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Accidents · NTSB CEN22LA146 · Final report

Hughes (MD Helicopters) 369 accident near Adair, Iowa, March 17, 2022

On March 17, 2022 at about 7:30 pm local time, a 1977 Hughes (MD Helicopters) 369, registered N500MZ, was substantially damaged in an accident during maneuvering (low-alt flying) near Adair, Iowa. It was an external-load flight under external-load helicopter rules (Part 133). 1 person had minor injuries. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

The mechanic’s failure to properly torque a fuel control unit B-nut, which resulted in a partial loss of engine power, an attempted autorotation, and an impact with terrain.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
March 17, 2022 · about 7:30 pm local time
Place
Adair, Iowa · map
Type
Accident
Injuries
1 person had minor injuries.
Weather
visual conditions (good weather)
Aircraft
Hughes (MD Helicopters) 369 D, built 1977
Registration
N500MZ · no longer on the register · serial 770159D
Damage
Substantial damage
Flight
External-load flight · external-load helicopter rules (Part 133)

The NTSB's narrative final · quoted from the NTSB record

During longline operations, and while flying to a structure, the helicopter sustained a partial loss of engine power. The helicopter was at 90ft above ground level and about 30 kts airspeed, when the pilot lowered the collective to attempt an autorotation. There was insufficient altitude and airspeed to increase main rotor rotation, and the helicopter impacted a muddy grass hill. The helicopter came to rest on its right side. After the helicopter came to rest, the pilot noticed the engine was still, “at a slow run, less than idle.” The helicopter sustained substantial damage to the fuselage, the main rotor system, and the tail rotor system. During the recovery of the helicopter from the field, it was noticed by the operator that the compressor discharge pressure (Pc) line B-nut connection at the fuel control unit (FCU) was not attached. It appeared the B-nut had backed off the FCU fitting. A postaccident examination was performed on the airframe with no anomalies noted. The engine was removed from the airframe and an engine test run was performed with no anomalies noted after the Pc line B-nut was properly torqued. During the Pc line Bnut torquing process, a “squeeze out” of pink paint, consistent with torque stripe paint, was observed emanating from the remaining threads on the line. On the day before the accident, the fuel control unit (FCU) was installed on the helicopter’s turboshaft engine. A calibrated torque wrench was used by the mechanic to tighten the various FCU B-nuts. The mechanic tightened and torqued each B-nut, one at a time, when completing the task. Another mechanic inspected the work after it was completed and found no issues. After the B-nuts were torqued, pink torque stripe paint was applied. Following the FCU installation, the fuel system was purged of air, and a leak check was performed with the helicopter running, an acceptable practice per the engine manufacturer, with no issues noted. It is likely that the mechanic failed to properly torque the B-nut that secures the Pc line to the FCU, which resulted in a partial loss of engine power due to the Pc line separation. Based on the available evidence, it was undetermined as to why the mechanic failed to properly torque the B-nut.

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

What happened, in order

  1. Loss of engine power (partial) during maneuvering (low-alt flying) defining event
  2. Aircraft maintenance event during prior to flight
  3. Autorotation Attempted remediation/recovery
  4. Collision during takeoff/land during landing (flare/touchdown)

The NTSB's findings

  • Aircraft › Aircraft power plant › Engine fuel and control › (general) › Incorrect service/maintenance
  • Personnel issues › Task performance › Maintenance › Installation › Maintenance personnel
  • Personnel issues › Psychological › Attention/monitoring › Monitoring equip/instruments › Maintenance personnel
  • Aircraft › Aircraft power plant › Engine (turbine/turboprop) › (general) › Malfunction
  • Personnel issues › Action/decision › Action › Forgotten action/omission › Maintenance personnel

Pilot

  • Certificate: flight instructor, commercial pilot
  • Ratings: instructor: helicopter; instrument: helicopter; rotorcraft: helicopter
  • Flight time: 5,715 hours in all; 4,031 in this make and model; 49 in the last 90 days; 20 in the last 30 days; 5,559 as pilot in command
  • Last flight review: March 12, 2022
  • Medical certificate: Class 2 (without waivers/limitations)
  • Seat: left
  • Injury: minor injuries

The aircraft

  • Airframe total time: 15,124.7 hours
  • Last inspection: 100-hour inspection, March 9, 2022; 17.2 hours since
  • Maximum gross weight: 3,000 lb
  • Seats: 2
  • Landing gear: fixed
  • Engine: Rolls-Royce 250-C20R/2 (turboshaft); 3,042 hours total
  • Operator: Winco, Inc.

The flight

  • Flight plan: none

Weather at the time

  • Light: daylight
  • Wind: from 360° at 12 knots
  • Visibility: 10 statute miles
  • Sky: broken clouds at 6,000 ft
  • Temperature: 41°F (5°C), dew point 37°F (3°C)
  • Altimeter: 30.00 inHg
  • Observation at 2:30 pm from KADU, 15 miles away

Weather report (METAR): KADU 171930Z AUTO 36012KT 10SM BKN060 05/03 A3000 RMK AO2

Injuries

FatalSeriousMinorNone
Flight crew1

Documents from the investigation the NTSB's docket: the evidence folder behind the report

8 documents, released by the NTSB on January 26, 2023. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.

The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.

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.