Hughes 369D accident near Ketchikan, Alaska, July 21, 2003
On July 21, 2003 at about 5:00 pm local time, a Hughes 369D (helicopter), registered N1091S, was substantially damaged in an accident near Ketchikan, Alaska. It was flown under charter and air-taxi rules (Part 135). 1 person had minor injuries; 2 others were unhurt. The weather was visual conditions (good weather).
The NTSB's probable cause their words, unchanged
The improper installation of a bolt in the gas generator governor linkage by company maintenance personnel, which resulted in a loss of the bolt, a loss of engine power while maneuvering, and subsequent forced landing and collision with trees. Factors contributing to the accident were an inadequate preflight inspection by the pilot, and an uncommanded surge in engine power.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- July 21, 2003 · about 5:00 pm local time
- Place
- Ketchikan, Alaska · map
- Type
- Accident
- Injuries
- 1 person had minor injuries; 2 others were unhurt.
- Weather
- visual conditions (good weather)
- Aircraft
- Hughes 369D · all 369Ds on the register
- Registration
- N1091S · registry record · serial 300691D
- Damage
- Substantial damage
- Flight
- Flight · charter and air-taxi rules (Part 135)
The NTSB's narrative final · quoted from the NTSB record
The commercial certificated pilot was conducting an on-demand air taxi flight in a turbine-powered helicopter. While performing an aerial survey, about 100 feet agl, the engine-out annunciator sounded, and the pilot entered an autorotation. As the helicopter touched down in a small clearing, the pilot had the collective pitch control full up to cushion the landing. When the helicopter touched down, the engine power suddenly surged, and the helicopter then began to climb. During the pilot's efforts to control the helicopter, the main rotor blades collided with several trees, and the blades then severed the tail boom. Following the collision with the trees, the pilot rolled the throttle to the off position, but the engine would not shut-down. He then pulled the emergency fuel shut off. Examintion of the helicopter revealed that a bolt, used to connect the N2 governor input arm to an airframe mounted bellcrank, was missing. The bellcrank is connected to the helicopter's collective control linkage. As the pilot moves the collective control, through the bellcrank and governor input arm, engine power increases or decreases. The bolt is normally retained by a castellated nut, and then secured in-place by a cotter pin. Company personnel returned to the accident scene and located the missing bolt and nut lying on the ground, under the location where the engine access doors were opened during an inspection of the engine, before the helicopter was removed from the accident scene. Also found was a cotter pin with one broken side, but it could not be determined if the broken cotter pin was the missing pin from the bolt. The most recent inspection of the helicopter was a 100 hour inspection, conducted by company personnel, 51.8 service hours before the accident. Numerous company pilots had flown the helicopter before the accident. In addition, each pilot conducted an inspection of the helicopter before beginning flight operations. On the day of the accident, the helicopter had flown about 2.5 hours before the accident.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record from the NTSB's investigation tables, in plain English
Pilot
- Certificate: commercial pilot
- Ratings: single-engine land; single-engine sea; rotorcraft: helicopter
- Flight time: 21,540 hours in all; 2,240 in this make and model; 218 in the last 90 days; 96 in the last 30 days; 21,540 as pilot in command
- Last flight review: May 5, 2003
- Medical certificate: Class 2 (valid medical--w/ waivers/lim.)
- Seat: left
- Injury: no injuries
The aircraft
- Airframe total time: 9,553 hours
- Last inspection: 100-hour inspection, July 8, 2003; 52 hours since
- Maximum gross weight: 3,000 lb
- Seats: 5
- Landing gear: fixed
- Engine: Allison 250-C20B (turboshaft); 0 hours total
The flight
- Departed from: 17AK Ketchikan AK at 11:30 am
- Destination: Ketchikan AK
Weather at the time
- Light: daylight
- Wind: from 115° at 10 knots, gusting 16
- Visibility: 10 statute miles
- Sky: broken clouds at 2,800 ft; scat at 1,200 ft
- Temperature: 57°F (14°C), dew point 55°F (13°C)
- Altimeter: 30.10 inHg
- Observation at 11:53 am from PAKT
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Crew | 1 | |||
| Passengers | 1 | 1 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.