CEN12LA525

NTSB accident investigation · Bell 214ST · Avalon, TX · August 7, 2012

Accident · No injuriesLimited investigationFinal report
Date
August 7, 2012, 08:45 local (13:45 UTC)
Place
Avalon, TX
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N409SBBell 214ST
Defining event
Maneuvering: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report March 24, 2014
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA FSDO, Bell Helicopter, Inc
FAA report
20120807018389A
Case key
84595

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

Maintenance personnel’s failure to properly torque the retaining nut and install the cotter pin that secured the helicopter’s tail rotor counterweight bellcrank. Contributing to the accident was the lack of detailed maintenance records that documented previous maintenance actions.

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.

Maintenance: installationPersonnel issues › Task performance · Maintenance personnelBell Helicopter Textron 214ST: 1 caseAll aircraft: 371 casesProbable cause
Documentation/record keeping: maintenance recordsOrganizational issues › Support/oversight/monitoring · OperatorBell Helicopter Textron 214ST: 1 caseAll aircraft: 16 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 helicopter was on its third test flight when the tail rotor 90-degree gearbox broke in two and separated from the helicopter. The crew conducted an autorotation to a field, and the helicopter came to rest on its side. Examination of the helicopter and components revealed that one of the tail rotor's two counterweight bellcranks and associated hardware were missing. Impact marks consistent with a counterweight bellcrank were found at the base of its associated tail rotor blade and on the aft right side of the helicopter. The remaining counterweight bellcrank was in place; however, the cotter pin for the castellated nut was missing. A review of the aircraft maintenance records revealed that the tail rotor assembly had been removed and reinstalled after the installation of test instrumentation. The maintenance records lacked specific details on whether the unit and its components were previously handled as a subassembly or as individual components when the tail rotor assembly was initially removed. Because the records did not indicate whether the unit should be handled as individual parts, the tail rotor was reinstalled as a complete subassembly, meaning that individual components, such as the nut and cotter pin, were not individually inspected before or after reinstallation on the helicopter. Reinstalling the tail rotor assembly in this manner led to the counterweight bellcrank retaining nut not being properly torqued and secured with a cotter pin.

Factual narrative

On August 7, 2012, about 0845 central daylight time, a Bell 214ST helicopter, N409SB, experienced a loss of tail rotor authority near Avalon, Texas. The commercial and airline transport pilots were not injured during the precautionary landing, and the helicopter was substantially damaged. The helicopter was owned and operated by Bell Helicopter, Textron, Inc. Fort Worth, Texas, under the provisions of 14 Code of Federal Regulations Part 91 as a research and development flight. Day visual meteorological conditions prevailed for the local flight which operated without a flight plan. The local flight originated from the Arlington Municipal Airport (KGKY), Arlington, Texas at 0815. According to the pilots the purpose of the flight was to collect data on the helicopter's rotor system. During the flight test, the helicopter completed a right turn and as they were setting up for another test condition, the pilot's heard a "bang," and felt the helicopter yaw. The pilot of the chase aircraft reported that something had departed the tail of the helicopter. The accident pilots then initiated an autorotation to a nearby field; however, helicopter yawed, rolled right, and came to rest on its side. The helicopter, the tail rotor gear box, and tail rotor blades were recovered and transported back to a Bell facility. Representatives from the NTSB, Federal Aviation Administration (FAA), and Bell Helicopter, then examined the helicopter and components at the manufacturer's facility. The tail rotor's 90-degree gear box was broken in two; one of the mast's two counterweight bellcranks and associated hardware were missing (and not located/recovered from the accident site); the remaining counterweight bellcrank remained attached. Examination of the remaining counterweight bellcrank, revealed that the assembly was in place, but "loose". The dustcap/grease cover for the remaining counterweight bellcrank was removed, exposing the castellated nut. The examination found that the nut's cotterpin was missing. Both tail rotor blades' attachments remained in place; both blades had separated outboard of their respective attachments. On the side with the missing counterweight bellcrank, impact marks consistent with the size and shape of a counterweight bellcrank, were found on the edge and base of its associated tail rotor blade, as well as on the right side of the helicopter. The rotor blade was torn in two, with the separation starting near the impact marks at the base of the blade. Since the accident helicopter was used to collect data on a new rotor system, the tail rotor blades and components had been removed to install test instrumentation. A review of the helicopters' maintenance workbook revealed the temporary re-installation of the instrumented tail rotor section. However, the maintenance entry was not specific as to whether the reinstallation of the instrumented tail rotor assembly was conducted as an assembly or as individual components. The mechanics installing theinstrumented tail rotor treated the unit as a complete sub-assembly and not as individual components. The difference meant that the individual components were not assembled or inspected, prior to or after installation onto the helicopter. The helicopter was on its third flight after the reinstallation of the instrumented tail rotor system and had accumulated about 2.8 flight hours, before the accident.

Aircraft

Registration
N409SB
Reported as
Bell 214ST
Category
Helicopter
Serial number
28199
Engines
General Electric CT7-2A, turbo shaftGeneral Electric CT7-2A, turbo shaft
Damage
Substantial damage
Flight
Flight test · Part 91
Operator
Bell Helicopter Textron Inc
Registered owner
Bell Helicopter Textron Inc
Airworthiness certificate
Special, Experimental (Special)
Departed
KGKY · Arlington Muni, TX
Destination
KGKY · Arlington Muni, TX
Flight plan
Company VFR
Equipment
Data recorder

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
52
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter, Airplane, Powered-lift
Medical
Class 2, With waivers/limitations
Seat
Right
Flight hours
6,597 total · 2.7 in this make and model · 3,918 as pilot in command · 18.7 in the last 90 days · 5.3 in the last 30 days · 0.6 in the last 24 hours
Role
Co-pilot
Age
39
Injuries
None
Certificates
Flight instructor, Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
April 15, 2012
Seat
Left
Flight hours
3,100 total · 2.7 in this make and model · 2,600 as pilot in command · 35 in the last 90 days · 12 in the last 30 days · 0.6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Temperature
84 °F, dew point 66 °F
Altimeter
29.96 inHg
Observed at
KGKY

Docket · 6

The files NTSB released with the investigation on February 3, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.3 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.