CEN22LA328

NTSB accident investigation · Eurocopter Deutschland EC 135 · Mount Vernon, IL · July 20, 2022

Accident · No injuriesClass 4 · LimitedFinal report
Date
July 19, 2022, 20:41 local (Jul 20, 2022, 01:41 UTC)
Place
Mount Vernon, IL · On helipad
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N228MTEurocopter Deutschland EC 135
Defining event
Landing: Airport occurrence
Weather
Visual (VMC) · Dusk
Status
Completed
Report
Approved by Office Director
Investigation class
Class 4 - Basic report with no Prelim publish
NTSB office
Central Region
Parties
FAA Springfield FSDO
FAA report
20220719007199A
Case key
105540

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 inadequate securement of the cloth fire extinguisher cover, which resulted in it being blown off the fire extinguisher and ingested into the helicopter’s fenestron during the landing.

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.

Object/animal/substance: debris/dirt/foreign objectEnvironmental issues › Physical environment · Effect on equipmentEurocopter Deutschland EC 135 P2+: 2 casesAll aircraft: 101 casesProbable cause
Tail rotorAircraft › Aircraft propeller/rotor · FailureEurocopter Deutschland EC 135 P2+: 3 casesAll aircraft: 23 casesProbable cause
Tail rotorAircraft › Aircraft propeller/rotor · Damaged/degradedEurocopter Deutschland EC 135 P2+: 3 casesAll aircraft: 23 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

During the landing, the pilot lowered the helicopter air ambulance down to the concrete pad. Shortly before touchdown, a cloth fire extinguisher cover from a nearby mobile fueling unit was blown airborne from the main rotor system wash. The cloth fire extinguisher cover was ingested into the tail rotor (the fenestron). During the cloth fire extinguisher cover ingestion sequence, the fenestron hub flexed, the metal fenestron hub cover detached, and it was also ingested. The pilot was able to land the helicopter without further incident. The helicopter sustained substantial damage to the fenestron. The evidence indicated that the ingestion of the metal fenestron hub cover contributed to the severity of the damage sustained. The operator reported there were no preimpact mechanical malfunctions or failures with the airframe and the engines that would have precluded normal operation. The investigation revealed that the cloth fire extinguisher cover, which did not have a lanyard installed, was not secured with the retention bracket for the fire extinguisher on the mobile fueling unit. The operator additionally reported that foreign object debris checks are conducted by crew members anytime they are on the pad and that the mobile fueling unit is inspected during the daily fuel quality check. The Accident Investigation Board Norway along with the European Aviation Safety Agency, previously issued a formal safety recommendation to Eurocopter (Airbus) regarding the securement of the metal fenestron hub cover.

Aircraft

Registration
N228MT
Reported as
Eurocopter Deutschland EC 135 (P2+)
Category
Helicopter
Serial number
0908
Built
2010
Airframe hours
1,271.2
Engines
Pratt & Whitney Canada PW206B2, 447 horsepower, turbo shaftPratt & Whitney Canada PW206B2, 447 horsepower, turbo shaft
Damage
Substantial damage
Flight
Part 135
Operator
Air Evac Lifeteam, doing business as Air Evac Lifeteam
Registered owner
Air Evac Lifeteam
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 12, 2022
Departed
CPS · Cahokia, IL
Destination
Same as departure
Flight plan
Company VFR
Airport
MVN · Mount Vernon
Equipment
Electronic multifunction display, Onboard weather, Satellite tracking device, ADS-B, Auto-pilot, Electronic flight bag or handheld 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
50
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
April 2, 2022
Seat
Right
Restraint
4-point
Flight hours
3,210.5 total · 2,671.3 as pilot in command

Weather

Conditions
Visual (VMC) · Dusk
Wind
170° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 73 °F
Altimeter
29.82 inHg
Observed at
KMVN
METAR
KMVN 200056Z AUTO 17004KT 10SM CLR 29/23 A2982 RMK AO2 SLP095 T02890228

Docket · 4

The files NTSB released with the investigation on August 22, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 15.4 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.