CEN09IA234

NTSB incident investigation · Bell 206L-3 · Abilene, TX · March 29, 2009

Incident · No injuriesIncident investigationFinal report
Date
March 29, 2009, 18:20 local (23:20 UTC)
Place
Abilene, TX
Injuries
3 uninjured
Damage
Minor damage
Phase of flight
Unknown
Aircraft
N708MBell 206L-3
Defining event
Unknown: Unknown or undetermined
Weather
Visual (VMC) · Day
Status
Completed · report March 23, 2010
Report
Approved by Office Director
NTSB office
Central Region
Parties
Bell Helicopter, FAA Flight Standards District Office
FAA report
20090329003029I
Case key
73587

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

On this page

Probable cause

The formation and propagation of a fatigue crack in the trailing edge of the main rotor blade due to interconnected porosity and resultant corrosion. The area of interconnected porosity was due to a manufacturing defect which was not detected during the manufacturing process.

Findings · 2

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.

Main rotor system: main rotor blade systemAircraft › Aircraft propeller/rotor · Fatigue/wear/corrosionAll aircraft: 60 casesProbable cause
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · ManufacturerAll aircraft: 61 cases

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

Following the post-flight inspection of a repositioning flight, the pilot noted a crack in the trailing edge of the rotor blade. He had characterized the previous flight as turbulent, but otherwise unremarkable and without any mechanical anomalies. An examination of the main rotor blade revealed a path of interconnected porosity between the lower trailing edge skin, trailing edge strip, and epoxy that allowed for the introduction of moisture and resultant corrosion. The failure was due to insufficient squeeze-out of the epoxy layer between the lower skin and the trailing edge strip during manufacture. The corrosion pit allowed the formation of a fatigue crack with a resultant crack along the blade surface.

Factual narrative

On March 29, 2009, approximately 1820 central daylight time, a crack was discovered on one main rotor blade on a Bell 206 L-3, N708M, operated by Air Evac EMS, Inc. The helicopter had just returned from a mission and landed uneventfully at the operations base in Abilene, Texas. Visual meteorological conditions prevailed during the mission and repositioning flight. The repositioning portion of the flight was being conducted under the provisions of Title 14 Code of Federal Regulations Part 91 without a flight plan. The pilot and two medical crewmembers were not injured. According to the operator, the preflight for the mission was without anomalies or issues. The mission flight and repositioning flight were turbulent, but otherwise, unremarkable. During the post-flight inspection of the helicopter, the pilot discovered a crack in one of the main rotor blades. The pilot states specifically that he was unable to detect any vibration in the system due to the turbulence. The operator removed the blade and sent it to the National Transportation Safety Board Materials Laboratory in Washington, DC. On July 15, 2009, an investigator with the Safety Board and an engineer from Bell Helicopter examined the blade. The crack was observed in the top and bottom skin of the trailing edge of the blade. The crack ran chord-wise approximately 8.75 inches from the trailing edge of the blade towards the leading edge of the blade. The crack then branched into two cracks running longitudinally in opposite directions; one crack measuring 9.5 inches inboard and the second crack measuring 7.75 inches outboard. Examination of the crack surface revealed features consistent with a fatigue crack that initiated from a pit along the leading edge of the trailing edge strip. The crack’s initiation site revealed a yellow discoloration consistent with corrosion. Further examination revealed a region of interconnected porosity that formed a channel through the adhesive layer that bonded the lower skin to the trailing edge strip. According to Bell Helicopter, during the manufacturing process, the blade is taken through two separate leak checks designed to detect porosity in the epoxy that bonds the upper and lower skins to the trailing edge strip. According to assembly records, these two leak checks were conducted by October 23, 2005, and October 26, 2005, respectively. There were no notes in the assembly records to indicate that a leak was noted; however, records did indicate, through a quality assurance stamp, that the leak checks had been performed. According to Bell Helicopter, if a leak is noted, additional adhesive is applied and an entry in the assembly records is not necessarily made. Engineers and investigators from Bell Helicopter reported that trailing edge blade cracks are a rare occurrence. If a trailing edge blade crack is not found during normal maintenance and pilot checks, then the crack will eventually become large enough that the pilot is able to detect a one perrevolution vibration in flight. They stated that when these events occur, the pilot is able to easily detect an imbalance situation in the operation of the aircraft; the situation does not propagate beyond the imbalance and vibration. The cracks are usually noted during the post flight inspection, while trying to diagnose the imbalance. According to the operator and company maintenance records, they had experiences a one per revolution vibration and had conducted tracking and balancing with the blade, in order to track the vibration. It was noted that after this maintenance, the vibration was no longer noted.

Aircraft

Registration
N708M
Reported as
Bell 206L-3
Category
Helicopter
Serial number
51186
Airframe hours
8,188
Engine
Allison 250 SER 250HP, 250 horsepower, turbo shaft
Damage
Minor damage
Flight
Positioning · Part 91
Operator
Air Evac Ems Inc
Registered owner
Air Evac Ems Inc
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · March 3, 2009
Departed
KLBB · Lubbock, TX
Destination
Abilene, TX
Flight plan
Company VFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
50
Injuries
None
Certificates
Private, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
July 15, 2008
Seat
Right
Flight hours
3,918 total · 2,247 in this make and model · 3,435 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 21 knots, gusting 31
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 16 °F
Altimeter
29.75 inHg

Docket · 3

The files NTSB released with the investigation on January 6, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.7 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.