- 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.