ANC18LA058

NTSB accident investigation · Robinson R44 · Bettles, AK · July 29, 2018

Accident · No injuriesLimited investigationFinal report
Date
July 29, 2018, 09:12 local (17:12 UTC)
Place
Bettles, AK
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N744AKRobinson R44
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 13, 2020
Report
Approved by Office Director
NTSB office
Alaska Regional Office
FAA report
20180729019989A
Case key
97949

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

Maintenance personnel's application of insufficient preload on the attachment hardware for the idler gear shaft during engine overhaul, which resulted in the dismounting of the idler gear shaft assembly due to wear and deformation and the subsequent total loss of engine power. Contributing to the accident was a mechanic's failure to identify metallic particles contained in the oil filter element at the most recent 100-hour inspection.

Findings · 6

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.

Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Fatigue/wear/corrosionRobinson Helicopter R44 II: 2 casesAll aircraft: 373 casesProbable cause
Maintenance/inspectionsAircraft › Aircraft handling/service · Incorrect service/maintenanceRobinson Helicopter R44 II: 2 casesAll aircraft: 103 casesProbable cause
MaintenancePersonnel issues › Task performance · Maintenance personnelRobinson Helicopter R44 II: 1 caseAll aircraft: 143 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · Inadequate inspectionRobinson Helicopter R44 II: 5 casesAll aircraft: 497 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelRobinson Helicopter R44 II: 1 caseAll aircraft: 167 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

According to the commercial pilot, about 4 minutes after liftoff for the public flight, the helicopter lost all engine power. He entered an emergency autorotation and landed the helicopter in a bog. During the emergency landing, the tips of the helicopter's skids broke through the vegetative matt on the bog's surface, and the main rotor blades impacted the tailboom. The helicopter sustained substantial damage to the fuselage and tailboom. Postaccident engine examination revealed that the crankshaft idler gear and gear shaft were loose in their mount. Both the bolt and stud for the idler gear shaft had separated from the crankcase, and their respective bores were elongated. Fragmented remains of the safety wire, stud, nut, and bolt were found in the oil sump. Examination of images of these components revealed that there was impact wear and deformation around both of the crankcase mounting holes and the shaft flange mounting face, which was consistent with the partial or complete loss of bolt and stud clamping force of the shaft flange to the crankcase. The insufficient preload on the bolt and stud for the idler gear shaft likely resulted in the dismounting of the idler gear shaft assembly. A review of maintenance records revealed that the last maintenance activity during which the fasteners could have been adjusted was during an engine overhaul performed about 3 years before the accident. The engine had accumulated about 727 operating hours since that time. It is likely that maintenance personnel applied insufficient preload to the bolt and stud at that time, which allowed them to wear and deform over time. The oil filter element from the most recent 100-hour inspection, which was conducted 18.1 hours before the accident, was examined and found to contain more than 60 small pieces of shiny, flakelike nonmagnetic metallic material; some of the flakes were estimated to be more than 1/16 inch in diameter. The operator reported that the mechanic who performed the inspections did not find any metallic material. The engine manufacturer had issued Mandatory Service Bulletin No. 480F, "Oil Servicing, Metallic Solids Identification After Oil Servicing, and Associated Corrective Action," which stated, in part, if "pieces of shiny flake-like, material (larger than 1/16 inch in diameter) with no copper tint" are found in the oil filter, the engine should be removed or disassembled for repair. The mechanic's failure to identify the metallic particles contained in the oil filter element at the most recent 100-hour inspection likely contributed to the accident because it allowed the helicopter to be returned to service when it should not have been.

Factual narrative

On July 29, 2018, at about 0912 Alaska daylight time, N744AK, a Robinson R44 II helicopter, sustained substantial damage during a forced landing following a total loss of engine power shortly after takeoff from the Bettles Airport (PABT), Bettles, Alaska. The commercial pilot and two passengers were not injured. The helicopter was registered to and operated by Quicksilver Air Inc., under the provisions of 14 Code of Federal Regulations Part 91 as a public-use flight. Visual meteorological conditions prevailed and company flight following procedures were in effect. The flight departed PABT about 0908. According to the pilot, he had computed the weight and balance and performed a preflight inspection prior to departure. After the passengers boarded the helicopter, the engine was started, and all ground run-up checks of the engine were satisfactory. He stated that about 4 minutes after liftoff the helicopter lost all engine power. He entered an emergency autorotation and landed the helicopter in a bog. During the emergency landing, the tips of the helicopter's skids broke though the vegetative matt on the bog's surface and the main rotor blades impacted the tailboom. The helicopter sustained substantial damage to the fuselage and tailboom. Examination of the recovered Lycoming IO-540-AE1A5 engine revealed that it remained attached to the airframe via all its mounts. All fuel lines, throttle, and mixture control cables were intact and remained attached to the engine. The bottom spark plugs were removed and remained free of mechanical damage. The bottom spark plugs exhibited coloration consistent with normal operation. The cooling fan nut was rotated in the direction of normal rotation. No movement of the intake and exhaust rocker arms was observed. The oil suction screen was removed and found to contain metallic fragments. The engine was removed from the airframe for further examination. The left and right magneto, vacuum pump, oil filter and rear accessory housing was removed from the engine. The crankshaft idler gear and gear shaft was observed loose from their mount. Both the bolt and stud were separated from the crankcase and their respective bores were elongated. Heavy fretting, gouging, and smearing was observed around the mounting surface for the crankshaft idler gear shaft. Fragmented remains of the safety wire, stud, nut and bolt were located in the oil sump. Examination of images of the components by the National Transportation Safety Board (NTSB) Materials Laboratory revealed impact wear and deformation around both crankcase mounting holes and the shaft flange mounting face, was consistent with the partial or complete loss of bolt and stud clamping force of the shaft flange to the crankcase. The NTSB's Materials Laboratory Factual Report is available in the public docket for this accident. Review of the helicopter's maintenance records revealed that the overhauled engine was installed on the accident helicopter on July 10, 2015 at a totaltime in service of 6,600.0 hours. The last logged maintenance activity in which the fasteners could have been manipulated was performed at the engine overhaul, about 3 years prior to the accident. The engine had accumulated about 727 operating hours since that time. The most recent 100-hour inspection was conducted 18.1 hrs before the accident on July 21, 2018, at an engine total time in service of 7,309.3 hrs, and 709.3 hrs since major overhaul. No logbook entries were observed concerning the idler gear shaft mounting stud and fasteners. The oil filter element which had been cut and examined at the most recent 100-hr inspection was located and reexamined and found to contain greater than 60 small pieces of shiny flake like metallic material with some of those flakes estimated to be greater than 1/16 inch in diameter. According to the operator, the mechanic who completed the most recent 100-hr inspection examined the oil filter with the aid of a magnet and found no ferrous material and did not observe any significant amount of non-ferrous particles. In addition, the oil screen was examined, and no metallic material was found. Lycoming Mandatory Service Bulletin No. 480F, Oil Servicing, Metallic Solids Identification After Oil Servicing, and Associated Corrective Action, states in part: Oil Filter Element Inspection 1. Cut open the removed oil filter element with an approved tool (e.g., for full-flow filters, use Champion Tool CT-470) per the tool manufacturer's instructions. 2. Remove the paper element from the oil filter. 3. Carefully unfold the paper element to prevent loss of collected particles which can compromise the integrity of this inspection. 4. Examine the material trapped in the filter. Look for shiny metallic particles/residue, shavings or flakes. Refer to the sections: "Identification of Metallic Solids After Oil Servicing" and "Visual Inspection of the Oil Filter Element, Oil Pressure Screen, and Oil Suction Screen" in this Service Bulletin. 5. Record all inspection findings and any corrective action in the engine logbook. Table 3 Guidelines for Particle Quantity and Size on Oil Filter, Oil Pressure Screen, or Oil Suction Screen Recommended Corrective Action Options Table 4 Recommended Corrective Action Options (Refer to the applicable Lycoming Engine manual for procedures) The closest weather reporting facility is Bettles Airport (PABT). At 0853, an METAR from PABT was reporting in part: wind, calm; visibility, 10 statute miles; sky condition, few clouds 11,000 feet; temperature, 66° F; dew point 55° F; and an altimeter setting of 30.11 inches of mercury.

Aircraft

Registration
N744AK
Reported as
Robinson R44 (II)
Category
Helicopter
Serial number
10001
Built
2003
Airframe hours
7,327.4
Engine
Lycoming IO-540 SER, 245 horsepower, reciprocating
Damage
Substantial damage
Flight
Public aircraft · Public use
Operator
Quicksilver Air Inc
Registered owner
Quicksilver Air Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 21, 2018
Departed
Bettles, AK
Destination
Bettles, AK
Flight plan
Company VFR
Equipment
Satellite tracking device, Handheld GPS

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
48
Injuries
None
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
May 20, 2018
Seat
Right
Restraint
5-point
Flight hours
2,791 total · 1,566 in this make and model · 2,656 as pilot in command · 98 in the last 90 days · 18 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 55 °F
Altimeter
30.11 inHg
Observed at
PABT

Docket · 7

The files NTSB released with the investigation on October 24, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.8 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.