CEN10IA397

NTSB incident investigation · Bell 206 · Gulf of Mexico, LA · July 12, 2010

Incident · No injuriesIncident investigationFinal report
Date
July 12, 2010, 14:28 local (19:28 UTC)
Place
Gulf of Mexico, LA
Injuries
2 uninjured
Damage
Minor damage
Phase of flight
Approach
Aircraft
N523RLBell 206
Defining event
Approach-VFR go-around: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report August 7, 2012
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA Baton Rouge FSDO, Bell Helicopter Textron, Transportation Safety Board of Canada
FAA report
20100712051679I
Case key
76634

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

Improper reassembly of the collective flight controls by maintenance personnel. Contributing to the incident were inadequate postmaintenance examinations by maintenance personnel and inadequate preflight inspections by two pilots.

Findings · 4

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.

Rotorcraft flight control: main rotor controlAircraft › Aircraft propeller/rotor · Incorrect service/maintenanceBell 206-L4: 1 caseAll aircraft: 28 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelBell 206-L4: 2 casesAll aircraft: 320 casesProbable cause
Inspection: post maintenance inspectionPersonnel issues › Task performance · Maintenance personnelBell 206-L4: 1 caseAll aircraft: 57 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotBell 206-L4: 1 caseAll aircraft: 551 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

According to the pilot, the helicopter was on final approach to a platform in the Gulf of Mexico when he raised the collective to perform a go-around. However, the helicopter did not respond properly; rather, its performance and torque indications remained fixed at 45 percent. The pilot began a slow climb and diverted to a land-based airport at a cruise speed of about 60 knots. Because of a complete loss of collective pitch control, the pilot made a running landing on the runway at the airport, touching down about 45 knots. The helicopter came to a stop in the grass about 100 feet past the end of the runway. An examination of the helicopter revealed that several fasteners were missing from the top clevis of the collective control tube, which led to the control tube becoming disconnected from the collective pitch arm on the swash plate. The missing fasteners were found loose on the deck in the transmission compartment. Records showed that maintenance to reinstall the transmission and main rotor hub had been completed about 6 flight hours before the incident and that several mechanics and two pilots had examined the helicopter before the incident flight without noting the improperly secured/missing fasteners.

Factual narrative

On July 12, 2010, about 1428 central daylight time, a Bell 206 L4 helicopter, N523RL, sustained minor damage after a flight control malfunction over the Gulf of Mexico approximately 62 miles south of Patterson, Louisiana. The commercial pilot and one passenger were not injured. The helicopter was owned and operated by Rotorcraft Leasing Company LLC, Broussard, Louisiana. A company flight plan had been filed for the 14 Code of Federal Regulations Part 135 passenger flight. Visual meteorological conditions prevailed at the time of the incident. The helicopter was attempting to land at a production platform in Eugene Island block 208-K after departing another platform approximately one mile away. According to the pilot, while on final approach to the platform, he raised the collective to perform a go-around, but the helicopter did not respond. The pilot noted that the helicopter performance and torque indication remained fixed at 45 percent. There were no abnormal noises, vibrations, or instrument indications. The pilot initiated a slow climb to 1,000 feet above ground level and diverted to Harry P. Williams Memorial Airport (PTN), Patterson, Louisiana, at a cruise speed of about 60 knots. On his first approach to runway 24, the pilot was not able to slow the helicopter and executed a go-around. On his second approach, with a complete loss of collective pitch control, the pilot made a successful running landing, touching down about 45 knots. The helicopter came to a stop in the grass about 100 feet past the end of the runway. The Federal Aviation Administration (FAA) inspectors who responded to the scene reported that the fasteners were missing from the top clevis of the collective control tube, mounted above the collective bellcrank. The control tube had subsequently become disconnected from the collective pitch arm on the swashplate. There was no deformation, bending, elongation, or damage in that area. The missing fasteners were found loose on the deck in the transmission compartment. Maintenance to reinstall the transmission and main rotor hub had been completed on July 7, 2010. Investigators were unable to establish why these fasteners were not properly secured, as several mechanics and pilots had examined the helicopter prior to the incident flight.

Aircraft

Registration
N523RL
Reported as
Bell 206 (L4)
Category
Helicopter
Serial number
52321
Airframe hours
4,399
Engine
Allison 250, 650 horsepower, turbo shaft
Damage
Minor damage
Flight
Part 135
Operator
Rotorcraft Leasing Company LLC
Registered owner
Rotorcraft Leasing Company LLC
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · July 7, 2010 · 6 hours before
Departed
NONE · Gulf of Mexico, LA
Destination
NONE · Gulf of Mexico, LA
Flight plan
Company VFR

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
26
Injuries
None
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
February 9, 2010
Seat
Right
Flight hours
1,819 total · 573 in this make and model · 123 in the last 90 days · 39 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
240° at 10 knots, gusting 14
Visibility
10 statute miles
Lowest ceiling
4,400 ft
Temperature
93 °F, dew point 30 °F
Altimeter
29.95 inHg
Observed at
KPTN, 62 nm away

Docket · 9

The files NTSB released with the investigation on June 18, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.2 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.