CEN16LA027

NTSB accident investigation · Bell 407 · San Antonio, TX · November 3, 2015

Accident · No injuriesLimited investigationFinal report
Date
November 2, 2015, 19:23 local (Nov 3, 2015, 01:23 UTC)
Place
San Antonio, TX
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N496AEBell 407
Defining event
Maneuvering-hover: Aircraft structural failure
Weather
Visual (VMC) · Night
Status
Completed · report August 1, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA Flight Standards District Office, Air Evac EMS, Bell Helicopters, Inc.
FAA report
20151102019619A
Case key
92279

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 NTSB’s determination of the probable cause, and any contributing factors.

The failure of the No. 3 tail rotor adapter and shaft due to a loss of torque on the retaining nut. Contributing to the accident was the lack of a requirement to inspect the tail rotor assembly for security in the helicopter manufacturer's maintenance manual and the operator's approved aircraft inspection program.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The commercial pilot was conducting an emergency medical services flight. The pilot reported that, when he climbed the helicopter to a 3-ft hover, he heard a loud bang, and the helicopter began an uncommanded right yaw. The pilot applied full left pedal, but this did not arrest the yaw. The pilot then lowered the collective, and the helicopter touched down and then rotated 270 degrees to the right before it came to a stop. The tail rotor was examined, and it could be manually rotated, but a grinding noise could be heard coming from the damaged No. 3 hanger bearing. The main rotor blades did not rotate in synchronization with the tail rotor blades. The No. 3 tail rotor shaft adapter and shaft splines were completely ground down, the adapter and shaft had failed, and there was evidence of excessive torsion beyond the intended allowable tolerances. The aluminum adapter washer hole was elongated, consistent with a loose through bolt, and the drive shaft through bolt had worn threads. There was a 1/8-inch gap between the adapter and the base of the hanger bearing, consistent with the adapter not being fully in contact with the bearing and potential stress within the adapter and shaft splines. The retaining nut had migrated almost .025 inch outward and was very loose, consistent with the loss of torque, which would have allowed movement between the tail rotor adapter and shaft and led to their eventual failure. A review of the helicopter maintenance manual and operator's approved aircraft inspection program revealed that neither had a requirement for the tail rotor assembly to be inspected for security.

Factual narrative

The factual narrative554 words

On November 2, 2015, at 1923 central standard time, the pilot of a Bell 407, N496AE, made a forced landing at San Antonio International Airport (KSAT), San Antonio, Texas. The pilot, flight nurse, and paramedic were not injured. The helicopter was substantially damaged. The helicopter was registered to and operated by AirEvac EMS, Inc., (EVCA), O'Fallon, Missouri, under the provisions of 14 Code of Federal Regulations Part 135 as an on-demand air medical flight. Night visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The flight was originating from KSAT, and was destined for Northeast Methodist Hospital (XS83), San Antonio. When the pilot lifted helicopter to a 3-foot hover, he heard a loud bang and the helicopter began an uncommanded right yaw. The pilot applied full left pedal, but this did not arrest the yaw. The pilot then lowered the collective and the helicopter touched down, rotating 270 degrees to the right before coming to a stop. Post-accident examination revealed substantial damage to the tail rotor spline, coupling, and hanger bearings. Postaccident examination revealed the tail rotor could be manually rotated, but a grinding noise could be heard coming from the damaged no. 3 hanger bearing. The main rotor blades did not rotate in synchronization with the tail rotor blades. The #3 tail rotor shaft adapter and shaft splines were completely ground down, and the adapter and the tail rotor shaft connecting point had failed. There was evidence of excessive torsion, beyond its intended allowable tolerances. There was excessive grease on the hanger bearing. The aluminum adapter washer hole was elongated, consistent with of a loose through-bolt. There was a 1/8th inch gap between the adapter and the base of the hanger bearing, consistent with the adapter not being fully in contact with the bearing and potential stress within the adapter and shaft splines. The smaller, stainless steel washer was mushroom-shaped. The drive shaft through-bolt had worn threads. On November 18 and 19, 2105, the tail rotor assembly was examined at the facilities of Able Engineering, Mesa, Arizona, under the auspices of an FAA aviation safety inspector from the Scottsdale, Arizona, FSDO. Bell Helicopters and AirEvac EMS also participated in the examination. The shaft, freewheeling unit and tail gear box were examined. No issues were noted except for the failed coupling and shaft. The retaining stud had migrated almost .025" outward and was very loose compared to the others, consistent with the loss of torque that would have allowed movement between the coupling and shaft and eventual failure. After the examination, Air Evac EMS ordered an inspection of their entire Bell 407 fleet. Two helicopters were found to have loose tail rotor drive shafts. The drive shaft, carrier bearing, coupling, and spline from one of those helicopters were examined the next day. The retaining nut was loose. Torque was measured at20 inch-pounds. Minimum torque is 30 to 50 inch-pounds. Tare was 5 to 0 inch-pounds. Stud extension was within millimeter limits. There was a slight motion between the coupling face and the face of the bearing. This motion had worn the coupling face and there was slight wear on some of the splines. In the Bell 407 Maintenance Manual and Air Evac EMS' AAIP, there is no requirement for the assembly to be inspected for security.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N496AE
Reported as
Bell 407
Category
Helicopter
Serial number
53328
Built
1999
Airframe hours
7,939
Engine
Rolls Royce M250-C47B, 630 horsepower, turbo shaft
Damage
Substantial damage
Flight
Part 135
Operator
Air Evac EMS, Inc.
Registered owner
Air Evac EMS, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · November 2, 2015
Departed
KSAT · San Antonio, TX
Destination
XS83 · San Antonio, TX
Flight plan
Company VFR
Airport
KSAT · San Antonio International
Equipment
None

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
32
Injuries
None
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 1, Without waivers/limitations
Last flight review
October 15, 2015
Seat
Right
Restraint
3-point
Flight hours
2,201 total · 28 in this make and model · 1,207 as pilot in command · 97 in the last 90 days · 2,626 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
130° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 54 °F
Altimeter
29.95 inHg
Observed at
KSAT

Docket · 6

The files NTSB released with the investigation on March 10, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.8 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.