CEN17LA188

NTSB accident investigation · Bell 407 · Fort Worth, TX · January 24, 2017

Accident · No injuriesLimited investigationFinal report
Date
January 24, 2017, 08:45 local (14:45 UTC)
Place
Fort Worth, TX
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N6040YBell 407
Defining event
Landing: Hard landing
Weather
Visual (VMC) · Day
Status
Completed · report September 6, 2017
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA Flight Standards, Bell Helicopter Textron
FAA report
20170124007419A
Case key
95195

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 instructor's failure to prevent the engine/rotor overspeed condition during the demonstration maneuver and the excessive descent rate during the emergency landing, which resulted in a hard landing. Contributing to the engine/rotor overspeed condition was the flight instructor's failure to comply with the demonstration procedure.

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · Instructor/check pilotBell 407: 19 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: descent rateAircraft › Aircraft oper/perf/capability · Not attained/maintainedBell 407: 2 casesAll aircraft: 242 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotBell 407: 6 casesAll aircraft: 1,391 casesProbable cause
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · Instructor/check pilotBell 407: 3 casesAll aircraft: 191 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 flight instructor was demonstrating the emergency procedure for a full-authority digital engine control (FADEC) failure that would cause it to switch from auto to manual mode as part of the helicopter manufacturer's training program. The instructor stated that the helicopter was in a stable 5-ft hover when he was demonstrating the maneuver. To begin the demonstration, the flight instructor intentionally switched the FADEC to the manual mode. After about 10 seconds, the engine speed began to increase, which resulted in a corresponding increase in the main rotor speed. The instructor increased the collective control input in an attempt to control the engine and rotor speeds. The helicopter subsequently climbed and began to shake violently. The instructor initiated a descent for landing with an excessive descent rate, which resulted in damage to the landing skids and tailboom upon touchdown. The helicopter flight manual emergency procedure for a FADEC failure and the training program procedure for the FADEC manual mode demonstration both noted that the engine and rotor speeds must be maintained between 95% and 100% with the collective and throttle controls. The demonstration procedure also noted that the throttle control should be in the fly position when the FADEC is placed into manual mode. A review of engine data recovered from the FADEC indicated that the throttle was not in the fly position before beginning the demonstration, which likely resulted in a greater increase in engine and rotor speeds than would have been expected. The flight instructor did not promptly manage the increase in the engine and rotor speeds, which resulted in an inadvertent overspeed condition and subsequent airframe vibrations that prompted the need for an emergency landing.

Factual narrative

On January 24, 2017, about 0845 central standard time, a Bell 407 helicopter, N6040Y, was substantially damaged during a hard landing at the Bell Training Facility Heliport (3XS7), Fort Worth, Texas. The flight instructor and pilot receiving instruction were not injured. The helicopter was registered to and operated by Bell Helicopter Textron as a 14 Code of Federal Regulations Part 91 instructional flight. Visual meteorological conditions prevailed at the time of the accident. The flight was not operated on a flight plan. The flight originated from the Bell Helicopter Hurst Heliport about 0820.The flight instructor stated that he was demonstrating the emergency procedure for a failure of the full authority digital engine control (FADEC) unit from auto to manual mode. The helicopter was in a stable 5-foot hover at the time. To begin the demonstration, the FADEC was intentionally switched into manual mode. After approximately 10 seconds, the engine speed began to increase, which resulted in a corresponding increase in the main rotor speed. The instructor increased the collective control input in an attempt to control the engine and rotor speeds. The helicopter subsequently climbed to about 25 feet above ground level (agl) and began to shake violently. The instructor initiated a descent for landing; however, the helicopter contacted the ground with a sufficient descent rate to "spread the skids." The helicopter was shut down and the pilots exited without injuries. Maintenance personnel noticed a crease in the tailboom after it was repainted as part of the repair process. The helicopter maintenance manual stated that creases in tailboom skins are not permitted under any circumstances. In such instances, the tailboom must be repaired or replaced. Data recovered from the FADEC unit revealed that, at the time the FADEC was switched from auto to manual mode, the throttle position (PLA) was 98%, the rotor speed was 100%, and the fuel flow 264 pounds per hour. About 3 seconds later, the rotor speed, engine speed, and fuel flow began to increase. The rotor speed reached a maximum of 118%. The throttle position was subsequently reduced with a corresponding decrease in engine and rotor speeds. The helicopter flight manual stated that in the case of a FADEC failure, the pilot must maintain the engine and rotor speeds between 95% and 100% with the collective and throttle controls, and land as soon as practical. The procedure included a warning that depending on the flight profile and power setting at the time of the failure, the transition to manual mode may result in an increase (overspeed) or a decrease (underspeed) of the engine/rotor speed within 2 to 7 seconds after the failure warning, requiring positive movements of the collective and throttle. The procedure for the FADEC manual mode demonstration noted that the throttle control should be in the fly position when the FADEC is placed into manual mode. The engine and rotor speeds should be maintainedbetween 95% and 100% during the maneuver. According to the helicopter manufacturer, the throttle fly position corresponded to a PLA of 90% in the FADEC data. As a result, a PLA of 98% was consistent with the throttle not being in the fly position at the time of the FADEC demonstration. Without the throttle in the fly position, when the FADEC is switched into manual mode, the unit will adjust fuel flow to that commanded by the throttle setting. In the accident scenario, this was an increase in fuel flow from that being provided by the FADEC in auto mode to maintain the hover, which caused the engine and rotor speeds to increase. As a result of the accident, the helicopter manufacturer revised the training program to perform the FADEC manual mode training in a flight simulator/training device rather than in the helicopter.

Aircraft

Registration
N6040Y
Reported as
Bell 407
Category
Helicopter
Serial number
53371
Built
1999
Airframe hours
8,530
Engine
Rolls-Royce 250-C47B, 650 horsepower, turbo shaft
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Bell Helicopter Textron Inc.
Registered owner
Bell Helicopter Textron Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · November 29, 2016 · 8 hours before
Departed
0TE2 · Hurst, TX
Destination
3XS7 · Fort Worth, TX
Airport
3XS7 · Bell Training Facility

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
Flight instructor
Age
36
Injuries
None
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
December 19, 2016
Seat
Left
Restraint
4-point
Flight hours
3,030 total · 18 in this make and model · 2,429 as pilot in command · 18 in the last 90 days · 18 in the last 30 days · 2 in the last 24 hours
Role
Pilot
Age
68
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, With waivers/limitations
Seat
Right
Restraint
4-point

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 10 knots
Visibility
10 statute miles
Lowest ceiling
25,000 ft broken
Temperature
55 °F, dew point 37 °F
Altimeter
29.64 inHg
Observed at
AFW, 13 nm away

Docket · 8

The files NTSB released with the investigation on June 15, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.1 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.

Other investigations on N6040Y · 1

Matched to the same aircraft by N-number and date.