# NTSB CEN10IA169: Sikorsky S-92A, N921AL, Galliano, LA, March 22, 2010

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: March 22, 2010, 06:05 local (12:05 UTC)
- Place: Galliano, LA
- Coordinates: 29.412221, -90.294441 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=29.4122&lon=-90.2944&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute: Miscellaneous/other](https://openairdocs.org/ntsb-events/900)
- Highest injury: No injuries
- Injuries: 14 uninjured
- Status: Completed, report April 12, 2011
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: FAA FSDO
- NTSB case key (mKey): 75566
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN10IA169
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75566/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75566
- Page: https://openairdocs.org/ntsb/CEN10IA169

## Probable cause

An unsecured access door, which departed the helicopter and damaged a main rotor blade and a tail rotor blade. Contributing to the incident was the helicopter's color scheme, which made visual inspection of the door difficult.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Doors: service doors](https://openairdocs.org/ntsb-findings/01035240): Aircraft › Aircraft structures · Incorrect service/maintenance (probable cause); cases with it: [Sikorsky S-92A, 1 case](https://openairdocs.org/ntsb-findings/01035240/cases.md?model=8141832), [All aircraft, 5 cases](https://openairdocs.org/ntsb-findings/01035240/cases.md)
- [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Sikorsky S-92A, 1 case](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=8141832), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Prior to flight: Aircraft inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Sikorsky S-92A, 2 cases](https://openairdocs.org/ntsb-events/050/sequence.md?model=8141832), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md)
- [Enroute: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Sikorsky S-92A, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=8141832), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md)

## Analysis

Prior to takeoff, the helicopter's upper Environmental Control System (ECS) panel was not properly secured. The helicopter departed to an off-station platform and returned back to the home base. At an unknown time during the flight the ECS panel departed the helicopter, resulting in damage to one main rotor blade and one tail rotor blade. The helicopter's ECS and auxiliary power unit panels were both painted the same color, impeding visual inspection of the panels for proper closure.

## Factual narrative

On March 22, 2010, at an undetermined time, a Sikorsky S-92A, N921AL, received minor damage when an Environmental Control System (ECS) panel departed the helicopter and struck one main rotor blade and one tail rotor blade. The two airline transport pilots and 12 passengers were not injured. Visual meteorological conditions prevailed and a company visual flight rules flight plan was filed for the Title 14 Code of Federal Regulations Part 135 on-demand air taxi flight. The helicopter was owned and operated by Bristow U.S. LLC. The flight departed the Air Logistics Galliano Heliport (2LS0), Galliano, Louisiana, at 0605, flew to offshore platform Walker Ridge 206, and returned to 2LS0 approximately 0855. According to a statement provided by the pilot, through the company's safety department, the helicopter entered moderate turbulence fifteen minutes into the flight. No unusual characteristics or noises were reported during the flight. Damage to the helicopter was found during a post-flight inspection. The ECS panel has not been recovered, and it is unknown when the panel separated from the helicopter. The helicopter's ECS and APU panels were both painted the same color. This made the visual inspection of the panels difficult to detect if the doors were properly secured. As a result of the incident the company applied contrasting paint to help detect if the doors are not properly secured.

## Aircraft

- Registration: [N921AL](https://openairdocs.org/deregistered/N921AL-2010-10-27), registration cancelled 2010-10-27, S/N 920090, built 2008 (OpenAirDocs)
- Reported make and model: SIKORSKY S-92A
- Registry model: [Sikorsky S-92A](https://openairdocs.org/model/sikorsky-s-92a) (registry code 8141832) (OpenAirDocs)
- Registry engine: [GE CT7-8A](https://openairdocs.org/engine/ge-ct7-8a) (registry code 30136, turbo-shaft) (OpenAirDocs)
- Category: Helicopter
- Serial number: 920090
- Airframe hours: 640
- Engines: GE CT7-8A 2498 horsepower turbo shaft; GE CT7-8A 2498 horsepower turbo shaft
- Damage: Minor damage
- Flight: Part 135
- Operator: Bristow U.S. LLC
- Registered owner: Bristow U.S. LLC
- Airworthiness certificate: Standard, Normal
- Last inspection: Continuous airworthiness, January 23, 2010, 140 hours before
- Departed: 2LS0, Galliano, LA
- Destination: 2LS0, Galliano, LA
- Flight plan: Company VFR
- Airport: 2LS0, Air Logistics Galliano

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 58; injuries: none; flight instructor, airline transport; instrument ratings: helicopter; medical: class 1, with waivers/limitations; last flight review August 5, 2009; seat: right; flight hours: 18,388 total, 520 in this make and model, 12,669 as pilot in command, 38 in the last 30 days
- Co-pilot; age 42; injuries: none; airline transport, commercial; instrument ratings: helicopter; medical: class 1, with waivers/limitations; last flight review October 14, 2009; seat: left; flight hours: 5,046 total, 168 in this make and model, 4,191 as pilot in command, 99 in the last 90 days, 25 in the last 30 days

## Weather

- Conditions: Visual (VMC), Dawn
- Wind: 270° at 12 knots, gusting 20
- Visibility: 10 statute miles
- Lowest ceiling: 3,200 ft overcast
- Temperature: 45 °F, dew point 36 °F
- Altimeter: 30.00 inHg
- Observed at: KGAO, 3 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Incident 20100322036039I](https://openairdocs.org/incident/20100322036039I), Mar 22, 2010: Sikorsky S-92A, Galliano, LA, Minor damage. N921AL departed 2LS0 at 0602 in route to WR206 to exchange passengers. After landing a passenger unload and load was conducted without shutdown. The flight was…

## Docket (2 files)

The files NTSB released with the investigation on October 26, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75566. 816 KB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 377 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40338137&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Photo: Missing ECS door (item 2, .PDF, 438 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40338134&FileExtension=.PDF&FileName=Photo%3A%20Missing%20ECS%20door-Master.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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