CEN19LA240

NTSB accident investigation · Robinson R44 · Blair, NE · July 27, 2019

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
July 27, 2019, 16:28 local (21:28 UTC)
Place
Blair, NE
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N7508ZRobinson R44
Defining event
Maneuvering-low-alt flying: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA, Robinson Helicopter Company
FAA report
20190727012669A
Case key
99945

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 failure of the lower actuator bearing support bracket, which resulted in the misalignment of the clutch actuator, the loss of belt tension on the main rotor drive system, and the subsequent forced landing on sloped terrain.

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.

Terrain: sloped/uneven terrainEnvironmental issues › Physical environment · Contributed to outcomeRobinson Helicopter R44 II: 10 casesAll aircraft: 270 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

After completing a spray pass during a helicopter aerial application flight, the pilot initiated a climb over trees to head south. The pilot reported that, at the top of the climb, he noticed that the engine rpm was beyond "max limitations" and that the main rotor rpm was in the green range. The pilot initiated a right pedal turn to the north and decreased the engine throttle to lower the engine rpm. The engine rpm remained at the upper limit, but the main rotor rpm decreased. The pilot then attempted to correct the main rotor rpm by increasing the throttle; however, the main rotor rpm fluctuated and then continued to decrease. Unable to control and maintain the main rotor rpm, the pilot performed a forced landing to a field with sloped terrain, during which the main rotor blades impacted terrain. The helicopter sustained substantial damage to the main rotor blades and tailboom. Postaccident examination of the upper and lower actuator support bearing brackets revealed they were separated from the scroll, and evidence of fretting and rub marks was noted between the brackets and scroll walls. In addition, elongated rivet holes were observed on the scroll wall, and the associated rivets were sheared. Torque paint was noted on the outboard rivets. It is likely that the bracket supporting the lower actuator bearing became loose and sheared the rivets, which allowed the actuator bearing to shift and led to a subsequent misalignment of the clutch actuator. The misalignment of the clutch actuator resulted in the loss of belt tension between the engine and main rotor drive system. The reason for the loose bracket and sheared rivets could not be determined due to damage. A manufacturer service bulletin required an inspection of the brackets for evidence of fretting or looseness, and that was accomplished about 169 flight hours before the accident. The compliance procedure, which was to occur at the next 100-hour or annual inspection, was to visually inspect the brackets and attaching rivets for evidence of fretting or looseness and, on the lower bracket, to apply torque seal in a vertical stripe across both outboard rivets to lower scroll to facilitate future inspections. It is likely that the wear was not apparent at the time of the inspection.

Factual narrative

On July 27, 2019, at 1628 central daylight time, a Robinson R44 II helicopter, N7508Z, impacted terrain near Blair, Nebraska. The pilot sustained minor injuries, and the helicopter sustained substantial damage to the main rotor blades and tailboom. The helicopter was registered to and operated by NE IA Helicopters, LLC, Tekamah, Nebraska, as a Title 14 Code of Federal Regulations Part 137 aerial application flight. Day visual meteorological conditions prevailed at the time of the accident, and a flight plan was not filed. The local flight departed an off-airport location for aerial application operations. According to the pilot, after completing the last spray pass, he initiated a climb over a tree ridge and began to head towards the south. At the top of the climb, he noticed the engine RPM was beyond "max limitations," and the main rotor RPM was in the green range. The pilot initiated a right pedal turn to the north and decreased the engine throttle in an attempt to lower the engine RPM. After adjusting the engine throttle, the engine RPM remained at the upper limit, but the main rotor RPM decreased. The pilot then attempted to correct the main rotor RPM by increasing the throttle; however, the main rotor RPM fluctuated up and down, and continued to decrease. Unable to control and maintain the main rotor RPM, the pilot performed a forced landing to a corn field. During the forced landing to sloped terrain, the main rotor blades impacted the terrain, and the helicopter came to rest upright. A review of the aircraft records revealed Robinson Helicopter Company service bulletin (SB) 94, Subject: Actuator Lower Bearing A185 Brackets, issued June 8, 2017, was completed on May 5, 2018, at an aircraft total time of 2,181.3 hours. The compliance procedure was to visually inspect the A185 brackets and attaching rivets for evidence of fretting or looseness, and on the lower A185 bracket, apply torque seal in a vertical stripe across both outboard rivets to lower scroll to facilitate future inspections. The records also revealed the most recent 100-hour/annual inspection was completed on May 3, 2019, at a total airframe time of 2,244.0 hours. The total airframe time at the accident was 2,350.5 hours. A postaccident examination included the removal of the clutch assembly, freewheel clutch, belt tension actuator, time delay assembly, cooling fan, sections of the scroll, and actuator bearing support brackets. The components were shipped to Robinson Helicopter Company for further examination. The components were examined by a National Transportation Safety Board engineer and a technical representative of the Robinson Helicopter Company. The lower actuator support bearing bracket had separated from the scroll. Torque paint had been applied on the outer rivets, in accordance with SB-94. Fretting and rub marks were also noted between the bracket and scroll wall. Elongated rivet holes were observed on the scroll wall, and associated rivets were sheared. The upperactuator bearing support brackets were separated from the scroll and displayed fretting and rub marks between the brackets and scroll wall. All rivet holes were elongated and the rivets were sheared. The clutch actuator upper housing had fractured from housing to slider tube. The fracture surface was jagged and angular. The actuator screw was fractured at the worm gear interface in a thread grove, and the fracture surface was jagged and angular. As received, the cooling fan was tested and found to be out of balance per the manufacturer specifications; however, the fan is dynamically balanced once installed on the airframe which may be different as received from the manufacturer.

Aircraft

Registration
N7508Z
Reported as
Robinson R44 (II)
Category
Helicopter
Serial number
10609
Built
2005
Airframe hours
2,350.5
Engine
Lycoming IO-540-AE1A5, reciprocating
Damage
Substantial damage
Flight
Aerial application · Part 137
Operator
NE IA Helicopters, LLC
Registered owner
NE IA Helicopters, LLC
Airworthiness certificate
Standard, Normal; Special, Restricted (Special)
Last inspection
Annual · May 3, 2019 · 106 hours before
Departed
Blair, NE
Destination
Blair, NE
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
46
Injuries
Minor
Certificates
Commercial, Flight instructor
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
April 12, 2019
Seat
Right
Restraint
3-point
Flight hours
3,162 total · 2,425 in this make and model · 3,089 as pilot in command · 170 in the last 90 days · 138 in the last 30 days · 15 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 10 knots
Visibility
10 statute miles

Docket · 7

The files NTSB released with the investigation on March 30, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.3 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.