CEN09LA198

NTSB accident investigation · Bell 206 · Galliano, LA · March 2, 2009

Accident · No injuriesLimited investigationFinal report
Date
March 2, 2009, 07:20 local (12:20 UTC)
Place
Galliano, LA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Standing
Aircraft
N410RLBell 206
Defining event
Standing-engine(s) operating: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report July 28, 2009
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA/FSDO
FAA report
20090302002519A
Case key
73466

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

The failure of the tail rotor driveshaft and coupling during engine start due to the mechanic's failure to properly reattach the tail rotor driveshaft and coupling during maintenance.

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.

Action: forgotten action/omissionPersonnel issues › Action/decision · Maintenance personnelBell Helicopter Textron Canada 206L-4: 1 caseAll aircraft: 440 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 commercial pilot was starting the single-engine helicopter's engine when he heard a loud bang and vibration. He immediately shut down the engine and exited the helicopter. Examination of the helicopter revealed that the tail rotor driveshaft and coupling had severed just forward of the gearbox, which resulted in substantial damage to the tail boom. The helicopter had undergone recent maintenance to the tail rotor gearbox input seal which included the removal of the tail rotor drive shaft from the coupling. When the two components were reattached, the mechanic only hand-tightened the bolts, figuring additional maintenance was still planned for the gearbox. He then installed the tail rotor drive shaft shaft cover. The mechanic moved on to another project and did not make a logbook entry of the work that he had completed or that the bolts were only hand-tightened. Another mechanic later performed additional maintenance to the gearbox, but the bolts were not checked since the maintenance manual did not require the removal of the tail rotor driveshaft cover. A .2-hour maintenance flight check was conducted and the helicopter was returned to service. The accident occurred on first engine start after it had been returned to service.

Factual narrative

On March 2, 2009, at 0720 central daylight time, a Bell 206L-3, N401RL, was damaged when the tail rotor drive shaft and coupling severed while the helicopter was sitting on the ramp with the engine running. The helicopter was operated by and registered to Rotorcraft Leasing Company, LLC, Broussard, Louisiana. The commercial pilot was not injured. Visual meteorological conditions prevailed and no flight plan was filed for the ferry flight conducted under 14 Code of Federal Regulations Part 91. According to the operator, the pilot heard a loud bang and vibration shortly after starting the engine. He immediately shut down the engine, and exited the helicopter. Examination of the helicopter revealed that the tail rotor drive shaft and coupling had severed just forward of the gearbox, which resulted in substantial damage to the tail boom. The helicopter had undergone recent maintenance to the tail rotor gearbox input seal which included the removal of the tail rotor drive shaft from the coupling. When the two components were reattached, the mechanic only hand tightened the bolts, figuring additional maintenance was still planned for the gearbox. He then installed the tailrotor drive shaft cover. The mechanic moved onto another project and did not make a logbook entry of the work that he had completed or that the bolts were only hand tightened. Another mechanic later performed additional maintenance to the gearbox, but the bolts were not checked since the maintenance manual did not require the removal of the tail rotor driveshaft cover. A .2-hour maintenance flight check was conducted and the helicopter was returned to service. The accident occurred on first engine start after it had been returned to service.

Aircraft

Registration
N410RL
Reported as
Bell 206 (L4)
Category
Helicopter
Airframe hours
5,118
Engine
Rolls Royce 260c30, 850 horsepower, turbo shaft
Damage
Substantial damage
Flight
Ferry · Part 91
Operator
Rotorcraft Leasing Company, LLC
Registered owner
Rotorcraft Leasing Company, LLC
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · February 15, 2009
Departed
GAO · Galliano, LA
Destination
GAO · Galliano, LA
Flight plan
Unknown
Airport
GAO · South Lafourche Leonard Miller

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
32
Injuries
None
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
October 20, 2008
Seat
Right
Flight hours
1,292 total · 81 in this make and model · 1,250 as pilot in command · 36 in the last 90 days · 15 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
30 °F, dew point 30 °F
Observed at
GAO

Docket · 3

The files NTSB released with the investigation on May 29, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 15.3 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.