ANC11IA059

NTSB incident investigation · Hughes 500D · McGrath, AK · July 5, 2011

Incident · No injuriesIncident investigationFinal report
Date
July 4, 2011, 19:15 local (Jul 5, 2011, 03:15 UTC)
Place
McGrath, AK
Injuries
3 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N315SHHughes 500D
Defining event
Enroute-descent: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report June 28, 2012
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
Federal Aviation Administration - Airworthiness
FAA report
20110705015549I
Case key
81044

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

On this page

Probable cause

A fatigue fracture of the governor-to-fuel control Pc line, which resulted in a partial loss of engine power.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Object/animal/substance: tree(s)Environmental issues › Physical environment · Contributed to outcomeHughes Helicopters HUGHES 369D: 4 casesAll aircraft: 933 cases
Engine fuel and control: fuel controlling systemAircraft › Aircraft power plant · Fatigue/wear/corrosionHughes Helicopters HUGHES 369D: 1 caseAll aircraft: 59 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that during a descent, the helicopter's engine sound changed abruptly and was immediately followed by the engine-out audio horn, and a red engine-out annunciator light. She entered an emergency autorotation, and then selected a mostly open area that contained some trees as an emergency landing site. During the emergency landing, the main rotor blades struck several small trees as the helicopter touched down on the uneven, tundra-covered terrain. A postincident inspection revealed a fatigue fracture in the engine Pc line that provided compressed air to operate the engine governor and fuel control units. The Pc line met the metallurgical material specifications, but there was a bend in a normally straight portion of the line, which would have placed stress on the Pc line when installed. The additional stress likely resulted in the eventual fatigue failure of the line. It could not be determined how or when the bend occurred.

Factual narrative

On July 4, 2011, about 1915 Alaska daylight time, a Hughes 500D (369D) helicopter, N315SH, sustained minor damage following a partial loss of engine power and subsequent emergency landing, about 3 miles southwest of McGrath, Alaska. The helicopter was operated as a visual flight rules (VFR) on-demand charter flight under the provisions of 14 CFR Part 135. The helicopter was operated by Soloy Helicopters LLC., Wasilla, Alaska. The airline transport pilot and two passengers were not injured. Visual meteorological conditions prevailed, and VFR company flight following procedures were in effect. The main rotor blades were damaged during the emergency landing. During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), on July 4, the operator's president/director of operations reported that the helicopter was being used for a crew change at a remote mine site, about 15 miles southwest of McGrath. He said that as the pilot began a gradual descent to the McGrath Airport, the engine sound changed abruptly, which was immediately followed by the engine out audio horn, and a red engine out annunciator light. The pilot entered an emergency autorotation, turned the helicopter left, and selected a mostly open area that contained some trees as an emergency landing site. During the descent, the helicopter's main rotor blades struck several small trees as it touched down on the uneven, tundra-covered terrain. The helicopter was equipped with a Rolls-Royce 250-C20 series engine. A postincident inspection of the helicopter's engine revealed a fractured Pc (pneumatic) line on the engine governor. According to the engine manufacturer, the Pc line provides compressed air (bleed air) from the compressor to the fuel control and governor units, and if it becomes disconnected or breached, the engine will roll back to an idle, or near idle condition. During a follow-up telephone conversation with the NTSB IIC on March 28, 2012, the operator's president/director of operations reported that he had recently leased the incident helicopter, and a new Pc line was installed by the owner. He said that the new Pc line was installed on April 28, 2011, and it had accumulated 233.7 hours before the incident. He noted that the Pc line had not been removed by his maintenance personnel. During the manufacturing process, the Pc line is bent and manipulated to specific drawing specifications, allowing the rigid Pc line to be connected to the threaded compression T fitting on the engine governor and a threaded compression fitting on the engine fuel control. The fractured Pc line was sent to the NTSB's Materials Laboratory for examination. A senior Safety Board metallurgist reported that the separated Pc line displayed evidence of fatigue cracking that emanated from the flared portion of the line. In use, a B-nut and sleeve seals the flared portion of the line to the threaded T fitting on the engine governor. The fracture surface wasfound within the sleeve, and adjacent to the flared radius of the Pc line. The Safety Board metallurgist noted that the Pc line met the metallurgical material specifications, but his examination revealed a bend in a normally straight portion of the line, which would have placed stress on the Pc line when installed. It could not be determined when or how the bend occurred. A copy of the Safety Board metallurgist's report is included in the public docket for this incident.

Aircraft

Registration
N315SH
Reported as
Hughes 500D
Category
Helicopter
Serial number
1120D
Airframe hours
8,601
Engine
Allison / Rolls Royce 250-C20B, 420 horsepower, turbo shaft
Damage
Minor damage
Flight
Part 135
Operator
Soloy Helicopters LLC
Registered owner
Wells Fargo Bank
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 11, 2011 · 91 hours before
Departed
PAMC · McGrath, AK
Destination
PAMC · McGrath, AK
Flight plan
Company VFR
Airport
PAMC · McGrath

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
61
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, With waivers/limitations
Last flight review
March 30, 2011
Seat
Left
Flight hours
15,382 total · 1,510 in this make and model · 13,857 as pilot in command · 30 in the last 90 days · 15 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
59 °F, dew point 54 °F
Altimeter
29.70 inHg
Observed at
PAFM, 3 nm away

Docket · 3

The files NTSB released with the investigation on May 14, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.2 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.