NTSB CAROL · Event
Event CHI04CA237
Registry · N9573
FAA Aircraft Registry record.
Make / Model
ENSTROM F-28A
Year of manufacture
1972 · 32 years old at event
TCDS
H1CE · ENSTROM HELICOPTER CORP THE
Engine
LYCOMING I0360 SER (180 hp)
Seats / Engines
3 seats · 1 engine
ADS-B equipped
Yes — Mode-S AD5169
Registrant of record
STYER DAVID B
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
The partial loss of engine power due to the missing 1/8-27 NPT Allen plug as a result of other maintenance personnel undertorquing the plug. Additionally, the pilot improperly excecuted a run on landing. A factor was the loss of tail rotor effectiveness.
Factual narrative
On August 23, 2004, at 0950 central daylight time, an Enstrom F-28A helicopter, N9573, sustained substantial damage when it impacted terrain and rolled over after a loss of engine power during takeoff near Leroy, Minnesota. The pilot received serious injuries, but the passenger was not injured. The 14 CFR Part 91 aerial observation flight was departing to conduct a local observation flight. Visual meteorological conditions prevailed. No flight plan was filed. The pilot reported that the engine was producing 3,000 rpm's when he brought the helicopter into a hover. He reported that he transitioned into forward flight and cleared a fence, and then the engine lost power. He reported that he thought that an exhaust valve was stuck. He attempted to do a run on landing to a field. The helicopter touched down on its left skid two times but the helicopter was not straight. He reported that the third time the helicopter touched down on its left skid, the helicopter was not straight and the rpm's were low. He reported that he ran out of tail rotor authority. The helicopter rolled over on it left side. A Federal Aviation Administration airworthiness inspector examined the engine at the Marion Airport, Marion, Iowa, on September 1, 2004. Representatives from Enstrom Helicopter, Textron Lycoming, and the operator attended the engine inspection. An engine run was conducted. The engine was run at 1,800 to 2,000 rpm, and then at 1,110 to 1,200 rpm; but the engine popped and ran unevenly. The engine inspection revealed that the 1/8-27 NPT Allen plug to the number four cylinder was missing. Once the hole was plugged, the engine ran smoothly. The helicopter sustained substantial damage when it impacted terrain and rolled over after a loss of engine power during takeoff. The pilot reported that the engine was producing 3,000 rpm's when he brought the helicopter into a hover. He transitioned into forward flight and cleared a fence, and then the engine lost power. He reported that he thought that an exhaust valve was stuck. He attempted to do a run on landing to a field. The helicopter touched down on its left skid two times but the helicopter was not straight. He reported that the third time the helicopter touched down on its left skid, the helicopter was not straight and the rpm's were low. He reported that he ran out of tail rotor authority. The helicopter rolled over on its left side. The engine was inspected and an engine run was conducted. The engine was run at 1,800 to 2,000 rpm, and then at 1,110 to 1,200 rpm; but the engine popped and ran unevenly. A re-inspection of the engine revealed that the 1/8-27 NPT Allen plug to the number four cylinder was missing. Once the hole was plugged, the engine ran smoothly. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_2004_CHI04CA237.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- 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 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.
- 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…
- 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 (IJAAA)
Just Culture in Aviation: A Metaphorical Study on Aircraft Maintenance Students
Just Culture, a sub-dimension of safety culture, has been a prominent and debated topic in aviation safety in recent years.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Performance PRISM: A Comprehensive Framework For Performance Measurement In Aircraft Maintenance
Aircraft maintenance is governed by rigorous safety requirements and high operational complexity, demanding robust performance measurement frameworks to ensure optimal maintenance practices.
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