CEN09IA003

NTSB incident investigation · MD Helicopter MD 900 · Weatherford, TX · October 8, 2008

Incident · No injuriesIncident investigationFinal report
Date
October 8, 2008, 14:10 local (19:10 UTC)
Place
Weatherford, TX
Injuries
1 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N902RNMD Helicopter MD 900
Defining event
Enroute-cruise: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report November 9, 2009
Report
Approved by Office Director
NTSB office
Central Region
Parties
MD Helicopters
Case key
69244

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

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Probable cause

The failure of the vertical stabilizer control adapter due to reverse bending fatigue.

Findings · 1

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.

Flight control system: stabilizer control systemAircraft › Aircraft systems · Fatigue/wear/corrosionMD Helicopters MD 900: 2 casesAll aircraft: 13 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

While in cruise flight, the helicopter experienced a hard right yaw and subsequent left nose tuck. The pilot was able to regain control of the helicopter and reduce the airspeed to under 100 knots. The flight continued to its destination without further incident. An examination revealed that the vertical stabilizer control system adapter failed. Metallurgical examination revealed that the failure mode was reverse bending fatigue. The vertical stabilizer control system adapter has since been redesigned. Installation of the improved design is now required by an Airworthiness Directive.

Factual narrative

On October 8, 2008, approximately 1410 central daylight time, an McDonnell Douglas Helicopter Inc., MD 900, N902RN, piloted by a commercial pilot, experienced a violent yaw while in cruise flight near Weatherford, Texas. Visual meteorological conditions prevailed at the time of the event. The positioning flight was being operated under the provisions of Title 14 Code of Federal Regulations Part 91 without a flight plan. The pilot was not injured. The flight was en route to Grand Prairie Municipal Airport (KGPM), Grand Prairie, Texas. According to the written statement submitted by the pilot, he had stopped in Plainview, Texas, for fuel, and was en route to KGPM at an altitude of 5,500 feet mean sea level. The pilot stated that there was a “right quartering tailwind” approximately 15 knots, the sky condition was clear, and there was no turbulence. The airspeed was 125 knots indicated airspeed and the autopilot was “engaged and coupled to [altitude] and [navigation] modes.” One hour and thirty-five minutes into the flight the helicopter experienced a “hard right yaw and subsequent left nose tuck.” The pilot was able to regain control of the helicopter and reduced the airspeed “below 100” knots. The flight continued to KGPM without further incident. The helicopter was examined under the supervision of National Transportation Safety Board (NTSB) investigators and a representative from MD Helicopters. The examination revealed that the adapter located between the actuator and the control rod for the left vertical stabilizer control system (VSCS) had fractured. Further examination revealed minor damage to the front and rear fairings located between the upper and lower fins and a small rub mark on the leading edge of the horizontal stabilizer. With the exception of the fractures, the actuation assembly was intact, correctly installed, and appropriately wire-locked. The actuator and the control rod rotated freely within the limitations of their respective rod-ends. Examination of the rigging of the right and left vertical fins revealed no anomalies. The left actuation assembly was removed from the helicopter and sent to the NTSB Materials Laboratory in Washington, D.C., for further examination. Examination of the fracture face on the adapter revealed two distinct opposing zones displaying crack arrest marks and ratchet marks, typical of reverse bending fatigue. A review of the maintenance records revealed that fractured adapter had been installed in September 2, 2008, in compliance with MDHI Service Bulletin (SB) 900-109, dated August 15, 2008. According to MDHI, at least three other helicopters encountered similar failures of the VSCS actuator, (Please reference NTSB case number SEA08SA170, DEN08RA132, and CEN09IA032) all within a six-month period of time. On October 17, 2008, MDHI issued SB 900-110 “Operational Restrictions Concerning VSCS Tube Adapters.” This SB was directed at all MD900 helicopters within a specific serial number range. The SBrequired owners and operators to reduce the operational airspeed of their helicopters to 100 knots indicated airspeed, or Velocity Never Exceed Speed (whichever was less), in visual meteorological conditions, with the autopilot off, VSCS on, until the VSCS adapters could be replaced. On December 3, 2008, MDHI issued SB 900-110R1 “Operational Restrictions and Replacement of VSCS Tube Adapters.” This SB superseded the SB 900-110 and directed operators to replace the two VSCS tube adapters with the “improved” tube adapters. Once this SB had been complied with, the operational airspeed and autopilot restrictions were no longer applicable. On December 17, 2008, Airworthiness Directive (AD) 2008-22-53 issued by the Federal Aviation Administration became effective. This AD required all MD900 helicopter operators with the old VSCS tube adapters to comply with airspeed and autopilot restrictions. If the operator had replaced the old VSCS tube adapter with the new “improved” design, the AD was not applicable.

Aircraft

Registration
N902RN
Reported as
MD Helicopter MD 900
Category
Helicopter
Serial number
900-00121
Airframe hours
201
Engines
Pratt & Whitney Canada PW 207E, 646 horsepower, turbo shaftPratt & Whitney Canada PW 207E, 646 horsepower, turbo shaft
Damage
Minor damage
Flight
Positioning · Part 91
Operator
California Shock and Trauma Air Rescue
Registered owner
California Shock and Trauma Air Rescue
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · September 25, 2008
Departed
KPVW · Plainview, TX
Destination
KGPM · Grand Prairie, TX

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
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
November 20, 2007
Seat
Left
Flight hours
5,600 total · 214 in this make and model · 5,200 as pilot in command · 44 in the last 90 days · 23 in the last 30 days · 9 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 46 °F
Altimeter
30.04 inHg
Observed at
KMWL

Docket · 6

The files NTSB released with the investigation on June 15, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.0 MB in all.