CEN11LA414

NTSB accident investigation · Enstrom F-28C-2 · Blair, NE · June 23, 2011

Accident · No injuriesLimited investigationFinal report
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.

Tail rotor drive systemAircraft › Aircraft propeller/rotor · FailureEnstrom F-28C: 1 caseAll aircraft: 10 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotEnstrom F-28C: 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

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.