CEN12LA120

NTSB accident investigation · Continental Copters 47G2 · Lohn, TX · January 1, 2012

Accident · Serious injuriesLimited investigationFinal report
Date
January 1, 2012, 14:00 local (20:00 UTC)
Place
Lohn, TX
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N9021RContinental Copters 47G2
Defining event
Maneuvering-low-alt flying: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report September 5, 2013
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, Scott's - Bell 47, Inc.
FAA report
20120101000549A
Case key
82607

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 improper installation of the tail rotor gearbox by maintenance personnel, which led to accelerated wear of the ring and pinion gears, resulting in the loss of tail rotor effectiveness and subsequent forced landing.

Findings · 3

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 system: tail rotor gearboxAircraft › Aircraft propeller/rotor · Fatigue/wear/corrosionBell-Continental Copters 47G2: 1 caseAll aircraft: 12 casesProbable cause
Tail rotor drive system: tail rotor gearboxAircraft › Aircraft propeller/rotor · Incorrect service/maintenanceBell-Continental Copters 47G2: 1 caseAll aircraft: 12 casesProbable cause
Maintenance: repairPersonnel issues › Task performance · Maintenance personnelBell-Continental Copters 47G2: 1 caseAll aircraft: 99 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 performed a preflight inspection of the helicopter to include checking the tail rotor oil level through its sight glass. He had flown the helicopter for more than an hour when the tail yawed to the left, slowly at first then rapidly. The pilot “cut” the throttle, flew the helicopter “to the ground as fast as possible,”and impacted terrain. A postaccident examination of the wreckage revealed that the tail rotor gearbox did not operate when it was rotated. A teardown revealed that the interior surfaces of the gearbox were covered with a black oily substance consistent with residual lubricating oil contaminated with liberated metal particles. The oil level sight glass exhibited no discoloration or other hindrance to normal oil level detection in service. Examination of the ring and pinion gears revealed that the teeth on the pinion gear were deformed and worn almost down to the tooth root in some locations. Wear was observed on the top land and drive faces of the ring gear. Wear patterns were noted on the coast faces of the ring and pinion gear teeth. The observation of wear on the coast faces of the gear teeth is most probably an indication that the spacing between the gears was too tight as a result of improper alignment during installation, causing accelerated wear. A logbook entry showed that the helicopter’s last annual inspection was completed about 6 months before the accident during which the tail rotor gearbox was overhauled and installed.

Factual narrative

On January 1, 2012, about 1400 central standard time, a Continental Copters Inc. 47G2 helicopter, N9021R, impacted terrain during a forced landing following a loss of tail rotor effectiveness near Lohn, Texas. The commercial pilot and passenger sustained serious injuries. The helicopter’s tailboom was substantially damaged during the forced landing. The helicopter was registered to and operated by Sky Horse Helicopters Inc. under the provisions of 14 Code of Federal Regulations Part 91 as an aerial observation flight. Day visual flight rules (VFR) conditions prevailed for the flight, which did not operate on a VFR flight plan. The helicopter departed on the local flight about 1300. The pilot stated in his accident report that he performed a preflight inspection of the helicopter to include checking the tail rotor oil level through its sight glass. He flew the helicopter for “over” an hour when the tail yawed to the left. The yaw was slow at first and then the helicopter yawed rapidly. The pilot “cut” the throttle and flew the helicopter “to the ground as fast as possible.” A logbook endorsement showed that the helicopter’s last annual inspection was completed on July 13, 2011, and that the helicopter had accumulated 8,989 hours of total flight time. The pilot reported that the helicopter had accumulated 9,057 hours of total flight time at the time of the accident and that he did not have any records in reference to the tail rotor gearbox. A Federal Aviation Administration (FAA) inspector examined the wreckage on-scene. The tail rotor gearbox did not operate when it was rotated. The FAA inspector measured the gearboxes' shim and he reported its thickness measurement as 0.015 inches, plus or minus 0.001 inches. The accident gearbox, marked with part no. 47-640-044-39 and serial no. A13-3661, was retained and was shipped to Scott’s – Bell 47 Inc. for detailed examination under FAA supervision. The examination, in part, revealed that the interior surfaces of the gearbox were covered with a black oily substance consistent with residual lubricating oil contaminated with liberated metal particles. The oil level sight glass exhibited no discoloration or other hindrance to normal oil level detection in service. Damage was noted on the upper aft portion of the main case assembly where the aft casting accommodated the tail rotor guard. This area of displaced or previously removed material was filled with a media consistent with an epoxy mix. The gearbox assembly was dismantled in accordance with procedures listed in its service instruction and no significant difficulties or abnormal conditions were encountered. Scott’s – Bell 47 Inc. report is appended to the docket material associated with this case. Parts, to include the ring and pinion gear, were removed and shipped to the National Transportation Safety Board (NTSB) Materials Laboratory. A NTSB Senior Materials Engineer examined the parts and produced Materials Laboratory Factual Report No. 13-028. Theexamination revealed that the teeth on the pinion gear were deformed and worn almost down to the tooth root in some locations. Wear was observed on the top land and drive faces of the ring gear. Wear patterns were noted on the coast faces of the ring and pinion gear teeth. Hardness testing revealed that both gears exhibited a trend of increasing hardness with decreasing distance from the bottom land surface. The NTSB Materials Laboratory report is appended to the docket material associated with this case.

Aircraft

Registration
N9021R
Reported as
Continental Copters 47G2
Category
Helicopter
Serial number
CCI-165
Airframe hours
9,057
Engine
Lycoming VO-435-A1D, 250 horsepower, reciprocating
Damage
Substantial damage
Flight
Aerial observation · Part 91
Operator
Sky Horse Helicopters Inc
Registered owner
Sky Horse Helicopters Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 13, 2011 · 68 hours before
Departed
Lohn, TX
Destination
Lohn, TX

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
54
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
May 3, 2011
Seat
Left
Flight hours
14,000 total · 14,000 as pilot in command · 35 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
55 °F, dew point 21 °F
Altimeter
30.52 inHg
Observed at
BBD, 12 nm away

Docket · 10

The files NTSB released with the investigation on July 2, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.0 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.

Other investigations on N9021R · 3

Matched to the same aircraft by N-number and date.