CEN18CA072

NTSB accident investigation · Bell Helicopter Textron Canada 407 · Norfolk, NE · January 5, 2018

Accident · No injuriesData collectionFinal report
Date
January 4, 2018, 19:00 local (Jan 5, 2018, 01:00 UTC)
Place
Norfolk, NE
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N214AMBell Helicopter Textron Canada 407
Defining event
Enroute: Part(s) separation from AC
Weather
Visual (VMC) · Night/dark
Status
Completed · report February 21, 2018
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA FSDO
FAA report
20180104006179I
Case key
96587

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

Maintenance personnel’s failure to properly secure the tail rotor drive shaft cover, which resulted in the cover departing the helicopter in 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.

Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelBell Helicopter Textron Canada 407: 1 caseAll aircraft: 320 casesProbable cause
Maintenance/inspectionsAircraft › Aircraft handling/service · Incorrect service/maintenanceBell Helicopter Textron Canada 407: 1 caseAll aircraft: 103 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 pilot and two medical crewmembers were on a return flight to a hospital helipad. During the approach to the helipad, the crew heard a noise outside the helicopter. The medical crewmembers reported they felt a slight "shudder" on the helicopter but attributed it to the wind as they approached the helipad. The pilot heard the noise, but there was no effect on the controls or flight characteristics, so he continued the landing without further incident. After engine shutdown, the oncoming pilot noticed that the helicopter's tail rotor drive shaft cover was missing. The surrounding area near the helicopter's approach path was searched, and the missing cover was found. An examination of the helicopter noted substantial damage to the tail rotor drive shaft. The day before the accident, scheduled maintenance was performed on the helicopter's tail rotor pitch change mechanism, which required removal of the drive shaft cover. The cover was reinstalled, and no problems were reported during a subsequent preflight inspection. It is likely that maintenance personnel did not properly secure the cover fasteners after the cover was reinstalled.

Factual narrative

The pilot and two medical crewmembers were on a return flight to a hospital helipad. During the approach to the helipad, the crew heard a noise outside the helicopter. The medical crewmembers reported they felt a slight "shudder" on the helicopter but attributed it to the wind as they approached the helipad. The pilot heard the noise, but there was no effect on the controls or flight characteristics, so he continued the landing without further incident. After engine shutdown, the on-coming pilot noticed the helicopter's tail rotor drive shaft cover missing. A search of the surrounding area near the helicopter's approach path, located the missing cover. An examination of the helicopter noted substantial damage to the tail rotor drive shaft. The day prior to the accident, scheduled maintenance was performed on the helicopter's tail rotor pitch change mechanism, which required removal of the drive shaft cover. The cover was reinstalled, and no problems were reported during a subsequent pre-flight inspection. It is likely the cover fasteners were not properly secured, after the cover was re-installed.

Aircraft

Registration
N214AM
Reported as
Bell Helicopter Textron Canada 407 (NO SERIES)
Category
Helicopter
Serial number
54485
Built
2014
Engine
Rolls-Royc 250-C47B, turbo shaft
Damage
Substantial damage
Flight
Positioning · Part 135
Operator
Air Methods Corp
Registered owner
Air Methods Corp
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · January 3, 2018
Departed
Omaha, NE
Destination
Norfolk, NE
Flight plan
Company VFR
Equipment
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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
63
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Seat
Right
Restraint
4-point

Weather

Conditions
Visual (VMC) · Night/dark
Wind
90° at 5 knots
Temperature
9 °F, dew point 7 °F

Docket · 2

The files NTSB released with the investigation on January 25, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 977 KB 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.