CEN11CA152

NTSB accident investigation · Eurocopter Deutschland MBB-BK 117 C-2 · Albert Lea, MN · January 2, 2011

Accident · No injuriesData collectionFinal report
Date
January 1, 2011, 18:14 local (Jan 2, 2011, 00:14 UTC)
Place
Albert Lea, MN
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N145SMEurocopter Deutschland MBB-BK 117 C-2
Defining event
Approach: Miscellaneous/other
Weather
Visual (VMC) · Night
Status
Completed · report May 26, 2011
Report
Approved by Office Director
NTSB office
Central Region
FAA report
20110101004179A
Case key
78154

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's inadequate preflight inspection of the engine cowling latches prior the flight, which resulted in the cowling door opening in-flight and striking the main rotor blades.

Findings · 2

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.

Doors: service doorsAircraft › Aircraft structures · Inadequate inspectionAll aircraft: 5 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotAll 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

The pilot said that he completed a preflight inspection at the beginning of his shift. He noted that earlier in the day, prior to the accident flight, he verified fuel control settings at the request of one of the mechanics. Both of these required that the engine cowling doors be opened. The pilot stated that prior to the accident flight, he visually checked the security of doors and cowlings, leaking fluids, tie downs, and the overall condition of the aircraft. He reported that after starting the number one engine, the flight medic commented that she heard an unusual sound. He subsequently asked her to check the security of the cowling door latches. When the flight medic returned, she informed him that the latches appeared to be secure. He stated that the flight proceeded without incident until about 1/2-mile from the destination helipad, he heard a loud bang and thump from the rear of the helicopter. Shortly thereafter the helicopter started to vibrate and he thought that the noise and vibration might be something from the rotor system. He elected to continue the approach to the destination helipad and subsequently landed without further incident. A postaccident examination revealed substantial damage to all four main rotor blades. The lower portion of the left engine cowling door was separated. No anomalies were observed with respect to the airframe side of the cowling door latches. The separated portion of the door was not recovered.

Factual narrative

The helicopter emergency medical services (HEMS) pilot stated that he had completed a pre-flight inspection at the beginning of his shift. He noted that earlier in the day, prior to the accident flight, he verified some fuel control settings at the request of one of the mechanics. Both of these required that the engine cowling doors be opened. The pilot stated that prior to the accident flight, he "visually checked for security of doors and cowlings, leaking fluids, tie downs, and overall condition of the aircraft." He reported that after starting the number one engine, the flight medic commented that she heard an "unusual rattle." The pilot subsequently asked her to check the security of the cowling door latches. When the flight medic returned, she informed him that the latches appeared to be secure. The pilot stated that the flight proceeded without incident until about one-half mile from the destination helipad, when he heard a "loud bang and thump from the rear of the aircraft." From that point in time, a "four per rev[olution] vibration had developed." He recalled thinking that due to the noise and vibration something might have separated from the rotor system. He elected to continue the approach to the destination helipad and subsequently landed without further incident. A post accident examination revealed substantial damage to all four main rotor blades. The lower portion of the left engine cowling door was separated. No anomalies were observed with respect to the airframe side of the cowling door latches. The separated portion of the door was not recovered. The helicopter was being repositioned in order to pick-up a patient, and only the pilot and medical crew were on-board at the time of the accident.

Aircraft

Registration
N145SM
Reported as
Eurocopter Deutschland MBB-BK 117 C-2
Category
Helicopter
Serial number
9298
Airframe hours
490
Engines
Turbomeca Arriel 1E2, 758 horsepower, turbo shaftTurbomeca Arriel 1E2, 758 horsepower, turbo shaft
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
Omniflight Helicopters, Inc.
Registered owner
Wells Fargo Bank Northwest Na Trustee
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · December 28, 2010
Departed
99MN · Rochester, MN
Destination
30MN · Albert Lea, MN
Flight plan
Company VFR
Airport
30MN · Albert Lea Medical Center

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
46
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
September 8, 2010
Seat
Right
Flight hours
5,520 total · 130 in this make and model · 5,520 as pilot in command · 54 in the last 90 days · 6 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
270° at 19 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
5 °F, dew point -0 °F
Altimeter
29.09 inHg
Observed at
RST, 39 nm away

Docket · 4

The files NTSB released with the investigation on February 16, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.3 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.