CEN15TA035

NTSB accident investigation · Bell UH1H · San Isidro, TX · October 23, 2014

Accident · No injuriesFinal report
Date
October 23, 2014, 14:00 local (19:00 UTC)
Place
San Isidro, TX
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N72595Bell UH1H
Defining event
Enroute: Part(s) separation from AC
Weather
Visual (VMC) · Day
Status
Completed · report February 23, 2015
Report
Approved by Office Director
NTSB office
Central Region
Parties
U. S. Customs and Border Protection, FAA Flight Standards
FAA report
20141023021459I
Case key
90334

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 flight crew's failure to ensure that the sliding cabin door was properly secured before the flight.

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.

Inspection: preflight inspectionPersonnel issues › Task performance · Flight crewBell UH-1H: 2 casesAll aircraft: 551 casesProbable cause
Doors: passenger/crew doorsAircraft › Aircraft structures · Incorrect use/operationBell UH-1H: 1 caseAll aircraft: 86 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

Before the accident flight, the flight crew completed a routine law enforcement patrol flight without incident. That flight was conducted with the pilot, copilot, and main cabin quarter doors removed and the sliding main cabin doors in the "full open" position. After refueling the helicopter, the flight crew conducted a preflight inspection, during which, the copilot and a tactical team member (TTM) noted that the door latch pin was missing from the left sliding door latch. The TTM stated that the copilot advised him that the pin was not required to be installed. The copilot stated that he informed the pilot about the missing pin but that he was not sure that the pilot adequately understood him. About 15 minutes after departing, during cruise flight, the flight crew heard "a loud bang," and the pilot felt a momentary upset in the helicopter's flightpath. Although the helicopter operated normally after the event, the pilot chose to perform a precautionary landing to an open field. During the postflight inspection, the flight crew determined that the left sliding cabin door had separated from the helicopter. A postaccident examination did not reveal any anomalies consistent with a failure of the door assembly or airframe structure that would have led to the separation. The helicopter's Pilot's Operating Handbook stated that the helicopter could be flown up to 120 knots with an open door if it is in the "full open" position and secured by the door latch. The lack of the door latch pin allowed the door to slide forward during flight and then aerodynamic forces separated the door from the sliding track.

Factual narrative

On October 23, 2014, about 1400 central daylight time, a Bell model UH-1H helicopter, N72595, was substantially damaged when the left cabin sliding door separated during cruise flight and impacted one of the main rotor blades near San Isidro, Texas. The three crew members were not injured. The helicopter was registered to the U.S. Department of Homeland Security and operated by U.S. Customs and Border Protection under the provisions of 14 Code of Federal Regulations Part 91 as a public use flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan. The flight originated from the Brooks County Airport (BKS), Falfurrias, Texas, about 1345. The intended destination was the McAllen Miller International Airport (MFE), McAllen, Texas, after conducting a routine law enforcement patrol flight. The crew originally departed MFE about 1100 and completed a routine law enforcement patrol about 2 hours 15 minutes in duration without incident. The flight was operated with the pilot and co-pilot doors, and the main cabin quarter doors removed. The sliding main cabin doors were secured in the fully open position. The crew subsequently landed at BKS in order to refuel and eat lunch. After refueling, the crew conducted a preflight inspection. During that inspection, the co-pilot and tactical team member (TTM), who were inspecting the left side of the helicopter, noted that the open door latch pin was missing from the left sliding door latch. The TTM reportedly discussed the missing pin with the co-pilot. The TTM stated that the co-pilot advised him that the pin was not required to be installed. The co-pilot stated that he had informed the pilot about the missing pin, but he was not sure that the pilot adequately understood him. The crew reported that about 15 minutes after departing BKS, during cruise flight, they heard a loud bang and the pilot felt a momentary upset in the helicopter's flight path. The helicopter performed normally after the event; however, the pilot elected to perform a precautionary landing to an open field. During the post-flight inspection, the crew determined that the left sliding cabin door had departed the aircraft. It was subsequently located separated into two pieces about 1 mile northeast of the landing site. One main rotor blade sustained substantial damage consistent with an in-flight impact with the door assembly. A postaccident examination did not reveal any anomalies consistent with a failure of the door assembly or airframe structure that would have led to the separation. The retaining angle remained attached to the door and appeared undeformed. The door latch pin had separated from the lanyard and was located lying on the aft cabin floor. The exact reason that the pin had separated from the lanyard before the accident flight could not be determined. The helicopter operating handbook permitted flight up to 120 knots with the door properly secured in the open position. In order toproperly secure the door, it must be in the full open position with the door latch pin installed. In the event that the door inadvertently opened in-flight, the airspeed should be reduced below 50 knots in order to allow the door to be closed. If the door could not be closed, then it must be fully opened and secured by the open door latch.

Aircraft

Registration
N72595
Reported as
Bell UH1H
Category
Helicopter
Serial number
73-21769
Built
1973
Airframe hours
5,736
Engine
Lycoming T53-L13-703, 1,438 horsepower, turbo shaft
Damage
Substantial damage
Flight
Other work use · Public use
Operator
U. S. Customs and Border Protection
Registered owner
U. S. Departement of Homeland Security
Airworthiness certificate
None
Last inspection
Condition · June 27, 2014 · 120 hours before
Departed
BKS · Falfurrias, TX
Destination
MFE · McAllen, TX
Equipment
Handheld GPS, Satellite tracking device

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
44
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
August 27, 2014
Seat
Right
Restraint
4-point
Flight hours
9,950 total · 406 in this make and model · 9,882 as pilot in command · 12 in the last 90 days · 8 in the last 30 days · 1 in the last 24 hours
Role
Co-pilot
Age
51
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
September 12, 2014
Seat
Left
Restraint
4-point
Flight hours
10,500 total · 1,851 in this make and model · 10,000 as pilot in command · 38 in the last 90 days · 14 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 63 °F
Altimeter
30.05 inHg
Observed at
EBG, 28 nm away

Docket · 5

The files NTSB released with the investigation on December 1, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.9 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.