ATL01LA047
2001-04-03 · LAKELAND, Florida, United States · None · 1 aircraft · Status: Completed
Airport LAL
N921MC has since been reassigned. It is now registered to a different aircraft (SOCATA TBM 700, built 2015), which was not involved in this event.
Aircraft involved
Probable cause & findings
THE PILOTS FAILURE TO PROPERLY USE THE HELICOPTER CHECKLIST
Factual narrative
On April 3, 2001, at 1430 eastern daylight time, a Bell OH-58A helicopter, N921MC, collided with the ground during an autorotation following the loss of engine power near Lakeland, Florida. The maintenance test flight was operated by the pilot under the provisions of Title 14 CFR Part 91 with no flight plan filed. Visual weather conditions prevailed at the time of the accident. The helicopter sustained substantial damage, and the commercial pilot was not injured. The flight departed Lakeland, Florida, at 1415 hours. This was the first flight following the completion of a maintenance inspection. According to the pilot, he followed the manufacturers normal operating checklist and began a test flight. Approximately 2 minutes after takeoff, the engine lost power and quit during cruise flight. The pilot initiated an autorotation for an emergency landing; the tail boom assembly was damaged during the emergency landing. Examination of the helicopter revealed that the fuel valve switch was still in the OFF position. It was discovered that the fuel valve had been switched OFF during the last maintenance inspection. The pilot stated he did not check the position of the fuel valve prior to takeoff. The thru-flight checklist used in the helicopter ,TM-55-1520-228-CL does not require the fuel valve position to be checked during preflight, engine start or takeoff procedures. The checklist in manufacturers technical manual TM 55-1520-228-10 , states under section 8-16 "Before Starting Engine procedures", item 3-p "FUEL VALVE HANDLE - Check ON (forward)." No mechanical problems with the helicopter were reported by the pilot. No mechanical problems were discovered during the airframe examination. This was the first flight following a maintenance inspection. The pilot followed the manufacturers normal operating checklist and began a test flight. Approximately 2 minutes after takeoff, the engine lost power and quit. The fuel valve switch was found in the OFF position. The pilot did not check the position of the fuel valve prior to takeoff. The thru-flight checklist did not mention a fuel switch check during engine start. An expanded checklist includes the item. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_2001_ATL01LA047.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
Matched on aircraft type or causal vocabulary (maintenance). All research papers
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA) From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- Semantic Scholar 2026 · Article (Reliability Engineering & System Safety) Understanding human error in military aviation maintenance: The role of Performance shaping factors, cognitive workload and error orientation
- Semantic Scholar 2025 · Article (Applied Sciences) Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Semantic Scholar 2024 · Article (Defence Science Journal) Modelling of Human Factors in Aviation Maintenance Using HFACS ME Human Factors Analysis and Classification System Maintenance Extension and Bayesian Network
Aircraft maintenance is a complex task involving a skilled human workforce, spare parts, and various other resources. Human factors are an inherent element of the human workforce.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER) A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER) Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…