ANC96FA098

NTSB accident investigation · Sikorsky CH-54A · Ketchikan, AK · July 13, 1996

Accident · FatalField investigationFinal report
Date
July 13, 1996, 13:25 local (21:25 UTC)
Place
Ketchikan, AK
Injuries
1 fatal, 1 serious
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N541SBSikorsky CH-54A
Weather
Visual (VMC) · Day
Status
Completed · report October 31, 1997
Report
Approved by Office Director
NTSB office
Alaska Regional Office
FAA report
19960713016949A
Case key
2757

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

failure of the number 5 tailrotor bearing. A factor relating to the accident was: the uneven/steep sloping terrain, where the pilot was forced to land. Possible factors were: inadequate handling/labeling of the 'relubed' bearing by intermediate supplyier(s), and/or insufficient shelf life/service limits for military surplus parts.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionHover - out of ground effect
Rotor drive system,tail rotor drive shaft bearing - failureCause
Procedure inadequateOther institutionFactor
Insufficient standards/requirementsOther institutionFactor
Loss of control - in flightHover - out of ground effect
Directional control - not possible
Forced landingEmergency descent/landing
Autorotation - attemptedPilot in command
In flight collision with terrain/waterEmergency descent/landing
Terrain condition - none suitableFactor
Terrain condition - mountainous/hillyFactor

Analysis

The pilot & copilot were on an external load, aero logging operation in a military surplus helicopter, lifting an estimated load of 18,000 lbs. Ground personnel heard a popping sound, then saw the tailrotor begin to slow down as the helicopter began to yaw/spin. It descended to sloping terrain in an area of cut logs. Postcrash exam of the tailrotor drive shaft revealed a separation at the number 5 bearing position. The shaft separation exhibited evidence of high heat & melting of adjoining shaft surfaces. The bearing & its housing were not recovered. The bearing had accrued 505 hrs of service, & was 1 of 2 bearing model numbers that were in use. The bearing was manufactured in 1991, & was purchased by the operator from surplus military supplies. The supplier (of the bearing to the operator) had performed an exterior exam of the bearing & marked 'relubed 10/95' on the bearing box. Exam of the remaining tailrotor drive shaft bearings revealed evidence of low grease fill, water & glycol contamination, & wear patterns consistent with misalignment. In civilian service, the bearing was an 'on condition' part. The operator established a service life of 1,000 hours for aero logging operations. A shelf life for the bearing was not established. The manufacturer indicated the bearing should support a 5 year shelf life. Other operators of the accident helicopter in aero logging reported similar examples of low grease fill & bearing contamination from water in both available models of bearing.

Factual narrative

History of the Flight

On July 13, 1996, about 1325 Alaska daylight time, a Sikorsky CH-54A helicopter, N541SB, crashed during aero logging operations, about 16 miles north-northeast of Ketchikan, Alaska. The helicopter was being operated as a visual flight rules (VFR) local area flight under Title 14 CFR Part 133 when the accident occurred. The helicopter, registered to and operated by Silver Bay Logging Company, Juneau, Alaska, was destroyed. The certificated commercial pilot received serious injuries. The copilot, holder of a commercial helicopter certificate, received fatal injuries. Visual meteorological conditions prevailed. The flight originated at a nearby logging camp about 1308.

The operator reported that logging operations were being conducted near Shelter Cove, located in the Tongass National Forest. The helicopter, a surplus military aircraft certificated in the restricted category, was using a 200 foot long external cable to retrieve logs.

The helicopter was operating on its 4th cycle of the day and was hovering above nearby trees over an area of cut logs. Ground personnel, communicating with the pilot by radio, hooked the helicopter's cable to a metal choker cable that was cinched around 2 large logs with an estimated total weight of 18,000 pounds. The helicopter lifted the logs about 60 feet above the ground when a popping sound was heard coming from the helicopter and the tailrotor began to slow down. The helicopter was observed to spin counter-clockwise about 5 complete turns. The pilot released the load of logs from the end of the cable and commented over the radio that "we're going down". Ground personnel dropped to the ground under fallen trees. The helicopter descended toward the ground and the main rotor blades struck a 170 foot high spruce tree, separating the top 20 feet of the tree. The helicopter continued toward the ground and collided with steeply sloped terrain.

The accident occurred during the hours of daylight at latitude 55 degrees, 33.33 minutes north and longitude 131 degrees, 25.09 minutes west.

Crew Information

The pilot holds a commercial pilot certificate with a rotorcraft helicopter rating. He holds private pilot privileges with airplane single-engine and instrument airplane ratings. The pilot holds a type certificate in Boeing Vertol 107, Sikorsky S-61, and S-64 helicopters. The type certificates are limited to VFR only. In addition, the pilot holds a flight instructor certificate with a rotorcraft helicopter rating and a mechanic certificate with powerplant and airframe ratings. The most recent second-class medical certificate was issued to the pilot on March 4, 1996, and contained no limitations.

No personal flight records were located for the pilot and the aeronautical experience listed on page 3 of this report was obtained from information contained in the pilot/operator report submitted by the operator. According to the report, the pilot's total aeronautical experience consists of 7,985 hours, of which 5,060 hours were accrued in helicopters and 500 hours accrued in the accident helicopter make and model. In the preceding 90 and 30 days prior to the accident, the report lists a total of 125 and 60 hours respectively.

The copilot held a commercial pilot certificate with a rotorcraft helicopter rating. The most recent second-class medical certificate was issued to the pilot on January 25, 1996, and contained no limitations.

No personal flight records were located for the copilot and the aeronautical experience listed on Supplement E of this report was obtained from information contained in the pilot/operator report submitted by the operator. According to the report, the pilot's total aeronautical experience consisted of 850 hours, of which 100 hours were accrued in the accident helicopter make and model as second-in-command. The copilot's duties during aero logging operations include monitoring the engine and hoist gauges and recording the total turns and log weights.

Aircraft Information

The helicopter's tailrotor drive system consists of 6 individual drive shaft segments between the main rotor transmission and the intermediate gear box. A seventh shaft is positioned between the intermediate gearbox and the tailrotor gearbox that is mounted at the top of the tail boom pylon. Each of the 6 drive shaft segments are connected to each other by a coupling flange that is bolted to the aft end of each shaft. A stack of stainless steel discs, know as a Thomas coupling, is utilized to permit flexing of the drive shaft segments and is installed between the coupling flange and the aft end of each drive shaft segment. A Thomas coupling is comprised of between 16 to 22 steel discs separated by isolators. The coupling flange has a splined center section that mates to the forward splined end of the next drive shaft segment.

The forward end of each drive shaft segment has a splined shaft that is inserted into the adjoining coupling flange. Just aft of the splines is a polished bearing surface where a support bearing is installed. The support bearings are pressed onto the drive shaft, over the splines, and onto the bearing surface. The bearings are installed in a bearing support housing that incorporates a viscous vibration dampner between the bearing and the housing. The bearings are retained in the housing by a snap ring on either side of the bearing. The bearing support housings are attached to the upper surface of the tail boom. The bearings are lubricated with Mobilgrease 28 lubricant. The normal amount of grease (by weight) in a bearing is between 4 and 6 grams or between 30 to 50 percent.

The operator utilized temperature sensitive tape applied to each bearing housing as indicators of bearing heat. In addition, the helicopter's crew chief took periodic temperature readings from each bearing housing by using a hand held, laser temperature sensor that measured temperature readings while the helicopter was running. The bearings and housings were part of every turn-around inspection and bearing temperatures were hand checked immediately following a shut-down of the helicopter.

The helicopter maintenance records indicate that a vibration was apparent in the airframe on July 9, 1996. The crew chief for the helicopter reported the pilot commented about a medium to high frequency vibration. An inspection revealed 6 discs of the number 7 tail rotor drive shaft segment's Thomas coupling were cracked. The coupling was replaced and in addition, an inspection of the intermediate tail rotor gear box revealed 3 slivers of metal. A serviceability inspection of the intermediate gear box was completed on July 11, 1996, and the helicopter was returned to service.

On the date of the accident, the crew chief reported the pilot again commented about a vibration. A reinspection of the number 7 drive shaft revealed a slight bow in the alignment of the shaft. An adjustment of the shaft reduced the vibration. Following the completion of the first logging cycle of the day, the pilot reported the vibration was a higher frequency than the previous occasion. Following the completion of the second cycle, the helicopter was shut down and the crew chief conducted a visual and hand inspection of the aircraft with no unusual results.

After lunch, the pilot flew the third cycle of the day and he commented that the vibration was barely being felt. The pilot landed for fuel and an inspection was conducted while the helicopter was running. The crew chief inspected the tail rotor bearings by a hand and visual inspection of the bearing housings. The crew chief did not notice any signs of grease splattering on the tail boom adjacent to the bearing housings. The helicopter then departed on the 4th cycle of the day. The accident occurred during the 7th turn of the cycle, about 17 minutes after the last inspection.

Telephone conversations with former pilots

Aircraft

Registration
N541SB
Reported as
Sikorsky CH-54A
Category
Helicopter
Serial number
68-18433
Airframe hours
4,362
Engine
P&W JFTD12A-4A, 4,500 horsepower, turbo shaft
Damage
Destroyed
Flight
Part 133
Registered owner
Silver Bay Logging Co.
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Continuous airworthiness · July 10, 1996 · 13 hours before
Departed
Shelter Cove, AK

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
34
Certificates
Commercial, Private, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
7,985 total · 500 in this make and model · 6,190 as pilot in command · 125 in the last 90 days · 60 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
15 statute miles
Lowest ceiling
None
Temperature
61 °F

Docket · 36

The files NTSB released with the investigation on August 26, 1997, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.7 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 408 KBSupplement CItem 2 · .PDF · 417 KBSupplement DItem 3 · .PDF · 539 KBSupplement EItem 4 · .PDF · 126 KBSupplement GItem 5 · .PDF · 104 KBSupplement KItem 6 · .PDF · 848 KBNTSB Materials Laboratory Factual ReportItem 7 · .PDF · 231 KBWitness StatementsItem 8 · .PDF · 422 KBAccident Area MapItem 9 · .PDF · 423 KBWreckage DiagramItem 10 · .PDF · 38 KBTorrington Company Report SummaryItem 11 · .PDF · 343 KBPurchase Order - Marsell Bearing CompanyItem 12 · .PDF · 209 KBAero Independent Bearing Report and RecordsItem 13 · .PDF · 412 KBSilver Bay Logging RecordsItem 14 · .PDF · 167 KBSilver Bay Logging Maintenance RecordsItem 15 · .PDF · 4.4 MBRecord of ConversationsItem 16 · .PDF · 246 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 17 · .PDF · 90 KBStatement of Party Representatives to NTSB InvestigationItem 18 · .PDF · 402 KBPhoto 1. View of left side of helicopter fuselage and cockpit at point of rest.Item 19 · .PDF · 63 KBPhoto 2. View of pylon, tail rotor, tail boom, and fuselage, looking upslope.Item 20 · .PDF · 48 KBPhoto 3. View of impact damage to the right engine.Item 21 · .PDF · 55 KBPhoto 4. View of 1) number 1 tail rotor drive shaft bearing support housing, 2) number 2 tail rotor drive shaft segment with rotational scoring, 3) broken number 2 Thomas Coupling.Item 22 · .PDF · 49 KBPhoto 5. View of 1) number 2 drive shaft bearing housing and attaching bracket, 2) number 3 drive shaft segment, both located on the ground.Item 23 · .PDF · 53 KBPhoto 6. View of broken number 3 Thomas Coupling.Item 24 · .PDF · 48 KBPhoto 7. View of 1) number 3 drive shaft segment, 2) number 3 bearing housing, 3) number 4 drive shaft segment.Item 25 · .PDF · 64 KBPhoto 8. View of number 4 bearing housing and Thomas Coupling.Item 26 · .PDF · 45 KBPhoto 9. View of number 5 drive shaft segment.Item 27 · .PDF · 62 KBPhoto 10. View of separated aft end of the number 5 drive shaft segment and Thomas Coupling. Note a separation just aft of the coupling where the number 5 bearing and housing are normally installed.Item 28 · .PDF · 58 KBPhoto 11. Closer view of separated number 5 drive shaft segment at the number 5 bearing location.Item 29 · .PDF · 41 KBPhoto 12. View of separated forward end of the number 6 drive shaft segment at the number 5 bearing location, looking downslope to the separated section of tail boom.Item 30 · .PDF · 69 KBPhoto 13. Closer view of separated number 6 drive shaft segment at the number 5 bearing location.Item 31 · .PDF · 34 KBPhoto 14. View of upper surface of tail boom at number 5 bearing support housing attach point. Note rotational scoring on surface of boom under, 1) the rotational path of the number 5 Thomas Coupling,& 2) rotational path ofItem 32 · .PDF · 36 KBPhoto 15. Closer view of tail boom attach point for the number 5 drive shaft bearing support housing.Item 33 · .PDF · 40 KBPhoto 16. View of tail rotor gearbox and blades. Note lack of rotational damage to blades.Item 34 · .PDF · 40 KBPhoto 17. Closer view of tail rotor pitch beam assembly crushed against the tail rotor gearbox. Note lack of rotational damage.Item 35 · .PDF · 63 KBPhoto 18. View of tail rotor pylon, horizontal stabilizer, and tail boom, lying in front of the separated cockpit.Item 36 · .PDF · 49 KB

FAA reports on this event · 1

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