# NTSB ANC96FA098: Sikorsky CH-54A, N541SB, Ketchikan, AK, July 13, 1996 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 13, 1996, 13:25 local (21:25 UTC) - Place: Ketchikan, AK - Coordinates: 55.610633, -131.579589 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=55.6106&lon=-131.5796&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report October 31, 1997 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - NTSB case key (mKey): 2757 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC96FA098 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/2757/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=2757 - Page: https://openairdocs.org/ntsb/ANC96FA098 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, hover - out of ground effect - rotor drive system,tail rotor drive shaft bearing - failure (cause) - procedure inadequate, other institution (contributing factor) - insufficient standards/requirements, other institution (contributing factor) - Loss of control - in flight, hover - out of ground effect - directional control - not possible - Forced landing, emergency descent/landing - autorotation - attempted, pilot in command - In flight collision with terrain/water, emergency descent/landing - terrain condition - none suitable (contributing factor) - terrain condition - mountainous/hilly (contributing factor) ## 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](https://openairdocs.org/deregistered/N541SB-1997-03-24), registration cancelled 1997-03-24, S/N 6818433 (OpenAirDocs) - Reported make and model: Sikorsky CH-54A - Registry model: [Silver Bay Logging CH-54A](https://openairdocs.org/model/silver-bay-logging-ch-54a) (registry code 8160000) (OpenAirDocs) - Category: Helicopter - Serial number: 68-18433 - Airframe hours: 4362 - Engines: P&W JFTD12A-4A 4500 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 34; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19960713016949A](https://openairdocs.org/incident/19960713016949A), Jul 13, 1996: Skrsky CH54A, Ketchikan, AK, Destroyed, 1 fatal. On logging expedition when rotor blade strcuk trees. (.4)the pilot & copilot were on an external load, aero logging operation in a military surplus helicopter,… ## Docket (36 files) The files NTSB released with the investigation on August 26, 1997, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=2757. 10.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 408 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446450&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Supplement C (item 2, .PDF, 417 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071835&FileExtension=.PDF&FileName=Supplement%20C-Master.PDF - Supplement D (item 3, .PDF, 539 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071836&FileExtension=.PDF&FileName=Supplement%20D-Master.PDF - Supplement E (item 4, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446449&FileExtension=.PDF&FileName=Supplement%20E-Redacted.PDF - Supplement G (item 5, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071838&FileExtension=.PDF&FileName=Supplement%20G-Master.PDF - Supplement K (item 6, .PDF, 848 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071839&FileExtension=.PDF&FileName=Supplement%20K-Master.PDF - NTSB Materials Laboratory Factual Report (item 7, .PDF, 231 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446451&FileExtension=.PDF&FileName=NTSB%20Materials%20Laboratory%20Factual%20Report-Redacted.PDF - Witness Statements (item 8, .PDF, 422 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446452&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Accident Area Map (item 9, .PDF, 423 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071843&FileExtension=.PDF&FileName=Accident%20Area%20Map-Master.PDF - Wreckage Diagram (item 10, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071844&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Torrington Company Report Summary (item 11, .PDF, 343 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446453&FileExtension=.PDF&FileName=Torrington%20Company%20Report%20Summary-Redacted.PDF - Purchase Order - Marsell Bearing Company (item 12, .PDF, 209 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446454&FileExtension=.PDF&FileName=Purchase%20Order%20-%20Marsell%20Bearing%20Company-Redacted.PDF - Aero Independent Bearing Report and Records (item 13, .PDF, 412 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446455&FileExtension=.PDF&FileName=Aero%20Independent%20Bearing%20Report%20and%20Records-Redacted.PDF - Silver Bay Logging Records (item 14, .PDF, 167 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446456&FileExtension=.PDF&FileName=Silver%20Bay%20Logging%20Records-Redacted.PDF - Silver Bay Logging Maintenance Records (item 15, .PDF, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446457&FileExtension=.PDF&FileName=Silver%20Bay%20Logging%20Maintenance%20Records-Redacted.PDF - Record of Conversations (item 16, .PDF, 246 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446458&FileExtension=.PDF&FileName=Record%20of%20Conversations-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 17, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446459&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 18, .PDF, 402 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446460&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photo 1. View of left side of helicopter fuselage and cockpit at point of rest. (item 19, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071853&FileExtension=.PDF&FileName=Photo%201.%20%20View%20of%20left%20side%20of%20helicopter%20fuselage%20and%20cockpit%20at%20point%20of%20rest.-Master.PDF - Photo 2. View of pylon, tail rotor, tail boom, and fuselage, looking upslope. (item 20, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071854&FileExtension=.PDF&FileName=Photo%202.%20%20View%20of%20pylon,%20tail%20rotor,%20tail%20boom,%20and%20fuselage,%20looking%20upslope.-Master.PDF - Photo 3. View of impact damage to the right engine. (item 21, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071855&FileExtension=.PDF&FileName=Photo%203.%20%20View%20of%20impact%20damage%20to%20the%20right%20engine.-Master.PDF - Photo 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 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071856&FileExtension=.PDF&FileName=Photo%204.%20%20View%20of%201)%20number%201%20tail%20rotor%20drive%20shaft%20bearing%20support%20housing,%202)%20number%202%20tail%20rotor%20drive%20shaft%20segment%20with%20rotational%20scoring,%203)%20broken%20number%202%20Thomas%20Coupling.-Master.PDF - Photo 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 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071857&FileExtension=.PDF&FileName=Photo%205.%20%20View%20of%201)%20number%202%20drive%20shaft%20bearing%20housing%20and%20attaching%20bracket,%202)%20number%203%20drive%20shaft%20segment,%20both%20located%20on%20the%20ground.-Master.PDF - Photo 6. View of broken number 3 Thomas Coupling. (item 24, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071858&FileExtension=.PDF&FileName=Photo%206.%20%20View%20of%20broken%20number%203%20Thomas%20Coupling.-Master.PDF - Photo 7. View of 1) number 3 drive shaft segment, 2) number 3 bearing housing, 3) number 4 drive shaft segment. (item 25, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071859&FileExtension=.PDF&FileName=Photo%207.%20%20View%20of%201)%20number%203%20drive%20shaft%20segment,%202)%20number%203%20bearing%20housing,%203)%20number%204%20drive%20shaft%20segment.-Master.PDF - Photo 8. View of number 4 bearing housing and Thomas Coupling. (item 26, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071860&FileExtension=.PDF&FileName=Photo%208.%20%20View%20of%20number%204%20bearing%20housing%20and%20Thomas%20Coupling.-Master.PDF - Photo 9. View of number 5 drive shaft segment. (item 27, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071861&FileExtension=.PDF&FileName=Photo%209.%20%20View%20of%20number%205%20drive%20shaft%20segment.-Master.PDF - Photo 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 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071862&FileExtension=.PDF&FileName=Photo%2010.%20%20View%20of%20separated%20aft%20end%20of%20the%20number%205%20drive%20shaft%20segment%20and%20Thomas%20Coupling.%20%20Note%20a%20separation%20just%20aft%20of%20the%20coupling%20where%20the%20number%205%20bearing%20and%20housing%20are%20normally%20installed.-Master.PDF - Photo 11. Closer view of separated number 5 drive shaft segment at the number 5 bearing location. (item 29, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071863&FileExtension=.PDF&FileName=Photo%2011.%20Closer%20view%20of%20separated%20number%205%20drive%20shaft%20segment%20at%20the%20number%205%20bearing%20location.-Master.PDF - Photo 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 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071864&FileExtension=.PDF&FileName=Photo%2012.%20%20View%20of%20separated%20forward%20end%20of%20the%20number%206%20drive%20shaft%20segment%20at%20the%20number%205%20bearing%20location,%20looking%20downslope%20to%20the%20separated%20section%20of%20tail%20boom.-Master.PDF - Photo 13. Closer view of separated number 6 drive shaft segment at the number 5 bearing location. (item 31, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071865&FileExtension=.PDF&FileName=Photo%2013.%20%20Closer%20view%20of%20separated%20number%206%20drive%20shaft%20segment%20at%20the%20number%205%20bearing%20location.-Master.PDF - Photo 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 of (item 32, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071866&FileExtension=.PDF&FileName=Photo%2014.%20%20View%20of%20upper%20surface%20of%20tail%20boom%20at%20number%205%20bearing%20support%20housing%20attach%20point.%20%20Note%20rotational%20scoring%20on%20surface%20of%20boom%20under,%201)%20the%20rotational%20path%20of%20the%20number%205%20Thomas%20Coupling,%26%202)%20rotational%20path%20of-Master.PDF - Photo 15. Closer view of tail boom attach point for the number 5 drive shaft bearing support housing. (item 33, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071867&FileExtension=.PDF&FileName=Photo%2015.%20%20Closer%20view%20of%20tail%20boom%20attach%20point%20for%20the%20number%205%20drive%20shaft%20bearing%20support%20housing.-Master.PDF - Photo 16. View of tail rotor gearbox and blades. Note lack of rotational damage to blades. (item 34, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071868&FileExtension=.PDF&FileName=Photo%2016.%20%20View%20of%20tail%20rotor%20gearbox%20and%20blades.%20%20Note%20lack%20of%20rotational%20damage%20to%20blades.-Master.PDF - Photo 17. Closer view of tail rotor pitch beam assembly crushed against the tail rotor gearbox. Note lack of rotational damage. (item 35, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071869&FileExtension=.PDF&FileName=Photo%2017.%20%20Closer%20view%20of%20tail%20rotor%20pitch%20beam%20assembly%20crushed%20against%20the%20tail%20rotor%20gearbox.%20%20Note%20lack%20of%20rotational%20damage.-Master.PDF - Photo 18. View of tail rotor pylon, horizontal stabilizer, and tail boom, lying in front of the separated cockpit. (item 36, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40071870&FileExtension=.PDF&FileName=Photo%2018.%20%20View%20of%20tail%20rotor%20pylon,%20horizontal%20stabilizer,%20and%20tail%20boom,%20lying%20in%20front%20of%20the%20separated%20cockpit.-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.