CEN09LA571

NTSB accident investigation · Messerschmitt-Boelkow-Blohm BO-105S · Thibodaux, LA · September 6, 2009

Accident · Minor injuriesLimited investigationFinal report
Date
September 6, 2009, 14:00 local (19:00 UTC)
Place
Thibodaux, LA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N131EHMesserschmitt-Boelkow-Blohm BO-105S
Defining event
Maneuvering-hover: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report March 3, 2010
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, American Eurocopter, ERA Helicopters
FAA report
20090906019909A
Case key
74681

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 pilot's inability to maintain control due to the mechanic's inadvertent switching of two cyclic control tubes of different lengths during maintenance.

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.

Flight control systemAircraft › Aircraft systems · Incorrect service/maintenanceMesserschmitt-Boelkow-Blohm BO-105S: 2 casesAll aircraft: 65 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleMesserschmitt-Boelkow-Blohm BO-105S: 1 caseAll aircraft: 1,269 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelMesserschmitt-Boelkow-Blohm BO-105S: 1 caseAll aircraft: 371 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 a 3-foot hover the helicopter began an uncommanded roll to the right. The pilot unsuccessfully attempted to arrest the roll by applying full left cyclic. Moments later the right landing skid made contact with the ground, followed by the main rotor blades. The helicopter came to rest in a right-side-low, upright position and the pilot was able to exit unassisted. The purpose of the flight was to perform an operational flight check of maintenance performed to the cyclic control system. The investigation revealed that the mechanic who had performed the maintenance had inadvertently switched two cyclic control tubes, of different lengths, during reassembly. This resulted in an out-of-rig condition in the cyclic control system. No other preimpact anomalies were noted with the helicopter's flight control system.

Factual narrative

On September 6, 2009, about 1400 central daylight time, a Messerschmitt-Boelkow-Blohm BO-105S helicopter, N131EH, was substantially damaged during a post maintenance flight near Thibodaux, Louisiana. The pilot, the sole occupant, sustained minor injuries. The helicopter was registered to and operated by ERA Helicopters LLC., of Lake Charles, Louisiana. Visual meteorological conditions prevailed and a company flight plan was filed for the 14 Code of Federal Regulations Part 91 local flight. According to the pilot, while in a 3-foot hover, the helicopter began an uncommanded roll to the right. The pilot attempted to arrest the roll by applying full left cyclic; however, the helicopter's roll could not be arrested. Moments later the right landing skid made contact with the ground followed by the main rotor blades. The helicopter came to rest in a right side low upright position and the pilot was able to exit unassisted. According to a Federal Aviation Administration (FAA) inspector who responded to the accident site, the purpose of the flight was to perform an operational flight check of maintenance performed to the cyclic control system. Prior to the accident flight, a company mechanic had removed both the lower lateral and longitudinal cyclic control tubes to replace the rod ends on both of the tubes. Although the lateral and longitudinal control tubes have the same part number, they are adjusted to different lengths. The rod ends were replaced with new ones and reinstalled in the helicopter; however, the investigation revealed that the mechanic had inadvertently switched the two control tubes during reassembly. This resulted in an out of rig condition in the cyclic control system. In addition, a bench check and a teardown were performed on the hydraulic control pack. There were no anomalies noted with the hydraulic system. Continuity was established in the "non-boosted" cyclic control system, and no anomalies were noted. The cyclic system above the hydraulic pack was damaged as result of the accident, but was functional. There also were no anomalies noted with the swashplate system or the main rotor system.

Aircraft

Registration
N131EH
Reported as
Messerschmitt-Boelkow-Blohm BO-105S
Category
Helicopter
Serial number
S-595
Airframe hours
16,155
Engines
Allison 250-C20 SER, 420 horsepower, turbo shaftAllison 250-C20B, 420 horsepower, turbo shaft
Damage
Substantial damage
Flight
Other work use · Part 91
Operator
Era Helicopters LLC
Registered owner
Era Helicopters LLC
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · May 15, 2009
Departed
L83 · Thibodaux, LA
Destination
L83 · Thibodaux, LA
Flight plan
Company VFR
Airport
L83 · Thibodaux Municipal

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
61
Injuries
Minor
Certificate
Airline transport
Instrument ratings
Helicopter
Medical
Class 1, With waivers/limitations
Last flight review
August 13, 2009
Seat
Right
Flight hours
10,033 total · 1,969 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 5 knots
Visibility
10 statute miles
Temperature
84 °F

Docket · 3

The files NTSB released with the investigation on November 3, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.4 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.