a g . V i b r a t o r y edgewise motion i n t h e l a g d i r e c t i o n a t t h e l a g
:h n a t u r a l frequency produces a n e g a t i v e p i t c h change which c a u s e s a n e a r l y
?r in-phase response i n f l a p p i n g . For p o s i t i v e coning a n g l e s , t h e r e s u l t i n g
edgewise C o r i o l i s f o r c e i s p r o p o r t i o n a l t o f l a p p i n g v e l o c i t y and i s t h e r e -
fore i n phase w i t h and i n t h e d i r e c t i o n of t h e l a g v e l o c i t y . This i s a
:rol negative damping f o r c e ; t o c o u n t e r a c t and m a i n t a i n s t a b i l i t y t h e a v a i l a b l e
lag damping m u s t be g r e a t e r . S i n c e aerodynamic damping i n p l a n e i s s m a l l ,
the l a g damper m u s t p r o v i d e t h e n e c e s s a r y damping.
5s
A second s t e p i n t h e a n a l y s i s was t o determine t h e e f f e c t of l a g
motion of t h e undamped b l a d e on t h e response of t h e o t h e r b l a d e s . An
analysis was developed which c o n s i d e r e d on t h e l a g motions of t h e b l a d e s
It)
)Val. and the response of t h e a i r f r a m e a s a r i g i d body. The a n a l y s i s was based
on the development used by Coleman 3 ' f o r ground resonance a n a l y s i s , b u t
ra s the r e s u l t a n t l i n e a r i z e d e q u a t i o n s of motion were solved t o determine t h e
response of a l l b l a d e s and t h e a i r f r a m e t o a u n i t a m p l i t u d e of motion of
one blade a t the l a g n a t u r a l frequency. The a n a l y s i s showed t h a t t h e two
blades o p p o s i t e t h e e x c i t i n g b l a d e would respond w i t h a m p l i t u d e s of a p p r o x i -
mately 60 p e r c e n t of t h e a m p l i t u d e of t h e e x c i t i n g b l a d e .

The a n a l y s i s was then expanded t o i n c l u d e the e f f e c t of b l a d e f l a p p i n g .

The p i t c h and r o l l components of hub i n p l a n e response of t h e o r i g i n a l
a n a l y s i s were determined, and e q u a t i o n s w r i t t e n t o determine f l a p p i n g
Le response due t o p i t c h and r o l l of t h e hub. This f l a p p i n g produces a

-
18/ Coleman R . P . "Theory of S e l f
Rotor Elades" NACA ARR G 2 9 ,
E x c i t e d Mechanical O s c i l l a t i o n s of Hinged
1943 r e i s s u e d a s NACA Rpt. 1351, 1958.
 - 20 -
C o r i o l i s f o r c e i n t h e l a g e q u a t i o n . By combining r e l a t i o n s , t h e f l a p p i n g
e f f e c t can b e reduced t o a set of a d d i t i o n a l c o u p l i n g terms between b l a d e
l a g motion and hub motion. These terms were found t o b e i n s i g n i f i c a n t .
Only minor changes i n response of t h e o t h e r b l a d e s were found.

I t then appeared t h a t , t o have i n t e r f e r e n c e between t h e b l a d e s , o r

even between t h e c o n t r o l s ( p i t c h h o r n l p i t c h change rod c o n n e c t i o n and t h e
a d j a c e n t b l a d e damper c l e v i s / h o r i z o n t a l p i n connection) of a d j a c e n t b l a d e ,
w i t h i n p r a c t i c a l f l a p p i n g and c o n t r o l limits, t h e limits imposed by t h e
damper s t o p s would have t o b e e l i m i n a t e d . I n o t h e r words, a damper would
have t o b e broken l o o s e o r t h e c o n n e c t i o n between i t and i t s a s s o c i a t e d
b l a d e s e p a r a t e d . I n t h e i n s t a n t c a s e , t h e s t o p l i m i t a t i o n s were broken o u t .

A s a r e s u l t of t h i s s t u d y , t h e f o l l o w i n g o b s e r v a t i o n s were made:

(1) Loss of damping a c t i o n on one b l a d e , through some f a c t o r

such a s loss of f l u i d o r s e p a r a t i o n of a damper s h a f t ,
can c a u s e l a r g e l a g o s c i l l a t i o n s of t h e undamped b l a d e
a t i t s l a g n a t u r a l frequency.

(2) The l a g o s c i l l a t i o n s of an undamped b l a d e can c a u s e a

s i m i l a r l e a d - l a g r e s p o n s e i n t h e two opposing b l a d e s ,
w i t h a m p l i t u d e s of approximately 60 p e r c e n t o f t h e
e x c i t i n g blade.

2. ANALYSIS AND CONCLUSIONS

2.1 Analysis

From t h e o v e r a l l p h y s i c a l e v i d e n c e , damage p a t t e r n s , t e s t s and

r e s e a r c h , and f a i l u r e a n a l y s e s t h a t were conducted i n c o n n e c t i o n w i t h t h i s
a c c i d e n t , t h e sequence o f e v e n t s f o l l o w i n g t h e i n i t i a l c a u s e i s r e a s o n a b l y
c l e a r . However, d e s p i t e e x t e n s i v e i n v e s t i g a t i v e e f f o r t s , t h e i n i t i a t i n g
c a u s e i s more obscure.

The o v e r a l l evidence i n d i c a t e s t h a t t h e sequence began w h i l e t h e

a i r c r a f t was i n c r u i s i n g f l i g h t about 2,000 f e e t above t h e s u r f a c e and
about 2 to 2 - 1 / 2 miles e a s t of where i t c r a s h e d . From t h e p h y s i c a l damage
found i n t h e components of t h e r o t o r head and p a t t e r n s of t h i s damage,
i t i s e v i d e n t t h a t t h e b l a c k , y e l l o w , and b l u e main r o t o r b l a d e s , followed
by t h e r e d and w h i t e , underwent a s e r i e s of extreme e x c u r s i o n s i n t h e i r
l e a d / l a g a x i s . These e x c u r s i o n s a r e c l e a r l y r e f l e c t e d by t h e s h e a r i n g of
b l a d e h o r i z o n t a l h i n g e p i n s , f a i l u r e s of t h e b l a d e damper p i s t o n s , and
damage t o damper housing a s s e m b l i e s . The o v e r a l l damage p a t t e r n s n o t o n l y
showed t h a t m u l t i p l e e x c u r s i o n s had o c c u r r e d , b u t a l s o t h a t some were so
extreme t h a t one b l a d e would even o v e r l a p t h e b l a d e n e x t t o i t . In one
i n s t a n c e , t h e p i t c h change horn of t h e yellow b l a d e j a m e d under t h e h o r i -
z o n t a l h i n g e p i n of t h e w h i t e b l a d e w h i l e t h e y e l l o w b l a d e was i n an extreme
l e a d p o s i t i o n . I t i s very p r o b a b l e t h a t i t was a t t h i s time t h e forward
 - 21 -
Iping s i d e of t h e yellow b l a d e p i t c h change c o n t r o l rod made c o n t a c t w i t h t h e
lade
leading e a r of i t s attachment t o t h e r o t a t i n g swashplate. I t i s a l s o
.t.
probable t h a t a t t h i s time t h e detachment f a i l u r e of t h e y e l l o w p i t c h change
c o n t r o l rod occurred.
or For s e v e r a l r e a s o n s , t h e S a f e t y Board concludes t h a t t h e l e a d and l a g
the excursions preceded and caused t h e detachment of t h e y e l l o w b l a d e p i t c h
lade,
change c o n t r o l rod a t i t s attachment t o t h e r o t a t i n g swashplate.
Lle
ould The f i r s t reason i s t h a t t h e damage and damage p a t t e r n s t o t h e compo-
ed
nents i n t h e l e a d and l a g a r e a s of t h e y e l l o w b l a d e were of t h e same type
en o u t . and extent as t h o s e found on t h e same components of t h e o t h e r b l a d e s . This
showed t h a t t h e yellow b l a d e must have p a r t i c i p a t e d i n t h e l e a d / l a g excur-
sions and was, t h e r e f o r e , i n t h e r o t o r d i s c a t t h e time they o c c u r r e d . Con-
v e r s e l y , s t r u c t u r a l examination r e v e a l e d c l e a r s t r i k e damage by t h e r e d ,
black, white, and b l u e b l a d e s i n both c o c k p i t and a f t p o r t i o n s of t h e a i r -
c r a f t , with the s t r i k e s progressively deeper i n t h e s t r u c t u r e i n t h e order
of blade r o t a t i o n . % e r e was no evidence of s t r i k e damage by t h e y e l l o w
blade on e i t h e r p o r t i o n of t h e a i r c r a f t . I t i s r e a s o n a b l e t o b e l i e v e t h a t
had the yellow b l a d e been i n t h e r o t o r d i s c and i n i t s normal p o s i t i o n
between t h e w h i t e and b l u e b l a d e s , i t would have i n f l i c t e d some of t h e damage.

A second reason i s t h a t t h e e y e w i t n e s s i n f o r m a t i o n c l e a r l y s u g g e s t s
the p i l o t s were a b l e t o descend t h e a i r c r a f t under p a r t i a l c o n t r o l from
about 2,000 f e e t above t h e ground t o between 600 and 800 f e e t b e f o r e t h e
s e r i e s of b l a d e s t r i k e s d e s t r o y e d t h e i n t e g r i t y of t h e a i r c r a f t and i t f e l l
u n c o n t r o l l a b l y t o the ground. Had t h e y e l l o w b l a d e become detached and h i t
the s i d e of the a i r c r a f t as t h e i n i t i a l o c c u r r e n c e , t h e a i r c r a f t would have
gone out of c o n t r o l immediately, making t h e d e s c e n t of some 1,200 f e e t o v e r
about 2 t o 2- 1/2 m i l e s i m p o s s i b l e . Eyewitness i n f o r m a t i o n i n d i c a t e s t h e
a i r c r a f t f e l l , n e a r v e r t i c a l l y , almost immediately a f t e r the r o t o r b l a d e s
:his s t r u c k t h e a i r c r a f t s e p a r a t i n g p i e c e s of s t r u c t u r e from.it.
blY
'g Another c o n s i d e r a t i o n i n t h e c o n c l u s i o n i s t h a t , had t h e y e l l o w b l a d e
p i t c h change c o n t r o l rod become detached i n i t i a l l y , i t i s improbable t h a t
the extreme l e a d and l a g e x c u r s i o n s of t h e o t h e r r o t o r b l a d e s would have
been t h e expected r e s u l t . This i s because when t h e b l a d e became f r e e , i t
was u n r e s t r a i n e d i n i t s p i t c h and f l a p a x i s . With i t s aerodynamic tendency
w e t o descent i n t h e r e t r e a t i n g ( l e f t h a l f ) p o r t i o n of r o t a t i o n and rise i n
the advancing ( r i g h t h a l f ) p o r t i o n , t h e b l a d e would n o t b e expected t o remain
wed
i n the plane of r o t a t i o n f o r any extended p e r i o d . Consequently, i t must
have s t r u c k t h e s i d e of t h e a i r c r a f t very s h o r t l y a f t e r i t s detachment.
of Once i t h i t t h e s i d e of t h e a i r c r a f t , was dragged around t h e f r o n t o f t h e
a i r c r a f t , and was wrapped around t h e r o t o r head, t h e r o t a t i o n of the main
nlY r o t o r head would have d e c e l e r a t e d so r a p i d l y t h e r e would have been i n s u f f i -
0
c i e n t time f o r t h e m u l t i p l e l e a d and l a g e x c u r s i o n s t o have taken p l a c e .
F u r t h e r , the f o r c e s r e s u l t i n g from t h e b l a d e h i t t i n g t h e a i r c r a f t should
ri- have been i n t h e l a g d i r e c t i o n r a t h e r than i n b o t h t h e l e a d and l a g d i r e c t i o n s .
xeme
1 Another, and probably t h e most convincing r e a s o n , i s t h e manner of
detachment of t h e y e l l o w b l a d e p i t c h change c o n t r o l r o d i t s e l f . P h y s i c a l
evidence and t e s t s and r e s e a r c h showed t h a t f o r t h e t r u n n i o n b e a r i n g cap
 - 22 -
t o have been pushed o u t and t o have f a i l e d t h e t r a i l i n g a t t a c h m e n t e a r ,
a l l o w i n g t h e t r u n n i o n t o come o u t o f t h e b e a r i n g , t h e downward and r e a r -
ward l o a d i n g on t h e c o n t r o l rod must have been many times t h e normal
o p e r a t i n g l o a d s . I n t h e S;.fety B o a r d ' s o p i n i o n , t h e extreme l e a d and l a g
e x c u r s i o n s were r e s p o n s i b l e f o r t h i s l o a d i n g . More s p e c i f i c a l l y , i t seems
p r o b a b l e t h a t t h e s e f o r c e s were g e n e r a t e d when t h e yellow b l a d e p i t c h
change c o n t r o l horn jammed under t h e w h i t e b l a d e h o r i z o n t a l h i n g e p i n . I n
t h i s s i t u a t i o n , t h e yellow b l a d e p i t c h change c o n t r o l rod could have r e s t e d
on t h e forward e a r of t h e y e l l o w p i t c h change c o n t r o l rod r o t a t i n g swash-
p l a t e attachment. This would c r e a t e a fulcrum e f f e c t , and when t h e y e l l o w
b l a d e , i n i t s jammed p o s i t i o n , t r i e d t o r e a c t aerodynamically and t o
c o l l e c t i v e c o n t r o l imputs i n i t s f l a p a x i s , the n e c e s s a r y l o a d i n g was pro-
duced t o c a u s e t h e detachment f a i l u r e .

From an a n a l y t i c a l v i e w p o i n t , i t i s p r o b a b l e t h a t t h e detachment of
t h e y e l l o w b l a d e a l s o caused o r c o n t r i b u t e d t o c a u s i n g t h e b l a d e s t r i k e s
on t h e a i r c r a f t . When t h e yellow b l a d e became d e t a c h e d , i t would have been
u n c o n t r o l l a b l e i n i t s p i t c h and f l a p axes and f r e e t o c r e a t e an extreme
imbalance i n t h e r o t o r head. Such imbalance could w e l l have caused t h e
main r o t o r head t o d i s p l a c e i n such a manner a s t o d e f l e c t t h e o t h e r f o u r
r o t o r b l a d e s downward i n t o t h e f r o n t and r e a r s t r u c t u r e of t h e a i r c r a f t .

Based on t e s t s and r e s e a r c h , and f o r t h e r e a s o n s s t a t e d above, t h e

S a f e t y Board concludes t h a t t h e extreme main r o t o r b l a d e e x c u r s i o n s i n
t h e i r l e a d / l a g a x i s o c c u r r e d f i r s t i n t h e sequence r e s u l t i n g from t h e
i n i t i a l a c c i d e n t c a u s e , and t h a t t h e detachment f a i l u r e of t h e y e l l o w b l a d e
p i t c h change c o n t r o l rod r e s u l t e d from o v e r l o a d s c r e a t e d by t h e extreme
b l a d e e x c u r s i o n s . Based on m e t a l l u r g i c a l e x a m i n a t i o n s , i t i s f u r t h e r con-
cluded t h e r e was no f a t i g u e o r m a t e r i a l d e f i c i e n c i e s i n v o l v e d i n t h e d e t a c h -
ment f a i l u r e ; and based on t e s t s and r e s e a r c h , t h e absence of t h e b e a r i n g
cap b o l t a t t h e t r u n n i o n attachment p o i n t d i d n o t c a u s e o r c o n t r i b u t e t o
t h e c a u s e of t h e yellow p i t c h rod detachment. The absence of t h e b e a r i n g
cap b o l t may have r e s u l t e d from i t s n u t b e i n g s t r i p p e d o f f d u r i n g t h e
extreme l o a d i n g on t h e b e a r i n g cap, o r i t may be r e f l e c t i v e of a m a i n t e -
nance omission.

Concluding, f o r t h e r e a s o n s s t a t e d above, t h a t t h e r e s u l t i n g sequence

of e v e n t s began w i t h t h e extreme l e a d and l a g e x c u r s i o n s of t h e main r o t o r
b l a d e s , t h e S a f e t y Board e x p l o r e d numerous p o s s i b l e r e a s o n s f o r t h e ex-
c u r s i o n s . Much of t h e t e s t i n g and r e s e a r c h was d i r e c t e d t o t h i s purpose,
and t h e a i r c r a f t manufacturer a s s i s t e d t o a maximum e x t e n t w i t h i t s f a c i l i -
t i e s and e x p e r t i s e .

Considered were t h e f a i l u r e of a main r o t o r b l a d e , t h e f a i l u r e o r

s e i z u r e of t h e main r o t o r gearbox, t h e f a i l u r e of a main r o t o r b l a d e
s p i n d l e , and t h e f a i l u r e of a s e r v o connection. A l l of t h e s e p o s s i b i l i t i e s
have t h e p o t e n t i a l f o r c r e a t i n g t h e e x c u r s i o n s ; however, they can b e d i s -
missed d e f i n i t i v e l y on t h e p h y s i c a l evidence and m e t a l l u r g i c a l examination
which c l e a r l y showed none of them had occurred.
 - 23 -
Both engines were developing l i t t l e o r no power a t impact, with
damage i n d i c a t i n g an approximate 15 p e r c e n t r o t a t i o n a l speed. This
suggested t h e p o s s i M i t y of a t o t a l power f a i l u r e s i t u a t i o n i n which t h e
p i l o t d i d n o t lower c o l l e c t i v e c o n t r o l f o r a u t o r o t a t i o n q u i c k l y enough.
This could r e s u l t i n a s e r i o u s main r o t o r speed l o s s and b l a d e s t a l l , t h u s
causing t h e extreme l e a d and l a g b l a d e e x c u r s i o n s . This p o s s i b i l i t y was
concluded by t h e S a f e t y Board a s b e i n g remote f o r s e v e r a l r e a s o n s . F i r s t ,
t h e r e was no evidence of engine m a l f u n c t i o n o r f a i l u r e . Each engine h a s
a s e p a r a t e f u e l system, and t h e p i l o t who was h i g h l y experienced could be
expected t o r e a c t promptly and e f f i c i e n t l y t o a power f a i l u r e . Addi-
t i o n a l l y , according t o t h e a i r c r a f t m a n u f a c t u r e r , a s e r i o u s b l a d e s t a l l
would r e s u l t i n e r r a t i c p i t c h a t t i t u d e changes of t h e a i r c r a f t which a r e
not i n d i c a t e d b y ground w i t n e s s o b s e v a t i o n s .

The S a f e t y Board i s of t h e o p i n i o n t h a t t h e l a c k of engine power

development was most probably t h e r e s u l t of t h e p i l o t s ' r e a c t i o n t o what
they knew was a most c r i t i c a l s i t u a t i o n and t o reduce, t o t h e e x t e n t p o s s i b l e ,
the c r a s h f i r e hazard. This r e a s o n i s supported by t h e l a s t t r a n s m i s s i o n
from the a i r c r a f t , "LA, w e ' r e c r a s h i n g ....1,

There were two s e v e r e impact damage marks on t h e yellow b l a d e a t t h e

j u n c t i o n of i t s t i p cap and b l a d e s p a r , t h e c a u s e of which could n o t b e
i d e n t i f i e d s a t i s f a c t o r i l y . This gave r i s e t o t h e p o s s i b i l i t y t h a t a
f o r e i g n o b j e c t had s t r u c k t h e b l a d e , d e f l e c t i n g i t c r i t i c a l l y or damaging
i t s p i t c h c o n t r o l components. However, one damage mark was n o t c o n s i d e r e d
of s u f f i c i e n t magnitude t o have c r e a t e d a problem and was dismissed a s
incapable of c a u s i n g a c r i t i c a l f a i l u r e i n t h e r o t o r head. The o t h e r mark,
because of o t h e r impact marks superimposed over i t , was c o n s i d e r e d t o have
occurred following s e p a r a t i o n of p i e c e s of the yellow b l a d e . This l a t t e r
mark, although s e v e r e , d i d n o t c a u s e s e p a r a t i o n of t h e b l a d e t i p cap and
was, t h e r e f o r e , a l s o c o n s i d e r e d i n c a p a b l e of c a u s i n g a c r i t i c a l c o n t r o l
f a i l u r e of the r o t o r head.

Another p o s s i b l e c a u s e , c a r e f u l l y c o n s i d e r e d , f o r t h e extreme l e a d
and l a g excursions was a m a l f u n c t i o n of t h e AFCS a l o n e , o r i n c o n j u n c t i o n
w i t h a maladjustment of t h e AFCS s e r v o , r e s u l t i n g i n a f o r c i b l e hardover
i n the yaw, p i t c h , o r r o l l axes of the a i r c r a f t . There a r e s e v e r a l
reasons f o r d i s m i s s i n g t h i s p o s s i b i l i t y .

The primary r e a s o n i s t h a t any c o n t r o l i n p u t t o t h e c o n t r o l system

a f f e c t s a l l f i v e b l a d e s n e a r l y s i m u l t a n e o u s l y and no one b l a d e a l o n e . This
cannot change i f c o n t r o l i n p u t was manual o r was an i n p u t i n t h e form of
an AFCS f o r c i b l e hardover from system m a l f u n c t i o n or maladjustment. In
t h i s a c c i d e n t , t h e evidence i s c l e a r t h a t t h e y e l l o w b l a d e was o u t of t h e
r o t o r d i s c when t h e o t h e r b l a d e s c u t i n t o t h e f r o n t and r e a r a r e a s of t h e
a i r c r a f t . I t i s t h e r e f o r e e v i d e n t t h a t t h e yellow b l a d e must have been
a f f e c t e d s i n g u l a r l y and b e f o r e t h e b l a d e s t r i k e s o c c u r r e d .

Another f a c t o r i s t h a t p r o p e r l y a d j u s t e d , t h e AFCS h a s l i m i t e d a u t h o r i t y
and, i n t h e event of m a l f u n c t i o n of t h e system, i t can immediately be c u t
off by e i t h e r p i l o t by d e p r e s s i n g a b u t t o n s w i t c h on h i s c o l l e c t i v e c o n t r o l .
 - 24 -
F i n a l l y , examination and tests and r e s e a r c h work on t h e a u x i l i a r y
s e r v o c o n t r o l i n p u t systems reasonably determined t h a t maladjustment a n d / o r
m a l f u n c t i o n of t h e sloppy l i n k a g e and i n p u t c o n t r o l v a l v e s d i d n o t e x i s t ,
A d d i t i o n a l v e r i f i c a t i o n of t h i s c o n c l u s i o n exists i n t h a t maladjustment
of t h e c o n t r o l i n p u t systems should have been e v i d e n t d u r i n g o p e r a t i o n of
t h e c o n t r o l systems. None of t h e p i l o t w r i t e u p s on t h e AFCS were i n d i c a -
t i v e of maladjustment o r m a l f u n c t i o n of t h e c o n t r o l systems.

The S a f e t y Board b e l i e v e s t h a t based on a l l t h e evidence, b o t h p o s i -

t i v e and n e g a t i v e , tests and r e s e a r c h , and f a i l u r e s t u d i e s , t h e extreme
e x c u r s i o n s occurred f i r s t a s a r e s u l t of t h e i n i t i a t i n g cause. From t h i s
c o n c l u s i o n , i t i s e v i d e n t t h a t t h e i n i t i a t i n g cause had t o be one which
would a f f e c t t h e b l a d e s i n t h e i r l e a d and l a g a x i s . In t h i s a c c i d e n t most
s u s p e c t w i t h t h i s c a p a b i l i t y would be a l o s s of damper i n t e g r i t y r e s u l t i n g
from a f a i l u r e of t h e b l a c k main r o t o r b l a d e damper o r a loss e f f e c t i v e
damping a c t i o n by t h e w h i t e main r o t o r b l a d e damper. These p o s s i b i l i t i e s
w i l l be d i s c u s s e d more f u l l y l a t e r i n t h e r e p o r t .

Based on t h e a n a l y t i c a l s t u d y and tests by S i k o r s k y A i r c r a f t and

o t h e r t e c h n i c a l d a t a (see r e f e r e n c e s i n f o o t n o t e s 18 and 1 9 ) , t h e Board
concludes i t would b e p o s s i b l e f o r t h e main r o t o r b l a d e s t o become u n s t a b l e
i n t h e l e a d / l a g a x i s a s t h e r e s u l t of a l o s s of a b l a d e damper i n t e g r i t y .
The s t u d y and r e f e r e n c e d a t a i n d i c a t e t h a t i n a r o t o r system w i t h t h r e e o r
more b l a d e s , t h e b l a d e s a r e a t t a c h e d to t h e r o t o r hub by a h o r i z o n t a l h i n g e
which p e r m i t s t h e b l a d e s t o move i n a v e r t i c a l p l a n e , i.e., f l a p up o r
d m a s they r o t a t e . In forward f l i g h t , l i f t i n c r e a s e s on advancing b l a d e s
c a u s i n g t h e b l a d e s t o f l a p up, which d e c r e a s e s t h e a n g l e of a t t a c k . L i f t
d e c r e a s e s on t h e r e t r e a t i n g b l a d e s c a u s i n g t h e r b l a d e s t o f l a p down, i n -
c r e a s i n g t h e a n g l e of a t t a c k . The combination of d e c r e a s i n g a n g l e of
a t t a c k on t h e advancing b l a d e s and i n c r e a s i n g a n g l e of a t t a c k on t h e
r e t r e a t i n g b l a d e through b l a d e f l a p p i n g a c t i o n t e n d s t o e q u a l i z e t h e l i f t
over t h e two s i d e s of t h e r o t o r d i s c .

A s a main r o t o r b l a d e f l a p s up on t h e advancing s i d e , i t must speed

up and a s i t f l a p s down on t h e r e t r e a t i n g s i d e , i t must slow down. This
i s because t h e d i s t a n c e of t h e c e n t e r of mass from t h e a x i s of r o t a t i o n
(measured p e r p e n d i c u l a r t o t h e a x i s of r o t a t i o n ) times t h e r o t a t i o n a l
v e l o c i t y must always remain t h e same f o r a given r o t o r r.p.m. Since the
d i s t a n c e becomes s h o r t e r when t h e b l a d e s f l a p up, t h e r o t a t i o n a l v e l o c i t y
must i n c r e a s e ; c o n v e r s e l y , when t h e b l a d e s f l a p d m , t h e d i s t a n c e becomes
g r e a t e r and t h e r o t a t i o n a l v e l o c must d e c r e a s e . T h i s phenomenon i s a n
f6Y
-
a p p l i c a t i o n of C o r i o l i s e f f e c t .

-
19/ F o r a more d e t a i l e d d i s c u s s i o n of C o r i o l i s e f f e c t , a s t h e phenomenon
applies t o helicopters, the reader i s referred t o the following
publications:
1. Sikorsky H e l i c o p t e r F l i g h t Theory f o r P i l o t s and Mechanics,
Sikorsky A i r c r a f t D i v i s i o n of United A i r c r a f t C o r p o r a t i o n ,
USA, 1964, a l l r i g h t s r e s e r v e d ( c h a p t e r 6 ) .
2 . B a s i c H e l i c o p t e r Handbook, 1965, F e d e r a l A v i a t i o n Agency,
U.S.Government P r i n t i n g O f f i c e , (pages 1 3 & 14).
 - 25 -
I n a d d i t i o n t o t h e C o r i o l i s e f f e c t which produces speed up and slow
d a m of the b l a d e s i n t h e i r p l a n e of r o t a t i o n , t h e r e i s t h e a c c e n t u a t i n g
e f f e c t of t h e change i n a n g l e of a t t a c k which accompanies t h e b l a d e f l a p -
ping. With a i r s p e e d c o n s t a n t , an i n c r e a s e i n a n g l e of a t t a c k of a n a i r f o i l
is accompanied by an i n c r e a s e i n drag. The d r a g i n t h i s i n s t a n c e t e n d s
t o f u r t h e r slow d a m t h e r e t r e a t i n g b l a d e , w h i l e t h e d e c r e a s e i n d r a g i n
the advance blade tends t o a i d t h e speed up.

The change of b l a d e v e l o c i t y i n t h e p l a n e of r o t a t i o n c a u s e s l e a d
and l a g a c t i o n about t h e v e r t i c a l hinge. This a c c e l e r a t i o n o r d e c e l e r a t i o n
(lead and l a g ) is absorbed by t h e dampers.

Another m a n i f e s t a t i o n of C o r i o l i s e f f e c t o c c u r s when t h e rotor system

i s t i l t e d a s i n forward f l i g h t . I n t h i s c o n d i t i o n , t h e forward b l a d e s a r e
flapping d a m w h i l e t h e rearward b l a d e s a r e f l a p p i n g up. The c e n t e r of
mass of t h e low f l a p p i n g b l a d e s h a s moved f a r t h e r a w a y from t h e a x i s o r
r o t a t i o n , w h i l e t h e c e n t e r of mass of t h e h i g h f l a p p i n g b l a d e s h a s moved
i n toward t h e a x i s of r o t a t i o n . Again t h e b l a d e s a c c e l e r a t e o r d e c e l e r a t e
a s t h e c e n t e r of mass moves c l o s e r o r f a r t h e r away from t h e a x i s of r o t a -
tion. These changes i n b l a d e v e l o c i t y a l s o cause l e a d and l a g about t h e
h o r i z o n t a l hinge and a r e absorbed by t h e dampers.

Without damping a c t i o n , t h e l e a d and l a g motions of t h e b l a d e would

be accentuated. Accordingly, a s t h e e x c u r s i o n s of t h e a f f e c t e d b l a d e
continue, they would b u i l d up i n amplitude. A s t h e amplitude b u i l d u p
continues, t h e o t h e r b l a d e s , beginning w i t h t h o s e on t h e o p p o s i t e s i d e of
the r o t o r d i s c , r e a c t i n response t o t h e motions of t h e a f f e c t e d b l a d e
u n t i l l e a d / l a g i n s t a b i l i t y of a l l b l a d e s occurs. It follows t h a t the blade
i n s t a b i l i t y would c o n t i n u e t o increase, u l t i m a t e l y c a u s i n g t h e extreme
blade excursions, b r e a k i n g of t h e mechanical l i m i t i n g s t o p s b l a d e over-
lapping, and t h e o t h e r r e s u l t s a s they have been d e s c r i b e d .

Concluding t h a t a loss of main r o t o r b l a d e damper i n t e g r i t y was t h e

cause of t h i s a c c i d e n t , t h e S a f e t y Board b e l i e v e s such loss of i n t e g r i t y
r e s u l t e d e i t h e r from a f a i l u r e of t h e b l a c k main r o t o r b l a d e damper o r t h e
l o s s of e f f e c t i v e damping a c t i o n of t h e w h i t e main r o t o r b l a d e damper.
The Board f i n d s t h e s u b s t a n t i v e evidence i n s u f f i c i e n t to d e f i n i t i v e l y
i s o l a t e one t o t h e e x c l u s i o n of t h e o t h e r .

I n r e g a r d t o damper f a i l u r e , examination of t h e r e d , yellow, and

blue dampers and t h e i r a s s o c i a t e d components r e v e a l e d no evidence t o sub-
s t a n t i a t e t h e i r involvement i n t h e i n i t i a l cause. The b l a c k damper,
however, was found w i t h i t s p i s t o n broken a t t h e r a d i u s of i t s t h r e a d e d
end s h a f t . As a l r e a d y d e s c r i b e d , t h e bumper, t r u n n i o n , t r u n n i o n b e a r i n g s ,
and h o r i z o n t a l h i n g e p i n s t u b and bushing of t h i s damper were m i s s i n g and
have never been found.

The Board b e l i e v e s i t i s p o s s i b l e t h a t t h e b l a c k main r o t o r b l a d e

damper, bumper and a s s o c i a t e d p a r t s s e p a r a t e d from t h e r o t o r head assembly
e a r l y i n t h e breakup sequence and f e l l t o t h e ground somewhere a l o n g t h e
 - 26 -
f l i g h t p a t h p r i o r t o t h e main impact s i t e . The absence of t h e s e p a r t s f o r
examination g i v e s rise t o s p e c u l a t i o n a s t o t h e i r d e g r e e of involvement
i n t h e c a u s e of t h e b l a d e e x c u r s i o n s . A s h a s a l r e a d y been s t a t e d , i f a
damper were t o become s e p a r a t e d , t h e extreme b l a d e e x c u r s i o n could r e s u l t .

There a r e t h r e e l o g i c a l r e a s o n s t o b e c o n s i d e r e d i n c o n s i d e r i n g damper
separation failure: (1) loss of t o r q u e between t h e damper bumper and
t h e damper p i s t o n s h a f t , (2) h o r i z o n t a l h i n g e p i n b u s h i n g f a i l u r e , and
(3) damper t r u n n i o n b e a r i n g f a i l u r e .

In t h e f i r s t i n s t a n c e , t h e damper bumper i s screwed t o t h e threaded

end of t h e damper p i s t o n , torqued t o a g i v e n v a l v e , and locked i n p l a c e
by a jam n u t . Should t h i s assembly l o s e i t s t o r q u e , stresses could b e set
up on t h e p i s t o n s h a f t i n t h e a r e a of i t s t h r e a d e d shank which c o u l d
e v e n t u a l l y l e a d t o f a i l u r e a s was n o t e d by examination of t h e b l a c k damper
piston.

E a r l i e r models of main r o t o r b l a d e dampers were known t o have p a i n t

on t h e mating s u r f a c e s of t h e p i s t o n s h a f t and bumper. It was t h e o r i z e d
t h a t i f t h e p a i n t worked o u t of t h i s a r e a , t o r q u e would b e l o s t and stresses
would b e set up i n the r a d i u s of t h e p i s t o n s h a f t and i t s t h r e a d e d e x t e n -
s i o n . Such stresses c o u l d l e a d t o u l t i m a t e f a i l u r e of t h e s h a f t .

This p o s s i b i l i t y must b e d i s c o u n t e d , however, s i n c e t h e p o r t i o n of t h e

damper p i s t i o n s h a f t t h a t was recovered showed no e v i d e n c e of ever h a v i n g
been p a i n t e d .

In e v a l u a t i n g t h e second r e a s o n , i t i s n o t e d t h a t t h e damper t r u n n i o n
i s connected t o t h e h o r i z o n t a l h i n g e p i n s t u b and r i d e s on a l u b r i c a t e d
bushing. Looseness o r d i s i n t e g r a t i o n of t h i s bushing would allow the s t u b
end of t h e h i n g e p i n t o hammer t h e damper t r u n n i o n and l e a d t o e v e n t u a l
f a i l u r e of t h e ' s t u b end, t r u n n i o n o r p i s t o n s h a f t . S i n c e t h e b l a c k damper
bumper, t r u n n i o n , p i s t o n s h a f t threaded end and p o r t i o n of t h e h i n g e p i n
s t u b end c o n t a i n i n g t h e bushing were n o t recovered t h i s p o s s i b i l i t y cannot
be accepted nor s a t i s f a c t o r i l y eliminated.

In t h e i n s t a n c e of a loss of e f f e c t i v e damping a c t i o n , t h e w h i t e main

r o t o r b l a d e damper i s s u s p e c t . There i s some evidence t h a t t h e w h i t e
damper quick d i s c o n n e c t may have been d i s c o n n e c t e d from i t s damper f l u i d
r e s e r v o i r p r i o r t o t h e a c c i d e n t . Although t h e q u i c k d i s c o n n e c t d i d n o t
l e a k f l u i d of any s i g n i f i c a n t amount i n l e a k a g e t e s t s , t h e p o s s i b i l i t y
remains i t may have done s o i f d i s c o n n e c t e d p r i o r t o t h e a c c i d e n t . S u f f i -
c i e n t l e a k a g e of f l u i d from t h e damper would r e s u l t i n a l o s s of e f f e c t i v e
damping a c t i o n , and t h e r e s u l t s would be t h e same a s t h o s e from a damper
failure.
 - -27

The a i r c r a f t manufacturer, based on i t s a n a l y t i c a l s t u d i e s , t e s t s and

research, a l s o reached t h e c o n c l u s i o n t h a t a loss of damper i n t e g r i t y was
t h e b a s i c mode of t h e a c c i d e n t . They, however, b e l i e v e t h a t t h i s was more
probably due t o t h e l o s s of damper e f f e c t i v e n e s s of t h e w h i t e b l a d e damper
r a t h e r than a f a i l u r e o f t h e b l a c k b l a d e damper.

The manufacturer c i t e d a s t h e i r major r e a s o n t h e f a c t t h a t t h e b l a c k

damper f a i l u r e s a t t h e damper p i s t o n and a t t h e h o r i z o n t a l h i n g e p i n were
conclusively determined t o be g r o s s overload. They conclude t h a t a
s t r u c t u r a l f a i l u r e w i t h i n t h e m i s s i n g p o r t i o n of t h e b l a c k damper would
produce f a t i g u e f a i l u r e s and n o t g r o s s overload o r s t a t i c f a i l u r e s . In
conclusion on t h i s p o i n t , t h e manufacturer c o n s i d e r e d t h e b l a c k damper
f a i l u r e was p a r t o f t h e r e s u l t sequence and n o t t h e i n i t i a l c a u s e of t h e
sequence.

The S a f e t y Board r e c o g n i z e s t h a t w h i l e i t could have been t h e w h i t e

damper t h e r e a r e a l s o good reasons t h a t i t could have been t h e b l a c k damper.
I n t h i s connection a f a i l u r e could have o c c u r r e d w i t h i n t h e m i s s i n g p o r t i o n
of t h e b l a c k main r o t o r b l a d e damper a l l o w i n g t h e damper t o s e p a r a t e at:
t h e p o i n t of f a i l u r e , and t h e f a i l u r e s a t t h e h o r i z o n t a l h i n g e p i n and damper
p i s t o n occurred l a t e r d u r i n g t h e extreme b l a d e e x c u r s i o n s i n t h e i r l e a d / l a g
axis.

Another s u b s t a n t i v e reason t h e manufacturer concluded t h e loss of

e f f e c t i v e damper a c t i o n by t h e w h i t e damper was more p r o b a b l e than f a i l u r e
of the b l a c k damper, i s based on t h e i r a n a l y t i c a l study. This i n d i c a t e d
t h a t a l o s s of e f f e c t i v e damper was probably c a p a b l e o f r e s u l t i n g i n b l a d e
i n s t a b i l i t y i n t h e l e a d and l a g a x i s , and i t was n o t n e c e s s a r y t o have a
damper f a i l u r e which took t h e component completely o u t of t h e r o t o r system.

As noted above, t h e S a f e t y Board a g r e e s t h a t a l o s s of damper e f f e c -

tiveness i s considered one of t h e p o s s i b l e reasons f o r a loss of damper
i n t e g r i t y . It n o t e s , however, t h a t o p e r a t i o n a l h i s t o r y s u g g e s t s t h a t a
loss of damper e f f e c t i v e n e s s , w h i l e producing roughness of f l i g h t and
passenger discomfort, would n o t be d i s a s t r o u s .

I n summary, t h e S a f e t y Board r e s p e c t s w i t h h i g h r e g a r d t h e manufac-

t u r e r ' s c o n v i c t i o n r e l a t i v e t o the s i n g l e i n i t i a l c a u s e f o r t h e loss of
damper i n t e g r i t y and b e l i e v e s t h e i r c o r r e c t i v e measures show t h e i r con-
v i c t i o n . g/ I n i t s judgment , however, t h e S a f e t y Board b e l i e v e s a loss
of e f f e c t i v e damping a c t i o n by t h e w h i t e damper should n o t b e concluded t o
the exclusion of f a i l u r e o f t h e b l a c k damper.

2.2 Conclusions

(a) Findings

1. The f l i g h t crewmembers were p r o p e r l y c e r t i f i c a t e d and

q u a l i f i e d f o r t h e f l i g h t involved.

-
20/ See S e c t i o n 3 , C o r r e c t i v e Measures.
 - 28 -
2. Weather c o n d i t i o n s f o r t h e f l i g h t were c l e a r w i t h
u n l i m i t e d v i s i b i l i t y , and i n f u l l d a y l i g h t .

3. The weight and c e n t e r of g r a v i t y o f t h e a i r c r a f t were

w i t h i n l i m i t a t i o n s a t d e p a r t u r e from Anaheim, C a l i f o r n i a ,
and a t t h e time of t h e a c c i d e n t .

4. The a c c i d e n t sequence began w h i l e t h e a i r c r a f t was i n

normal c r u i s i n g f l i g h t about 2,000 f e e t above t h e ground,
on c o u r s e and heading, and about 2 t o 2-1J2 miles from
where i t crashed.

5. The c r a s h sequence began w i t h t h e main r o t o r b l a d e s

undergoing a s e r i e s of extreme e x c u r s i o n s i n t h e i r
lead/lag axis.

6. The extreme l e a d and l a g e x c u r s i o n s caused t h e o v e r l o a d

detachment f a i l u r e of the yellow main r o t o r b l a d e p i t c h
c o n t r o l rod a t i t s lower t r u n n i o n end attachment t o t h e
r o t a t i n g swashplate.

7. Detachment of t h e yellow b l a d e made t h e b l a d e u n c o n t r o l l a b l e

i n i t s p i t c h and f l a p axes, and i t s t r u c k t h e r i g h t s i d e
of t h e a i r c r a f t .

8. The f o u r remaining b l a d e s i n t h e r o t o r d i s c , a s t h e r e s u l t
o f imbalance, s t r u c k and p e n e t r a t e d t h e c o c k p i t and a f t
fuselage o f ' t h e a i r c r a f t .

9. S t r i k e s by t h e r o t o r b l a d e s d e s t r o y e d t h e s t r u c t u r a l
i n t e g r i t y of t h e a i r c r a f t and i t f e l l n e a r l y v e r t i c a l l y
t o t h e ground.

10. There was no f i r e i n f l i g h t ; however, postimpact ground

f i r e occurred.

11. The cause of t h e extreme e x c u r s i o n s of t h e main r o t o r

b l a d e s i n t h e i r l e a d and l a g a x i s r e s u l t e d from a loss
of damper i n t e g r i t y . Probable r e a s o n s are f a i l u r e of t h e
b l a c k main r o t o r damper or a loss of e f f e c t i v e damping
a c t i o n of t h e w h i t e main r o t o r b l a d e damper.

12. An important p o r t i o n o f t h e b l a c k damper was n o t recovered

f o r examination.

(b) Probable Cause

The S a f e t y Board determines t h a t t h e p r o b a b l e cause of t h i s

a c c i d e n t was t h e loss of main r o t o r b l a d e damper i n t e g r i t y due t o
e i t h e r a f a i l u r e o f t h e b l a c k b l a d e damper o r a loss of e f f e c t i v e
damping a c t i o n by t h e w h i t e b l a d e damper. This r e s u l t e d i n un-
c o n t r o l l e d e x c u r s i o n s of t h e main r o t o r b l a d e s i n t h e i r l e a d / l a g
 - -29

a x i s , an o v e r l o a d detachment of t h e y e l l o w main r o t o r b l a d e p i t c h
change c o n t r o l rod and d e s t r u c t i o n of t h e s t r u c t u r a l i n t e g r i t y of
t h e a i r c r a f t by b l a d e s t r i k e s . The p r e c i s e reason f o r e i t h e r of
t h e p o s s i b i l i t i e s f o r t h e loss of damper i n t e g r i t y i s undetermined.

3. CORRECTIVE MEASURES

As a r e s u l t of t h i s a c c i d e n t , a second a c c i d e n t i n v o l v i n g a
Los Angeles Airways S-61L, on August 14, 1968, and an i n c i d e n t i n v o l v i n g
a c o n t r o l m a l f u n c t i o n on June 26, 1968, a number of c o r r e c t i v e measures
were taken t o improve t h e s a f e t y of o p e r a t i o n s of t h e S-61L a i r c r a f t .
The p r e t a k e o f f check of t h e AFCS was expanded t o check t h e system f o r
proper o p e r a t i o n .

P r i o r t o t h e aforementioned a c c i d e n t s and i n c i d e n t , a hardover i n p u t

i n t e n t i o n a l l y induced through t h e h a r d o v e r p a n e l could n o t be c u t o f f
by t h e c u t o f f b u t t o n s w i t c h on t h e c o l l e c t i v e c o n t r o l of t h e p i l o t . An
e l e c t r i c a l w i r i n g change was i n c o r p o r a t e d e n a b l i n g t h e p i l o t ? \ f o c u t o f f
any AFCS i n p u t from t h e hardover p a n e l , a s well a s t o c u t o f f h t h e AFCS
normal i n p u t t o t h e c o n t r o l system. A s i n d i c a t e d , t h e l a t t e r c a p a b i l i t y
xble a l r e a d y e x i s t e d w i t h r e s p e c t t o t h e system.

The tests and r e s e a r c h conducted i n ’ c o n n e c t i o n w i t h t h e s u b j e c t a c c i -

dent i n a n e f f o r t t o determine i t s c a u s e a l s o s e r v e d t o r e c o n f i r m stress
It loadings i n t h e main r o t o r head. Loadings were found t o b e somewhat
h i g h e r t h a n o r i g i n a l l y determined b u t n o t beyond t h e margin of s a f e t y
designed i n t o t h e r o t o r head. I n t h e i n t e r e s t of s a f e t y , t h e u n l i m i t e d
l i f e f o r h o r i z o n t a l h i n g e p i n s was reduced t o a l i f e l i m i t of 5,000 hours.

The m a n u f a c t u r e r of t h e a i r c r a f t i s s u e d a S e r v i c e B u l l e t i n t o a l l
o p e r a t o r s r e q u e s t i n g them t o check a l l main r o t o r b l a d e dampers f o r p r o p e r
torque of t h e screw- in f i t t i n g of t h e damper p i s t o n t o t h e damper t r u n n i o n
end bumper or shock a b s o r b e r .

A s a r e s u l t of t h e a c c i d e n t , on August 14, 1968, an A i r w o r t h i n e s s

D i r e c t i v e , AD, was i s s u e d . T h i s AD r e q u i r e d t h a t o n l y new main r o t o r
blade s p i n d l e s be used on S-61 a i r c r a f t . I t a l s o p l a c e d a l i f e l i m i t of
.e 2,400 hours on t h e s p i n d l e s . P r i o r t o t h e A D, reworked s p i n d l e s were
used and t h e r e was no l i f e l i m i t on t h e s p i n d l e s .

.ed

i
:0
re

F4
 - 30 -
For a period of time the aircraft manufacturer considered the use
of a quick disconnect of an improved design in the lines from the damper
fluid reservoirs to the main rotor blade damper or, in the alternative,
B
to eliminate entirely the use 0f.a quick disconnect in the line. By
letter dated October 3 0 , 1969, the manufacturer advised it had decided to
eliminate the quick disconnect. The Board believes this is an appropriate
action in the area of corrective measures.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD:

/s/ REED
J O H N H.
Chairman

/s/ OSCAR M. LAUREL

Member

/s/ FRANCIS H. McADAMS

Member

/s/ LOUIS M. THAYER

Member

Isabel A. Burgess, Member, did not take part in the

adoption of this report.
I
December 18, 1969.

I
Attachment 1. Explanatory Diagram of Main Rotor Head
 -
APPENDIX A

-Investigation and Hearing

1. -
--Invest&ation
The Board received notification of the accident at approximately
2200 on May 2 2 , 1968. An investigation team was immediately dispatched
to the scene from Washington, D. C. Working groups were established
for operations, witnesses, structures, powerplants, aircraft and mainte-
nance records, systems, and human factors. Parties to the Investigation
were Los Angeles Airways, the Federal Aviation Administration, Air Line
Pilots' Association, and Sikorsky Aircraft Division of the United Aircraft
Corporation. The on-scene phase of the investigation was completed in
about 10 days; however, extensive tests and research and failure analyses
were continued for many months thereafter at the aircraft manufacturer's
facilities at Stratford, Connecticut.

2. Hearing

A public hearing was convened September 2 5 , 1968, at El Segundo,

California, and lasted approximately 3 days.

3. fjreliminary Reports

A summary of the testimony taken at the public hearing was

published by the Board on October 15, 1968. A preliminary report was
not issued on the accident.
I

APPENDIX B

Crew Information

-Captain John E . Dupies

Captain Dupies, aged 45, had been an employee of Los Angeles

Airways s i n c e 1953. A t t h e time of t h e a c c i d e n t , h e h e l d A i r l i n e
Transport C e r t i f i c a t e No. 554033, w i t h r a t i n g s (VFR) on Sikorsky S-61
S-55, S-62 a i r c r a f t and an u n r e s t r i c t e d (IFR) r a t i n g i n t h e S-61 h e l i -
c o p t e r . He had a t o t a l of 12,096 f l y i n g hours, of which 4,208 were i n
t h e S-61. I n t h e 60- and 30-day p e r i o d s b e f o r e t h e a c c i d e n t , h e had
flown 124 and 55 hours, r e s p e c t i v e l y . On t h e day of t h e a c c i d e n t , h e had
flown about 15 minutes.

Captain Dupies had completed s a t i s f a c t o r i l y h i s most r e c e n t p r o f i -

ciency check on February 28, 1968, h i s most r e c e n t l i n e check on
January 5 , 1968, and h i s most r e c e n t r e c u r r e n t t r a i n i n g on A p r i l 23, 1968.
He h e l d a c u r r e n t f i r s t - c l a s s medical c e r t i f i c a t e w i t h no l i m i t a t i o n s ,
dated December 26, 1967.

C o p i l o t Terry R . Herrington

C o p i l o t Herrington, aged 27, was employed by Los Angeles Airways

on January 26, 1968. A t t h e time of t h e a c c i d e n t , h e h e l d Commercial
P i l o t C e r t i f i c a t e No. 1600649, w i t h a i r p l a n e s i n g l e - and m u l t i e n g i n e
l a n d , Sikorsky S-58 a i r c r a f t and instrument i n c l u d i n g h e l i c o p t e r r a t i n g s .
He had a t o t a l of 872 f l y i n g h o u r s , of which 589 were i n h e l i c o p t e r s .
I n t h e 60- and 30-day p e r i o d s preceding t h e a c c i d e n t , h e had flown 118
and 62 h o u r s , r e s p e c t i v e l y .

C o p i l o t Herrington completed s a t i s f a c t o r i l y i n i t i a l c o p i l o t t r a i n i n g
on February 18, 1968, and a l i n e check q u a l i f y i n g him t o make t a k e o f f s
and l a n d i n g s on May 6 , 1968. He h e l d a f i r s t - c l a s s medical c e r t i f i c a t e
w i t h no l i m i t a t i o n s , d a t e d January 1, 1968.

F l i g h t Attendant Donald P . Bergman

F l i g h t Attendant Bergman was employed by Los Angeles Airways on

J u l y 3 , 1967, a s a u t i l i t y h e l p e r . , He became a cargo agent on
August 8 , 1967, and a f l i g h t a t t e n d a n t on August 28, 1967. H i s most
r e c e n t r e f r e s h e r t r a i n i n g was completed s a t i s f a c t o r i l y on February 29,
1968.
I

-- --
APPENDIX C

A i r c r a f t Information

H e l i c o p t e r S-61L, N303Y, s e r i a l No. 61060, was manufactured i n

J u n e 1962 by t h e Sikorsky D i v i s i o n of United A i r c r a f t C o r p o r a t i o n . I t s
A i r w o r t h i n e s s C e r t i f i c a t e was i s s u e d t o Los Angeles Birdays on August 18,
1962.

A t t h e time of t h e a c c i d e n t , t h e a i r c r a f t had accumulated 11,128

t o t a l hours. The a i r c r a f t was l a s t overhauled on November 14, 1967, by
Los Angeles Airways w i t h 9,973 h o u r s . It r e c e i v e d a M3-3 (2,400 hour)
p e r i o d i c check on March 13, 1968, 533 h o u r s b e f o r e t h e a c c i d e n t . The
most r e c e n t M2-0 (200 hour) and M1-02 (50 hour) p e r i o d i c checks were on
May 1 9 , 1968. I t r e c e i v e d a M1-01 ( d a i l y ) i n s p e c t i o n on May 22, t h e day
of t h e a c c i d e n t .

The a i r c r a f t was equipped w i t h two General E l e c t r i c e n g i n e s ,

Model CT 58-140-1. T o t a l time of t h e No. 1 e n g i n e was 6,581 h o u r s ,
i n c l u d i n g 1,273 s i n c e o v e r h a u l . T o t a l time on t h e No. 2 e n g i n e was
6,873 h o u r s , i n c l u d i n g 1 , 1 4 3 s i n c e overhaul.