- Date
- May 15, 2019, 18:33 local (23:33 UTC)
- Place
- Morrilton, AR
- Injuries
- 6 uninjured
- Damage
- Substantial damage
- Phase of flight
- Enroute
- Aircraft
- N761AFSikorsky S76
- Defining event
- Enroute-cruise: Powerplant sys/comp malf/fail
- Weather
- Visual (VMC) · Day
- Status
- Completed
- Report
- Approved by Office Director
- Investigation class
- Class 3
- NTSB office
- Central Region
- Parties
- FAA
- FAA report
- 20190515011089A
- Case key
- 99455
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 improper securing of the exhaust duct bolts, which resulted in the duct becoming unseated and substantial heat damage to the tail rotor drive shaft.
Findings · 3
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.
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 of the helicopter air ambulance flight reported that he experienced fumes in the cockpit while enroute, and shortly thereafter, received visual and aural warnings of smoke in the aft baggage compartment. The pilot initiated an emergency descent into an alternate airport, declared an emergency with air traffic control, and landed uneventfully. Examination of the helicopter revealed that the No. 2 engine exhaust duct was disconnected and unseated, which resulted in engine exhaust entering the compartment containing the tail rotor drive shaft and substantial heat damage to the drive shaft and surrounding areas. Examination of the No. 1 engine exhaust duct revealed that its attach bolts were not tightened to the specified torque value. Additionally, examination of the operator’s other helicopter revealed that the bolts securing both of its two exhaust ducts were not tightened to the specified torque value. The maintenance history of these components was not determined, but given the available information, it is likely that they were improperly secured, which resulted in their loosening and subsequently allowed the exhaust duct to become unseated.
Factual narrative
On May 15, 2019, about 1833 central daylight time, a Sikorsky S-76D helicopter, N761AF, sustained substantial damage while in cruise flight near Morrilton, Arkansas. The pilot, 2 crewmembers, and 3 passengers were not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 135 on-demand air medical flight. The pilot reported that, 43 minutes into the flight, he experienced fumes in the cockpit. He turned the environmental control system off and immediately descended. Within seconds, he received visual and aural warnings of smoke in the aft baggage compartment. He initiated an emergency descent and declared an emergency with air traffic control and subsequently landed without further incident. A postaccident examination of the helicopter by a Federal Aviation Administration inspector revealed that the exhaust duct from the No. 2 engine was disconnected and not in its seated position. Exhaust from the No. 2 engine entered the compartment containing the tail rotor drive shaft and resulted in heat damage to drive shaft and surrounding areas. The exhaust ducts are attached using two bolts secured at 110 ft-lbs of pressure. Upon inspection of the No. 1 engine, as well as the operator’s second helicopter, all bolts were found partially disengaged and not tightened to the specified torque value.
Aircraft
- Registration
- N761AF
- Reported as
- Sikorsky S76
- Category
- Helicopter
- Serial number
- 761039
- Built
- 2013
- Airframe hours
- 2,488
- Engines
- Pratt and Whitney PW210S, 1,248 horsepower, turbo shaftPratt and Whitney PW210S, 1,248 horsepower, turbo shaft
- Damage
- Substantial damage
- Flight
- Business · Part 135
- Operator
- Arkansas Childrens Hospital
- Registered owner
- Arkansas Childrens Hospital
- Airworthiness certificate
- Standard, Transport
- Last inspection
- Continuous airworthiness · March 13, 2019 · 205 hours before
- Departed
- 14AR · Springdale, AR
- Destination
- AR62 · Little Rock, AR
- Flight plan
- Company VFR
- Airport
- BDQ · Morrilton Muni, runway 09/27, 4,000 × 75 ft, asphalt
- Equipment
- Auto-pilot, Data recorder, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Onboard weather, 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 · 3
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 50
- Injuries
- None
- Certificates
- Airline transport, Commercial
- Airplane ratings
- Single-engine land, Multi-engine sea
- Instrument ratings
- Airplane, Helicopter
- Medical
- Class 1, Without waivers/limitations
- Last flight review
- March 28, 2019
- Seat
- Right
- Restraint
- 5-point
- Flight hours
- 6,518 total · 431 in this make and model · 5,165 as pilot in command · 32 in the last 90 days · 13 in the last 30 days · 4 in the last 24 hours
- Role
- Other flight crew
- Seat
- Rear
- Restraint
- 4-point
- Role
- Other flight crew
- Seat
- Rear
- Restraint
- 4-point
Weather
- Conditions
- Visual (VMC) · Day
- Wind
- 300° at 4 knots
- Visibility
- 10 statute miles
- Lowest ceiling
- None
- Temperature
- 84 °F, dew point 64 °F
- Altimeter
- 29.90 inHg
- Observed at
- KRUE, 25 nm away
Docket · 3
The files NTSB released with the investigation on October 5, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.7 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 N761AF · 1
Matched to the same aircraft by N-number and date.