CEN09IA618

NTSB incident investigation · Bell 230 · Peoria, IL · July 1, 2009

Incident · No injuriesIncident investigationFinal report
Date
July 1, 2009, 18:15 local (23:15 UTC)
Place
Peoria, IL
Injuries
4 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N880SFBell 230
Defining event
Enroute: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC)
Status
Completed · report November 17, 2011
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration
FAA report
20090701020029I
Case key
78143

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 loss of the number one hydraulic system fluid and hydraulic pressure during cruise due to the failure of the bolts that secure the hydraulic pump's cover.

Findings · 3

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.

Hydraulic power system: pump, mainAircraft › Aircraft systems · FailureBell 230: 1 caseAll aircraft: 7 casesProbable cause
Fluids: hydraulic fluidAircraft › Fluids/misc hardware · Fluid levelBell 230: 1 caseAll aircraft: 33 casesProbable cause
Misc hardware: fastenersAircraft › Fluids/misc hardware · Not specifiedBell 230: 1 caseAll aircraft: 58 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

The helicopter pilot observed a caution light for the number one hydraulic system and a corresponding complete loss of hydraulic system pressure for that system. The pilot declared an emergency and performed a run-on landing. A postincident examination of the system's hydraulic pump revealed that two of its cover attachment bolts had separated. The bolt heads fractured in tension from their shanks via intergranular cracks which initiated at the filet radius between the bead and the shank. The bolt fractures exhibited intergranular fracture features over 90 percent of the surface. The operator’s incident report safety recommendation stated that the pump's cover bolts should be replaced at overhaul; however, it is not required. The helicopter had accumulated 269 hours since overhaul.

Factual narrative

On July 1, 2009, at 1815 central daylight time, a Bell 230 helicopter, N880SF, sustained no damage during a forced landing at the General Downing - Peoria International Airport (PIA), near Peoria, Illinois, after it lost fluid in its number one hydraulic system during cruise flight. The commercial helicopter pilot, two emergency medical services (EMS) crewmembers, and the patient were not injured. Visual meteorological conditions prevailed and no flight plan was filed. The local non-scheduled domestic 14 Code of Federal Regulations Part 135 EMS transport flight departed PIA at time unknown. According to the operator’s incident report, the pilot observed a caution light for the number one hydraulic system and a corresponding complete loss of hydraulic system pressure for that system. The pilot declared an emergency and performed a run-on landing. Examination of the system's hydraulic pump revealed that two of its cover attachment bolts had separated. The separated bolt heads were retained by safety wire. This hydraulic pump manufacturer’s part number was 65132-1. The Bell Helicopter part number is 222-380-009-105, which is also usable on the Bell 222 series and 430 model helicopters. The bolts that sustained the separation were part number MS24678-17. According to the helicopter manufacturer, these hydraulic pumps do not have a scheduled overhaul cycle and the pumps are replaced on-condition. The manufacturer does not track the service times of these pumps. Reportedly, this was the first failure of the hydraulic pump cover attachment bolts. The pump manufacturer had the failed bolts examined. The bolt heads fractured in tension from their shanks via intergranular cracks initiating at the filet radius between the bead and the shank. The bolt fractures exhibited intergranular fracture features over 90 percent of the surface. According to the operator, the incident pump accumulated 269 hours of time prior to the bolt failures. The operator’s incident report safety recommendation indicated, “Recommend pump cover bolts be replaced at overhaul.”

Aircraft

Registration
N880SF
Reported as
Bell 230
Category
Helicopter
Serial number
23024
Airframe hours
5,673
Engines
Rolls Royce C30 G/2, turbo shaftRolls Royce C30 G/2, turbo shaft
Damage
No damage
Flight
Part 135
Operator
Osf Aviation LLC
Registered owner
Osf Aviation LLC
Airworthiness certificate
Standard, Transport
Departed
PIA · Peoria, IL
Destination
PIA · Peoria, IL
Flight plan
Unknown
Airport
PIA · General Downing - Peoria IAP

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
46
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Seat
Right
Flight hours
7,100 total · 865 in this make and model

Weather

Conditions
Visual (VMC)
Observed at
PIA

Docket · 5

The files NTSB released with the investigation on September 30, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.3 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.

Other investigations on N880SF · 1

Matched to the same aircraft by N-number and date.