CEN15LA156

NTSB accident investigation · Agusta Aerospace AW119 Mkii · Gulf of Mexico · February 20, 2015

Accident · No injuriesLimited investigationFinal report
Date
February 20, 2015, 07:50 local (13:50 UTC)
Place
Gulf of Mexico
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N802SMAgusta Aerospace AW119 Mkii
Defining event
Enroute-cruise: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report November 29, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
Precision Aviation Group d/b/a Precision Heliparts, Agenzia Nazionale per la Sicurezza del Volo, FAA FSDO, Era Helicopters
FAA report
20150220006439A
Case key
90780

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 fracture of the tail rotor pitch change link due to excessive bearing rotational friction, which resulted from the bearings being installed in exceedance of the maximum allowable torque during the last overhaul of the pitch change link.

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.

Tail rotorAircraft › Aircraft propeller/rotor · Incorrect service/maintenanceAgusta Aerospace AW119 MKII: 1 caseAll aircraft: 23 casesProbable cause
Tail rotorAircraft › Aircraft propeller/rotor · FailureAgusta Aerospace AW119 MKII: 1 caseAll aircraft: 23 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 commercial pilot was conducting an on-demand air taxi helicopter flight. The pilot reported that, while in cruise flight over water, the helicopter experienced an abrupt, uncommanded left yaw. The pilot returned to the departure airport and performed a run-on landing. A postflight examination of the helicopter revealed that one of the tail rotor pitch change links (PCL) was fractured. A review of maintenance records revealed that the fractured PCL had recently been overhauled and installed on the helicopter and that it failed 14.8 flight hours since overhaul. Examination of the PCL revealed that it had fractured due to undetected fatigue cracking that appeared to be the result of bending loads caused by stiff bearings. The stiffness was likely the result of the lack of control of the bearing replacement process. The PCL bearing replacement procedures, which incorporated rotational torque inspection and bearing staking procedures, were contained in the overhaul manual; these procedures were revised about 3 months before the accident, and the overhaul facility used the revised procedures during the replacement of the PCL. Examination of the PCL revealed that both of the bearings exceeded the maximum allowable rotational torque by at least two times the maximum allowed. Based on the findings of this investigation, the PCL manufacturer corrected the figure in the PCL replacement procedures to display the correct method of inspecting spherical bearing rotational torque.

Factual narrative

On February 20, 2015, about 0750 central standard time, an Agusta A119 Mk II helicopter, N802SM, experienced an abrupt, uncommanded left yaw during cruise flight over the Gulf of Mexico. The pilot and passenger were not injured. The helicopter sustained substantial damage. The helicopter was registered to and operated by Era Helicopters LLC., under the provisions of 14 Code of Federal Regulations Part 135 as an on-demand air taxi flight. Visual meteorological conditions prevailed for the flight which operated on a company visual flight rules flight plan. The flight departed the Houma-Terrebonne Airport (HUM), Houma, Louisiana, at 0720 and was en route to an off-shore platform.After the uncommanded left yaw, the pilot returned to HUM and performed a run-on landing. A post-flight inspection of the helicopter revealed one of the tail rotor pitch change links (PCL) was fractured. While no further damage was sustained to any helicopter components, the fractured pitch change link had an adverse effect on the helicopter's flight characteristics and required replacement meeting the definition of substantial damage. The tail rotor pitch change link (PCL) assembly comprises a single-piece cast aluminum body with two circular ends, each end containing a spherical bearing. The PCL end connected to the tail rotor blade contains the larger of the two spherical bearings, and is identified as the "large bearing" in this report. The PCL end connected to the tail rotor pitch change mechanism is identified as the "small bearing" in this report. A review of maintenance documentation found that the fractured PCL was overhauled by Precision Heliparts (PHP) and issued an authorized release certificate on December 8, 2014. It was installed on N802SM on February 13, 2015. The fractured pitch link failed at 14.8 flight hours since overhaul and 1,129.8 of total flight hours. Representatives from the National Transportation Safety Board (NTSB), AgustaWestland, PHP, Era Helicopters, and the Federal Aviation Administration convened at Agusta Westland facilities in Philadelphia, Pennsylvania to evaluate the bearing friction for the tail rotor PCLs. The method of inspecting PCL bearing rotational torque was found in the maintenance manual (MM) and overhaul manual (OM). The earlier version of the OM, dated November 25, 2012, differed from the more recent version of the OM, dated November 10, 2014. The 2012 version of the OM required rotational torque inspection by rotating the inspection tool, a 100 millimeter (mm) lever arm, about the axis of the bearing bolt hole, while the 2014 version of the OM required the inspection tool to be rotated away from the axis of the bearing bolt hole. This revision changed the bearing staking procedure. The bearing replacement procedures between the 2012 and 2014 versions of the OM remained the same. AgustaWestland identified the 2012 version of the OM contained the correct bearing rotational torque inspection method. PHP identified they hadused the 2014 version of the bearing rotational torque inspection method. During the postaccident examination of the accident PCL, the 2012 and the 2014 inspection procedures were used to measure rotational torque. Both the large and small bearings of fractured PCL exceeded the maximum allowable bearing rotational torque either measured with 2012 and 2014 procedure. For the fractured PCL, the 2012 inspection method consistently returned a higher rotational torque value than the 2014 inspection method. The fractured PCL was examined by the NTSB Material Laboratory. The fracture surface exhibited evidence of fatigue that originated at a raised dash that was part of the part number marking on the PCL. The materials laboratory characterized fatigue cracking across 60% to 70% of the fracture cross section. For additional details on the materials laboratory examination see the Materials Laboratory Factual Report in the docket for this investigation. On March 4, 2015, the FAA issued emergency airworthiness directive (EAD) No. 2015-05-52 for owners and operators of certain A109-series and AW119-series helicopters to inspect PCL part number 109-0130-05-117 for freedom of movement, corrosion, excessive friction of the spherical bearings, and cracks. FAA EAD No. 2015-05-52 was prompted by European Aviation Safety Agency (EASA) issuance of EASA EAD No. 2015-0035-E on February 27, 2015. According to AgustaWestland and the FAA, there have been no reports to date of tail rotor PCL spherical bearings exhibiting excessive friction after inspection directed via the aforementioned FAA and EASA EADs. Based on the findings of this investigation, AgustaWestland had corrected the figure in the replacement procedures to display the correct method of inspecting spherical bearing rotational torque. Additionally, the PCL bearing replacement procedures were removed from the MM and are now found only within the OM.

Aircraft

Registration
N802SM
Reported as
Agusta Aerospace AW119 Mkii (NO SERIES)
Category
Helicopter
Serial number
14711
Engine
PWC PT6B-37A, 917 horsepower, turbo shaft
Damage
Substantial damage
Flight
Part 135
Operator
Era Helicopters LLC
Registered owner
Era Helicopters LLC
Airworthiness certificate
Standard, Normal
Departed
HUM · Houma, LA
Destination
Gulf of Mexico, GM
Flight plan
Company VFR
Airport
HUM · Houma-Terrebonne

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
43
Injuries
None
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 1, Without waivers/limitations
Seat
Right
Restraint
4-point

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 8 knots
Visibility
7 statute miles
Temperature
46 °F, dew point 39 °F
Altimeter
30.28 inHg
Observed at
KHUM, 72 nm away

Docket · 6

The files NTSB released with the investigation on September 1, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.8 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.