NTSB CAROL · Event
Event LAX04LA197
Registry · N61415
FAA Aircraft Registry record.
Make / Model
QUICKSILVER SPORT 2
Year of manufacture
1995 · 9 years old at event
Engine
ROTAX 582SER (65 hp)
Seats / Engines
2 seats · 1 engine
Last airworthiness date
20100124
ADS-B equipped
Yes — Mode-S A80033
Registrant of record
ASHBY ROBERT D
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
the failure of maintenance personnel to ensure the proper charge of the aft landing gear dampers in accordance with the manufacturer's recommendations.
Factual narrative
On April 27, 2004, at 1440 Pacific daylight time, N61415, a Schweizer 269C-1 helicopter, encountered a severe vibratory event during the initial run-up at the Van Nuys Airport, Van Nuys, California. Group 3 Aviation was operating the helicopter under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) and the private pilot undergoing instruction (PUI) were not injured; the helicopter sustained substantial damage. Visual meteorological conditions prevailed for the local instructional flight that was originating at the time. The CFI said that during the run-up, the magneto checks produced a rough running engine. At 2,000 rpm he attempted to correct the roughness by leaning the mixture. The helicopter then began shaking from side-to-side, indicating ground resonance. Due to the low rpm, the CFI elected to close the throttle rather than lift the helicopter from the ground. The ground resonance increased and neither the PUI nor the CFI could hold onto the controls. The CFI then pulled the mixture control and the engine stopped. According to the PUI, he was performing the run-up check when the right magneto failed the check twice. The CFI assumed the controls and attempted to troubleshoot the problem. A small vibration developed into a violent bucking. The PUI then assisted the CFI in shutting down the helicopter. A witness submitted a statement. While walking along a fence he heard a loud noise. He turned and saw a helicopter violently shaking fore and aft. The tailboom impacted the ramp, then the blades started to break apart. The landing gear collapsed, and the movement of the helicopter ceased. The skid damper assemblies were examined and tested for charge at a maintenance facility in the presence of the National Transportation Safety Board investigator-in-charge. The landing gear dampers are pressurized with nitrogen gas. Technicians pressurize the dampers in accordance with the current operating temperatures and environments at the time of the maintenance period. The dampers assist in absorbing the vibration consistent with helicopter operations. In post accident tests, the rear dampers had a lower charge than that specified in the maintenance manual for the helicopter. The forward dampers were within limits. The main rotor dampers were examined with no mechanical anomalies noted. The last inspection on the helicopter was a 100-hour inspection approximately 61 hours prior to the accident. In table B-2 of the Schweizer Handbook of Maintenance Instructions, Section 2, page 2-8, item 30 on the 100-hour inspection checklist states the following: "Forward and aft landing gear dampers (LH [left-hand] side and RH [right-hand] side) for operation and conditions, and for damper extension with full fuel tank (Basic HMI, Section 12). Visually check dampers for leakage; replace if leakage is obvious or extension is not within limits (Basic HMI, Section 12). According to FAA publication FAA-H-8083-21, "Rotorcraft Flying Handbook:" "Ground resonance is an aerodynamic phenomenon associated with fully-articulated rotor systems. It develops when rotor blades move out of phase with each other and cause the rotor disc to become unbalanced. This condition can cause a helicopter to self-destruct in a matter of seconds.... If the rpm is low, the corrective action to stop ground resonance is to close the throttle immediately and fully lower the collective to place the blades in low pitch. If the rpm is in the normal range, you should fly the helicopter off the ground, and allow the blades to automatically realign themselves. You can then make a normal touchdown...." The helicopter encountered ground resonance during the initial run-up prior to takeoff. During the run-up, the magneto checks produced a rough running engine. At 2,000 rpm the certified flight instructor (CFI) attempted to correct the roughness by leaning the mixture. The helicopter then began shaking from side-to-side, indicating ground resonance. Due to the low rpm, the CFI elected to close the throttle rather than lift the helicopter from the ground. The ground resonance increased and neither the pilot-undergoing-instruction nor the CFI could hold onto the controls. The CFI then pulled the mixture control and the engine stopped. The skid damper assemblies were examined and tested for charge. The rear dampers had a lower charge than that specified in the maintenance manual for the helicopter. The forward dampers were within limits. The Schweizer 269 maintenance instructions call for the dampers to be checked and correctly pressurized at each 100-hour inspection. The last 100-hour inspection was 1 month 61 hours prior to the accident. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_2004_LAX04LA197.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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