CEN14LA174

NTSB accident investigation · Bell 47G 3B · Oglesby, TX · March 30, 2014

Accident · No injuriesLimited investigationFinal report
Date
March 30, 2014, 11:30 local (16:30 UTC)
Place
Oglesby, TX
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N147WTBell 47G 3B
Defining event
Maneuvering-low-alt flying: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report June 1, 2015
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA
FAA report
20140330004939A
Case key
88989

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 safety wire the throttle control adapter per maintenance instructions when the carburetor was replaced and to detect that the adapter was not safety wired during the annual inspection, which resulted in the throttle control disconnecting and subsequent loss of engine control.

Findings · 4

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 47G-3B-1: 1 caseAll aircraft: 371 casesProbable cause
AircraftAircraft › Aircraft systems · Incorrect service/maintenanceBell 47G-3B-1: 2 casesAll aircraft: 63 casesProbable cause
Maintenance/inspectionsAircraft › Aircraft handling/service · Incorrect service/maintenanceBell 47G-3B-1: 1 caseAll aircraft: 103 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelBell 47G-3B-1: 1 caseAll aircraft: 167 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 reported that, during an en route climb in the helicopter, he increased the throttle and noticed a "slight resistance." Shortly after, the throttle freed up, but it was ineffective; there was no corresponding change in engine power when he moved the throttle control. Both the engine and rotor rpm were indicating in the green, but they began to decrease when he adjusted the collective. When he stopped moving the collective, the engine and rotor rpm increased rapidly and continued to accelerate. The pilot initiated an autorotation and cut off the fuel. The pilot then increased the collective, and the helicopter yawed left, touched down, and rolled over to the right, which resulted in the tailboom separating. A postaccident examination of the helicopter revealed that the throttle control adapter had disconnected from the serrated shaft on the carburetor. The retention screws on the throttle control adapter were not safety wired to the carburetor idle stop lever as required in the helicopter manufacturer's maintenance manual. A review of maintenance records revealed that the carburetor was removed and replaced about 1 1/2 years before the accident and that the helicopter's last annual inspection was conducted about 4 1/4 months before the accident.

Factual narrative

On March 30, 2014, about 1130 central daylight time, a Bell 47G-3B helicopter, N147WT, rolled over during an autorotation near Oglesby, Texas. The pilot and passenger were not injured. The helicopter was registered to and operated by Lazy 7 Agricultural Services LLC as a 14 Code of Federal Regulations Part 91 aerial observation flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan. The local flight originated from the Gatesville Municipal Airport (GOP), Gatesville, Texas at 1100. The pilot reported the purpose of the flight was to spot wildlife. He stated that during the flight he initiated a climb to transit from one area to another. As he increased the throttle he noticed a "slight resistance." Shortly thereafter, the throttle freed up, but there was no response to the throttle movements. The pilot stated that both the engine and rotor rpm were indicating in the green, but the rotor and engine rpm decayed when he increased the collective. When he stopped increasing the collective, the rotor and engine rpm increased rapidly and continued to accelerate. The pilot initiated an autorotation, during which time he cutoff the fuel. During the final collective application to cushion the landing, the helicopter suddenly yawed to the left and simultaneously rolled to the right on touchdown. A postaccident examination of the helicopter revealed the throttle control adapter had disconnected from the serrated shaft on the carburetor. The retention screws on the throttle control adapter were not safety wired to the carburetor idle stop lever as required in the Bell Helicopter maintenance manual. Service Bulletin 131SB was issued on December 2, 1960, which addressed the reworking the adapter screw holes and safety wiring of the adapter to the carburetor idle stop lever. This Service Bulletin addressed the Bell 47G-2 and 47J-2 models. The maintenance manual for the 47G-3B was later revised to reflect the information in the Service Bulletin. Maintenance records show the carburetor was removed and replaced on September 25, 2012, and the last annual inspection was performed November 11, 2013.

Aircraft

Registration
N147WT
Reported as
Bell 47G 3B
Category
Helicopter
Serial number
2920
Built
1964
Airframe hours
3,280
Engine
Lycoming TVO-435-B1, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Aerial observation · Part 91
Operator
Lazy 7 Agricultural Services LLC
Registered owner
Lazy 7 Agricultural Services LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 5, 2013 · 30 hours before
Departed
GOP · Gatesville, TX
Destination
GOP · Gatesville, 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
41
Injuries
Minor
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
3,800 total · 54 in this make and model · 3,000 as pilot in command · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 15 knots, gusting 21
Visibility
10 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 46 °F
Altimeter
30.19 inHg
Observed at
TPL, 11 nm away

Docket · 5

The files NTSB released with the investigation on April 28, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.4 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.