- Date
- June 23, 2011, 12:55 local (17:55 UTC)
- Place
- Blair, NE
- Injuries
- 2 uninjured
- Damage
- Substantial damage
- Phase of flight
- Maneuvering
- Aircraft
- N5694AEnstrom F-28C-2
- Defining event
- Maneuvering: Flight control sys malf/fail
- Weather
- Visual (VMC) · Day
- Status
- Completed · report April 20, 2012
- Report
- Approved by Office Director
- NTSB office
- Central Region
- Parties
- FAA/FSDO
- FAA report
- 20110623011789A
- Case key
- 80869
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 failure of a tail rotor pitch change link due to the retaining bolt becoming separated in flight. Contributing to the accident was the pilot’s inadequate preflight inspection.
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.
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 was conducting an aerial observation flight in a helicopter when he felt a high vibration in the tail rotor system in conjunction with a sharp jerk in the anti-torque pedals. The pilot autorotated to a wet field and the helicopter subsequently rolled over. A postaccident examination of the helicopter revealed that a pitch link retaining bolt had come loose from the pitch link attachment horn. The bolt and its associated hardware separated in flight and the bolt hole where the pitch link attached was elongated. According to the helicopter’s preflight inspection checklist, the pitch link should have been checked before flight for binding or looseness; however, the pilot could not recall if he actually checked it. The helicopter underwent a 100-hour maintenance inspection two weeks before the accident. At that time, the maintenance manual required an inspection in which the pitch links would have to be disconnected then reassembled. Since the pitch link retaining bolt and its associated hardware were never recovered, it could not be determined if the pitch link assembly had been properly installed or torqued at the last inspection. The pitch link failure occurred about 14 hours after this inspection. The Federal Aviation Administration reported that they were not aware of any instances prior to this accident where the tail rotor pitch link assemblies became loose and failed prematurely after proper installation.
Factual narrative
On June 23, 2011, at 1255 central daylight time, N5694A, an Enstrom F-28C helicopter, was substantially damaged during a forced landing to a field near Blair, Nebraska, following a tail rotor control failure. The commercial pilot and the passenger were not injured. The helicopter was registered to and operated by P and N Corporation, Marion, Iowa. Visual meteorological conditions prevailed and no flight plan was filed for the aerial observation flight conducted under 14 Code of Federal Regulations Part 91. The pilot said he was flying along the Missouri River at 200 feet when he felt an abrupt "high vibration" in the tail rotor system in conjunction with a sharp jerk in the anti-torque pedals. The pilot made an autorotation to a wet field and landed on the left skid. The skid collapsed and the helicopter rolled on to its left side, damaging the tailboom and the main rotor blades. A Federal Aviation Administration (FAA) inspector, who had extensive operational experience in Enstrom helicopters, performed an examination of the helicopter and found that the pitch change link retaining bolt for the tail rotor pitch system had come loose in the pitch change link attachment horn. The attachment hole in the pitch link attachment horn showed "excessive wear" and was elongated. The tail rotor control cables were also severed. According to the inspector, the tail rotor pitch links are critical components of the helicopter and they are required to be checked during the pre-flight inspection. The inspector said the pilot "should have caught the loose bolt" during this inspection. The pilot said he performed a pre-flight inspection of the helicopter the day before the accident and did not recall any problems with the tail rotor pitch links. He then flew from Iowa to Nebraska, and placed the helicopter in a hangar overnight. When the pilot conducted a pre-flight of the helicopter the following morning, he could not recall if he had inspected the pitch links as required per the FAA approved Enstrom F28C Pre-flight Inspection checklist (item 21), for binding or looseness. The pilot said that even though he could not recall specifically checking/touching the pitch links, it was an item that was required to be inspected and something he would normally check. He also reported that the operator operates several Enstrom helicopters and has had previous problems with the pitch links coming loose "in a very short amount of time." After the accident, the operator inspected the remaining seven Enstrom helicopters in their fleet and reported there were no anomalies with any of the pitch link assemblies. An FAA inspector reviewed the maintenance records and verified that the helicopter underwent a 100-hour maintenance inspection on June 9, 2011, at an airframe total time of 3,706 hours, just two weeks before the accident. Enstrom requires (per the Enstrom Helicopter Maintenance Manual section 3-7) that the feather bearings in the tail rotor be inspected for brinelling andlubrication every 50 hours. To do this inspection, the pitch links have to be disconnected and the tail rotor blades rotated 2 or 3 turns. Then the pitch links and associated hardware have to be reconnected. According to the FAA, this inspection was completed at the last 100-hour inspection. The pitch link assembly failed approximately 14 hours later. Since the pitch change link retaining bolt and its associated hardware had separated from the helicopter in-flight and were never recovered, it was not determined if the pitch link assembly was installed and torqued correctly. According to the FAA Aircraft Certification Office (ACO) that oversees the type certificate for Enstrom, they were not aware of any instances prior to this accident where the tail rotor pitch link assemblies were becoming loose and failing prematurely if they had been properly installed. As a result of this accident, Enstrom released a revision to their Service Information Letter (SIL) Number 0165, on November 14, 2011, to include an inspection of the tail rotor rotating controls for proper hardware, modifying the installation hardware, if necessary, and checking the torque of the pitch change link attachment. The SIL also stated that this tail rotor assembly should be inspected at every 50 or 100 hour/annual inspection as recommended in Section 3 of the applicable maintenance manual.
Aircraft
- Registration
- N5694A
- Reported as
- Enstrom F-28C-2
- Category
- Helicopter
- Serial number
- 491-2
- Airframe hours
- 3,706
- Engine
- Lycoming HIO-360-E1AD, 205 horsepower, reciprocating
- Damage
- Substantial damage
- Flight
- Aerial observation · Part 91
- Operator
- P And N Corporation
- Registered owner
- P And N Corporation
- Airworthiness certificate
- Standard, Normal
- Last inspection
- 100 hour · June 9, 2011 · 14 hours before
- Departed
- PMV · Plattsmouth, NE
- Destination
- Blair, NE
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
- 68
- Injuries
- None
- Certificates
- Commercial, Flight instructor
- Airplane ratings
- Multi-engine land, Single-engine land
- Instrument ratings
- Helicopter, Airplane
- Medical
- Class 2, With waivers/limitations
- Last flight review
- May 19, 2010
- Seat
- Right
- Flight hours
- 35,000 total · 5,000 in this make and model · 100 in the last 90 days · 50 in the last 30 days · 6 in the last 24 hours
Weather
- Conditions
- Visual (VMC) · Day
- Wind
- 310° at 14 knots
- Visibility
- 10 statute miles
- Temperature
- 70 °F, dew point 57 °F
- Altimeter
- 29.88 inHg
- Observed at
- OMA, 10 nm away
Docket · 8
The files NTSB released with the investigation on February 2, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.0 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.