ANC15LA073

NTSB accident investigation · Robinson Helicopter R44 · Fort Glenn, AK · September 19, 2015

Accident · No injuriesLimited investigationFinal report
Date
September 18, 2015, 17:00 local (Sep 19, 2015, 01:00 UTC)
Place
Fort Glenn, AK
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N7162RRobinson Helicopter R44
Defining event
Maneuvering-hover: Part(s) separation from AC
Weather
Visual (VMC) · Day
Status
Completed · report November 15, 2018
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
FAA Anchorage FSDO, Transportation Safety Board of Canada, Robinson Helicopter Company
Case key
92018

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

On this page

Probable cause

The separation of the tail rotor gearbox from the tailboom attachment point due to overstress loads imposed by a tail rotor blade imbalance as the result of impact with an undetermined object during low-level flight operations.

Findings · 4

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.

Not determinedNot determined › Not determined · Unknown/Not determinedRobinson Helicopter R44: 11 casesAll aircraft: 2,247 casesProbable cause
Object/animal/substanceEnvironmental issues › Physical environment · Effect on equipmentRobinson Helicopter R44: 1 caseAll aircraft: 224 casesProbable cause
Tail rotor: tail rotor bladeAircraft › Aircraft propeller/rotor · Damaged/degradedRobinson Helicopter R44: 1 caseAll aircraft: 31 casesProbable cause
Tail rotor drive system: tail rotor gearboxAircraft › Aircraft propeller/rotor · Damaged/degradedRobinson Helicopter R44: 1 caseAll aircraft: 12 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 commercial helicopter pilot was conducting an aerial mustering flight with cattle on a remote island. The pilot reported that, while in a hover, he heard "metallic grinding noises" from behind his position in the front right seat; however, the helicopter was "stable with engine power," the rotor rpm was within normal limitations, and the had "normal responding controls and tail rotor authority." The pilot immediately landed the helicopter on a sandbar, completed the shutdown process, and exited from the helicopter without further incident. While conducting a postflight inspection, the pilot observed that the tail rotor gearbox had separated from the tailboom mounting assembly and was lying on the ground. An examination of the tail rotor gearbox mounting flange bolts and the tail rotor blades revealed signatures consistent with overstress. No signatures of pre-existing damage were observed during the examination. During the low-level profile flown during the aerial mustering operation, it is likely that the tail rotor blades impacted an object which resulted in a severe imbalance of the blades and subsequent separation of the tail rotor gearbox. During the impact and separation sequence, the tail rotor blades likely impacted the vertical stabilizer where the red tail rotor blade "danger" decal is mounted. An examination of the components could not determine what object was impacted. No evidence of impact with foreign objects such as birds, vegetation, or cattle was observed, although such an impact could not entirely be ruled out since neither of the tail rotor blade tips was recovered.

Factual narrative

Systems Description The R-44 Pilot's Operating Handbook (POH), systems description section, describes the tail rotor system and states in part: The tail rotor has two all metal blades and a teetering hub with a fixed coning angle. The pitch change bearings have self-lubricated liners. The teeter hinge bearings either have self-lubricated liners or are elastomeric. The tail roto blades are constructed with aluminum skins and root fittings. The POH additionally describes the drive system and states in part: The long tail rotor drive shaft has no support bearings but has a lightly-loaded damper bearing. The tail gearbox contains a splash lubricated spiral bevel gear set. Loss of Tail Rotor Thrust Indication The R-44 POH, emergency procedures section, describes the indication for a loss of tail rotor thrust for a forward flight profile and in a hover profile and states in part: Failure is usually indicated by nose right yaw which cannot be corrected (or stopped for in a hover profile) by applying left pedal. Tail Rotor Blade Clearance The NTSB IIC asked the manufacturer on February 12, 2018, if any sort rapid pedal inputs at certain airspeeds by the pilot could result in the tail rotor blades contacting (via flapping) with the vertical stabilizer and or the tailboom. The manufacturer reported on February 19, 2018, that short of a component failure (such as a pitch link, pitch link rod end, hub bearing, etc.) even the most aggressive pedal input will not cause contact with the airframe. Title 14 CFR Part 27.661 discusses rotor blade clearance, applicable to both main rotor blades and tail rotor blades, and states: There must be enough clearance between the rotor blades and other parts of the structure to prevent the blades from striking any part of the structure during any operating condition. Aerial Mustering Operations The Civil Aviation Safety Authority of Australia has produced Sector Risk Profile for the Aerial Mustering Sector (2015). This document provides a background on aerial mustering and states: Aerial mustering, by definition, involves low level flying. Its hazards include vulnerability to wind shear, bank-angle illusions in crosswinds near the ground, and the inherent danger of being only a few seconds away from impact in case of an emergency or pilot distraction. The aerial mustering sector constitutes a group of individuals and organizations holding permissions to conduct aerial mustering operations for locating and concentrating stock in specific areas using a similar make and type of helicopter. Aerial mustering using a helicopter is predominantly a task specific and role related operation. The task entails locating and aggregating livestock in specific areas and driving them by means of aerial maneuvering to specific areas. Mustering operations are conducted below 500 feet agl. The aerial mustering sector is hazard rich due to the inherent characteristics of the operation, such as very low level flying, high workload, negativeeffects from weather, obstacles such as power lines, trees, and terrain, pilot distraction, small power margins, and extended time operating within the shaded area of the height/velocity diagram ("deadman's curve"). Aerial Mustering Recommended Equipment The Flight Safety Foundation has produced Basic Aviation Risk Standard Aerial Mustering (2016). This document provides recommended helicopter equipment and pilot equipment to be used during aerial mustering operations. This document recommends that helicopters have bladder-type fuel tanks, upper torso seat restraints, a first aid kit, an environmental survival kit, and a 406 MHz ELT. This document also recommends that pilots wear flight helmets, wear non-synthetic long pants and a long-sleeved shirt (or a fire-retardant flight suit) with cotton undergarments, wear robust enclosed footwear, and carry a satellite telephone. On September 18, 2015, about 1700 Alaska daylight time, a Robinson R-44 Astro helicopter, N7162R, sustained substantial damage following a separation of the tail rotor gearbox while hovering in a remote bay on Umnak Island, about 24 miles southwest of Fort Glenn, Alaska. The commercial pilot, the sole occupant, sustained no injury. The helicopter was registered to 62 Romeo, LLC, Van Nuys, California, and was operated by Bering Pacific Ranches, Ltd., Calgary, Alberta, Canada, as a Title 14 Code of Federal Regulations (CFR) Part 91 visual flight rules aerial mustering flight. Visual meteorological conditions existed near the accident site at the time of the accident, and no flight plan was filed for the local flight. The flight originated from the operator's base of operations at Fort Glenn at 1500. In the National Transportation Safety Board (NTSB) Accident/Incident Reporting Form 6120.1, the pilot reported that after departing from Fort Glenn and traveling about 30 miles, he arrived at Russian Bay. The aerial mustering flight involved cattle located in a flat valley of marsh and sandbars. While in a hover between 10 to 15 feet above ground level behind a ground of cattle over a flat gravel sandbar, he heard "metallic grinding noises" from behind his position in the front right seat of the cockpit. The pilot reported the helicopter was "stable with engine power," the rotor rpm was within normal limitations, and he had "normal responding controls and tail rotor authority." The pilot immediately landed the helicopter on the sandbar, completed the shutdown process, and exited from the helicopter without further incident. While conducting a postflight inspection, the pilot observed that the tail rotor gearbox had separated from the tailboom attachment point and was laying on the ground. After securing the helicopter, a second company helicopter from the operator retrieved the pilot and returned him to Fort Glenn. The helicopter sustained substantial damage to the tailboom and tail rotor system. Additionally, one of the main rotor blades sustained substantial damage. Photographs ofthe helicopter post accident showed the tailboom attached to the fuselage, and the vertical stabilizer attached to the tailboom with the tail rotor system guard and the tail rotor skid intact. The helicopter was subsequently recovered, although the tips of the two tail rotor blades were not recovered. The tailboom, the tailboom mounting flanges, the tail rotor gearbox, and the two tail rotor blades were shipped to the NTSB Materials Laboratory in Washington, District of Columbia for examination. A review of the airframe maintenance records revealed that an annual inspection was conducted on July 21, 2015 at 2,490.5 hours (helicopter total time). No preexisting malfunctions or failures with the tail boom, the tail rotor drive shaft, the tail rotor gearbox, and the tail rotor blades were noted in the airframe maintenance records. The helicopter was not equipped with an emergency locator transmitter (ELT) for remote operations in Alaska, nor was it required to be. Additionally, the helicopter was not equipped with a skid-based emergency floatation system for overwater operations, nor was it required to be. The operator is based at Fort Glenn, a remote decommissioned United States military installation and airfield on Umnak Island. Fort Glenn is located about 9 miles southeast of the Mount Okmok volcano. The operator conducts cattle ranching operations and utilizes helicopters to aid in the mustering of cattle located throughout Umnak Island. Umnak Island is part of the Aleutian Islands archipelago. The tailboom, the tailboom mounting flanges, the tail rotor gearbox, and the two tail rotor blades were examined by a NTSB materials engineer and the NTSB investigator-in-charge (IIC) on June 13, 2017 at the NTSB Materials Laboratory. The tail rotor gearbox was submitted with 3 of the 4 mounting flanges separated – both top flanges and the bottom flange on the port (left) side. The separated top flanges were submitted separately with the mating bolts still assembled. The bolt from the separated bottom flange was also submitted, but the flange was not recovered. The helicopter tail boom was also submitted, with the other ends of the top and bottom bolts from the port (left) side still assembled. All of the bolts were still assembled inside the flanges and the tail boom had fracture surfaces that were in-line with the plane where the two components mated. All of the bolt pieces, both still assembled and submitted loose, had corrosion on the fracture surfaces. The bolt pieces still assembled inside the tail boom were the most heavily corroded. The bolt piece still assembled inside the remaining attached bottom starboard (right) side flange was removed for examination. That piece and the pieces submitted loose were examined using a 5X to 50X digital-zoom microscope. All of the pieces had fracture surfaces that were relatively flat, with some directional smearing. The bottom starboard (right) side bolt piece was cleaned using Evapo-Rust (Harris InternationalLaboratories, Inc., Springdale, Arkansas). The cleaned bottom starboard (right) side bolt piece was examined using a Zeiss Auriga 40 field emission (FE) scanning electron microscope (SEM). The fracture surface features were consistent with microvoid coalescence. The microvoids were elongated and aligned in one direction. The fracture surface features were consistent with shear overstress. No additional work was performed on the bolt pieces. Light fret damage was observed on the mating surfaces of the tail rotor gearbox flanges and the tailboom. Most of the fret damage was obscured by secondary contact damage and corrosion that occurred after the assembly separated. There was extensive deformation to both tail rotor blades, and the tips of both had separated. The deformation, fracture path, and fracture surface features on the tail rotor blade skins were consistent with overstress. Red marks on the surfaces of the tail rotor blades near the separations were observed. The red marks were likely paint transfer from an object struck by the tail rotor blades while they were rotating, which resulted in the deformation and subsequent separation of the tail rotor blades. A Robinson Helicopter Company Service Bulletin applicable to the R44 model helicopter, SB-83 (issued May 30, 2012), references an on-going issue with tail rotor blade fatigue cracks. The fatigue cracks are observed propagating from the leading edge of a tail rotor blade in the most inboard white paint stripe. No such fatigue cracks were observed in the tail rotor blades that were examined. The tail rotor gearbox and the tail rotor blades were examined under black light. A few very small spots were observed on the leading edges of the tail rotor blades fluoresced under the black light. The spots were consistent with insect debris. No snarge or other evidence of bird strike was observed. Refer to the Materials Laboratory Factual Report in the public docket.

Aircraft

Registration
N7162R
Reported as
Robinson Helicopter R44
Category
Helicopter
Serial number
0670
Built
1999
Airframe hours
2,490.5
Engine
Lycoming O-540-F1B5, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Other work use · Part 91
Operator
Bering Pacific Ranches, Ltd.
Registered owner
62 Romeo, LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 21, 2015
Departed
Fort Glenn, AK
Destination
Fort Glenn, AK
Equipment
None

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
68
Injuries
None
Certificate
Commercial
Medical
Class 2, With waivers/limitations
Last flight review
February 12, 2015
Seat
Right
Restraint
Lap only
Flight hours
3,278 total · 3,278 in this make and model · 3,150 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 16 knots
Visibility
10 statute miles
Lowest ceiling
3,600 ft broken
Temperature
48 °F, dew point 37 °F
Altimeter
29.94 inHg
Observed at
PADU, 79 nm away

Docket · 5

The files NTSB released with the investigation on September 13, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.5 MB in all.