# NTSB CEN10LA036: Bell 206, N272M, High Island A-442A, November 1, 2009 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: November 1, 2009, 10:40 local (16:40 UTC) - Place: High Island A-442A - Coordinates: 28.399999, -93.941665 - Nearby events: https://openairdocs.org/map.md?lat=28.4000&lon=-93.9417&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report May 6, 2010 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Flight Standards District Office - NTSB case key (mKey): 74996 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN10LA036 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74996/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74996 - Page: https://openairdocs.org/ntsb/CEN10LA036 ## Probable cause A total loss of engine power due to maintenance personnel's failure to correctly torque the Pc line following removal and reinstallation of the turbine module. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (turbine/turboprop)](https://openairdocs.org/ntsb-findings/01057200): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Bell Helicopter Textron 206L-1, 1 case](https://openairdocs.org/ntsb-findings/01057200/cases.md?model=1182107), [All aircraft, 67 cases](https://openairdocs.org/ntsb-findings/01057200/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Bell Helicopter Textron 206L-1, 2 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=1182107), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Bell Helicopter Textron 206L-1, 7 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1182107), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Ditching](https://openairdocs.org/ntsb-events/441); cases with it: [Bell Helicopter Textron 206L-1, 1 case](https://openairdocs.org/ntsb-events/441/sequence.md?model=1182107), [All aircraft, 186 cases](https://openairdocs.org/ntsb-events/441/sequence.md) ## Analysis The helicopter had landed on an off-shore oil platform and was refueled. It then took off with one passenger. Shortly after lifting off, the pilot "heard a loud pop as the nose of the aircraft passed over the edge of the helideck. The noise was simultaneously accompanied by illumination of the engine out warning light and a needle split indication was observed on the engine and rotor tachometer gauge. As the aircraft yawed and lost climb performance, the pilot lowered the collective pitch full down and activated the floats. Upon landing on the water, the aircraft rolled left until inverted. The helicopter was later recovered and the engine disassembled and examined. The only anomaly noted was a loose Pc line, which would cause a loss of fuel flow and subsequent loss of engine power down to or below idle. It was determined that the torque required to realign the B-nut would be between hand-tight and 27 inch-pounds. The required torque is 80 to 120 inch-pounds. Torque values on the other air line fittings between the power turbine governor and the fuel control were found to range from 55 to 85 inch-pounds. A review of the engine maintenance records revealed that 36.7 hours prior to the accident, the turbine module was completely disassembled and overhauled. This would have required the removal and re-installation of the Pc line. ## Factual narrative On November 1, 2009, approximately 1040 central standard time, a Bell 206L-1, N272M, registered to and operated by Rotorcraft Leasing Company LLC, was substantially damaged when it impacted water following a loss of engine power shortly after lifting off from an oil drilling platform. Visual meteorological conditions prevailed at the time of the accident. The non-scheduled domestic passenger flight was being conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135. The pilot was seriously injured and the passenger received minor injuries. The flight had just originated from platform High Island A442A, and was en route to platform High Island A515, both in the Gulf of Mexico. According to the company accident report, the helicopter had landed on the platform and was refueled. It then took off with one passenger. Shortly after lifting off, the pilot "heard a loud pop as the nose of the aircraft passed over the edge of the helideck. The noise was simultaneously accompanied by illumination of the engine out warning light and a needle split indication was observed on the engine and rotor tachometer gauge. As the aircraft yawed and lost climb performance, the pilot lowered the collective pitch full down and activated the floats. Upon landing on the water, the aircraft rolled left until inverted. The pilot and the only passenger exited the aircraft and inflated their life vests and crawled onto the belly of the aircraft and inflated the life rafts. The pilot and the passenger hung on to the side of one of the inflated life rafts until a nearby crew boat arrived and pulled them out of the water." The helicopter was later recovered and taken to the operator's base in Broussard, Louisiana, where, on November 19, 2009, the engine was disassembled and examined under the supervision of an FAA inspector. The only anomaly noted was a loose Pc line. According to Rolls Royce, a loose Pc line would cause a loss of fuel flow and subsequent loss of engine power down to or below idle. Using a picture taken during the on-site engine examination, the position of the B-nut on the fuel control when torque paint was last applied was approximated. Re-connecting the B-nut to the fuel control fitting, the torque required to realign the B-nut was between hand-tight and 27 inch-pounds. The required torque is 80 to 120 inch-pounds. Torque values on the other air line fittings between the power turbine governor and the fuel control were found to range from 55 to 85 inch-pounds. The turbine wheels and nozzles exhibited signs of corrosion from salt water immersion. The engine controls were intact with no apparent damage. A review of the engine maintenance records revealed that 36.7 hours prior to the accident, the turbine module had been completely disassembled and overhauled. This work would have required removal and re-installation of the Pc line. ## Aircraft - Registration: [N272M](https://openairdocs.org/deregistered/N272M-2013-08-15), registration cancelled 2013-08-15, S/N 45365, built 1980 (OpenAirDocs) - Reported make and model: BELL 206 (L1) - Registry model: [Bell Helicopter Textron 206L-1](https://openairdocs.org/model/bell-helicopter-textron-206l-1) (registry code 1182107) (OpenAirDocs) - Registry engine: [Allison 250-C30 series](https://openairdocs.org/engine/allison-250-c30-series) (registry code 03015, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 45365 - Airframe hours: 13668 - Engines: ALLISON 250-C30P 650 horsepower turbo shaft - Damage: Substantial damage - Flight: Part 135 - Operator: Rotorcraft Leasing Company LLC - Registered owner: Rotorcraft Leasing Company LLC - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, October 10, 2009, 85 hours before - Departed: HI-A442, GM - Destination: HI-A515, GM - Flight plan: Company VFR - Airport: A442, High Island A442A ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 27; injuries: serious; commercial; instrument ratings: helicopter; medical: class 2, without waivers/limitations; last flight review November 18, 2008; seat: right; toxicology performed; flight hours: 1,874 total, 1,549 in this make and model, 1,874 as pilot in command, 139 in the last 90 days, 39 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 45° at 11 knots - Visibility: 6 statute miles - Lowest ceiling: none - Temperature: 61 °F, dew point 48 °F - Altimeter: 30.20 inHg - Observed at: BPT, 95 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). - [Accident 20091101021479A](https://openairdocs.org/incident/20091101021479A), Nov 1, 2009: Bell 206L1, Destroyed. Helicopter departed offshore Platform HIA442 after refueling at 1040 hours and the engine quit once helicopter cleared the offshore Platform. Pilot initiated… ## Other investigations on N272M (1) 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. - [NTSB DFW06IA151](https://openairdocs.org/ntsb/DFW06IA151), Jun 6, 2006: Bell 206L-1 (N272M), South Pass 57 (Gulf of Mexico), incident, no damage. Probable cause: The passenger's failure to follow procedures associated with operations in the vicinity of the helicopter and his failure to see/avoid the tail rotor of the helicopter. ## Docket (8 files) The files NTSB released with the investigation on December 14, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74996. 9.1 MB in all. - NTSB Form 6120.1-2, Pilot-Operator Aircraft Accident Report (item 1, .PDF, 682 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322052&FileExtension=.PDF&FileName=NTSB%20Form%206120.1-2,%20Pilot-Operator%20Aircraft%20Accident%20Report-Redacted.PDF - Portion of the Houston Sectional Chart (item 2, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321549&FileExtension=.PDF&FileName=Portion%20of%20the%20Houston%20Sectional%20Chart-Master.PDF - Weather Reports and Records (item 3, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321443&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Toxicology Report (item 4, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321548&FileExtension=.PDF&FileName=Toxicology%20Report-Redacted.PDF - Photo 1. N272M, inverted and submerged in Gulf of Mexico. (item 5, .PDF, 282 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321703&FileExtension=.PDF&FileName=Photo%201.%20N272M,%20inverted%20and%20submerged%20in%20Gulf%20of%20Mexico.-Master.PDF - Photo 2. N272M after recovery. (item 6, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321704&FileExtension=.PDF&FileName=Photo%202.%20N272M%20after%20recovery.-Master.PDF - Photo 3. Collapsed front seats. (item 7, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321705&FileExtension=.PDF&FileName=Photo%203.%20Collapsed%20front%20seats.-Master.PDF - Photo 4. Disconnected Pc line. (item 8, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321706&FileExtension=.PDF&FileName=Photo%204.%20Disconnected%20Pc%20line.-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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.