NTSB CAROL · Event
Event LAX04LA331
Aircraft involved
Probable cause & findings
the failure of maintenance personnel to correctly service the forward landing gear strut dampers in accordance with the manufacturer's maintenance instructions.
Factual narrative
On September 25, 2004, at 1549 Pacific daylight time, a Schweizer 269C-1 helicopter, N61413, encountered a severe vibratory event after landing at the Bob Hope Airport, Burbank, California. Group 3 Aviation was operating the helicopter under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) and private pilot undergoing instruction (PUI) were not injured; the helicopter sustained substantial damage. Visual meteorological conditions prevailed for the local instructional flight, and no flight plan had been filed. The helicopter departed from the Van Nuys Airport, Van Nuys, California, about 1515. According to the operator, the PUI was taking refresher training in the helicopter. The PUI performed a normal approach; however, the touchdown was harder than normal. With the helicopter situated on the ground, the CFI began to discuss the touchdown with the PUI, and the helicopter started to vibrate. The CFI said he did not have time to react prior to the helicopter self-destructing. The three main rotor dampers and four landing gear dampers were examined at the Schweizer Aircraft Corporation on October 12, 2004, in the presence of a Federal Aviation Administration (FAA) inspector from the Rochester, New York, Flight Standards District Office. The results of the examination noted that the damage to all of the dampers was consistent with a ground resonance event. The two aft landing gear dampers tested slightly low but near minimum operating condition. The two forward landing gear dampers contained fluid in excess of the specified levels. When examined, the pistons were in the fully extended condition, and the fluid level was 1.025 inches when measured from the top of the piston to the fluid. The dampers were tested and they were out of compliance with design data, as well as the Schweizer Handbook of Maintenance Instructions (HMI) and production assembly instructions. It was noted in the report that dampers in this condition will not compress or attenuate airframe motion and vibrations or prevent ground resonance. The last inspection on the helicopter was the 100-hour completed 4.5 hours prior to the accident flight. The total time on the airframe was 6,298.7 hours. The landing gear dampers were serviced on January 12, 2004, at a total airframe time of 5,750.1 hours. In the Schweizer HMI, Part III, Section 5, the procedures for reassembly, charging, and leakage check on the landing gear damper assembly are discussed. On page 5-2 it noted that the fluid level for the 269A3150-19 dampers (the forward dampers) should reach 0.5-inch below the top of the piston. The fluid level for the 269A3150-21 dampers (the rear dampers) should be 1.40 inches below the top of the piston. When the fluid is added, the piston is to be compressed, not extended. A warning, also on page 5-2, states the following: "Incorrect fluid levels, improper pressure, or inoperable valving will deteriorate the damping capabilities of the landing gear dampers. These conditions may result in ground resonance and destruction of the helicopter. Follow all instructions in the HMI carefully, to ensure safe helicopter operation." 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 after landing and sustained substantial damage in the vibratory event. The pilot-undergoing-instruction (PUI) was taking refresher training in the helicopter. The approach was normal; however, the touchdown was harder than normal. With the helicopter on the ground, the certified flight instructor (CFI) began discussing the touchdown with the PUI and the helicopter began to vibrate. The CFI did not have time to react prior to the helicopter self-destructing. Post-accident examination of the components found that in the forward landing gear dampers the pistons were fully extended and they contained fluid in excess of the levels specified in the maintenance instructions. Dampers in this condition will not compress or attenuate airframe motion and vibrations or prevent ground resonance. The last inspection on the helicopter was a 100-hour that was completed 4.5 hours prior to the accident flight. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_2004_LAX04LA331.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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