CEN19LA146

NTSB accident investigation · Sikorsky S76 · Morrilton, AR · May 15, 2019

Accident · No injuriesClass 3 · LimitedFinal report
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.

Misc hardware: fastenersAircraft › Fluids/misc hardware · Incorrect service/maintenanceSikorsky S-76D: 1 caseAll aircraft: 58 casesProbable cause
Engine exhaustAircraft › Aircraft power plant · Incorrect service/maintenanceSikorsky S-76D: 1 caseAll aircraft: 56 casesProbable cause
MaintenancePersonnel issues › Task performance · Maintenance personnelSikorsky S-76D: 1 caseAll aircraft: 143 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 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.