CEN22LA351

NTSB accident investigation · Bell Helicopter Textron 206B · Arcadia, IA · August 1, 2022

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
August 1, 2022, 09:15 local (14:15 UTC)
Place
Arcadia, IA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N169AABell Helicopter Textron 206B
Defining event
Maneuvering: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
TSB Canada, Rolls-Royce, Federal Aviation Administration
FAA report
20220801007599A
Case key
105642

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 torque a fuel control unit B-nut, which resulted in a loss of engine power at low altitude and an impact with terrain.

Findings · 1

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.

Engine fuel and control: fuel controlling systemAircraft › Aircraft power plant · Incorrect service/maintenanceBell Helicopter Textron 206B: 1 caseAll aircraft: 59 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 reported that he was completing an aerial application flight about 6 ft above the corn field when the engine sustained a loss of power. The helicopter descended into the corn and impacted the field. A small postcrash fire ensued near the engine and was extinguished. Postaccident examination revealed all external air, fuel, and oil line connections were tight except for the pneumatic air line (Pc line) B-nut connecting the power turbine governor (PTG) to the fuel control unit (FCU). The Pc line was not connected to the FCU and a gap was noted between the B-nut and FCU union. Residual torque paint was identified; however, there was no new-effective torque paint identified on any B-Nut. It appeared the B-nut had backed off the FCU fitting. This Pc is one of several that use air pressure to communicate fuel scheduling demands between the PTG and FCU. The security of this line is necessary for proper engine operation. Operation of the engine without the B-nut properly connected would result in the FCU reducing fuel to a sub-idle condition, with the engine not capable of producing power for continued flight. There were no other mechanical functions or failures that would have precluded normal operation. Maintenance was performed on the helicopter 23 days and 12 flight hours before the accident. It is likely that the maintenance personnel did not properly torque this B-but or apply torque stripe paint, which resulted in a disconnection of the B-nut and a loss of engine power.

Factual narrative

On August 1, 2022, about 0915 central daylight time, a Bell 206B helicopter, N169AA, was substantially damaged when it was involved in an accident near Arcadia, Iowa. The pilot sustained minor injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot reported that he was completing an aerial application run about 6 ft above the corn field when the engine sustained a loss of power. The helicopter descended into the corn and impacted the field. A small postcrash fire ensued near the engine and was extinguished. The pilot stated that the helicopter recently had significant maintenance performed and he had only flown it about 12 hours since then. Postaccident examination of the helicopter revealed thermal damage and soot noted on the top of the engine and cowling with fire retardant residue noted. The engine compressor turbine (N1) system was not examined. The engine power turbine (N2) system was locked and the No. 5 bearing area of the exhaust collector was buckled. The fourth stage turbine wheel appeared normal when viewed from the exhaust collector but was covered in fire retardant residue. A fuel sample was taken from the aircraft fuel filter bowl; the fuel was clear and appeared normal. The fuel filter element was clear of contamination. An oil sample was taken from the aircraft-mounted scavenge oil filter bowl and was dark brown in appearance. The filter element was clear and some minor non-ferrous debris was noted in the bowl, consistent with carbon particles. The pending bypass button was not extended. Linkages from the collective to the PTG and from the throttle twist grip to the FCU were secure. The FCU throttle input lever was rigged correctly and contacted the minimum and maximum stops when the throttle was rotated to the cut off and fly position respectively. The PTG rotated through about 20° when the collective was moved from full down to full up. All external air, fuel, and oil line connections were at least finger tight except for the Pc line B-nut connecting the PTG to the FCU. The Pc line was not connected to the FCU and a gap was noted between the B-nut and FCU union (Figure 1). Residual torque paint was identified; however, there was no new-effective torque paint identified on any B-Nut. This Pc line is one of several that use air pressure to communicate fuel scheduling demands between the PTG and FCU. Figure 1. Disconnected Pc line B-nut that connects the PTG to the FCU. The only anomaly observed that would have precluded normal engine operation was the disconnected B-nut on the Pc line. On July 9, 2022, about 23 days before the accident flight, a maintenance facility completed 100-hour engine and airframe inspections, 300-hour engine and airframe inspections, a 12-month airframe inspection, an engine oil change, and many other inspection items. Additional maintenance work included removing the turbine assembly for an over-temperature inspection and turbineoutlet temperature indicator reset due to the over-temperature event. During a postmaintenance engine start attempt, the fuel management system failed to properly control the temperature. The engine start was aborted with no exceedances noted. A fuel nozzle was removed, and a newly overhauled fuel control unit was installed. A postmaintenance ground run was completed. The logbook noted that an independent control check was performed for security and safety of, among other things, the fuel control linkage at the control lever and the droop compensator at the governor control arm. On July 10, 2022, a postmaintenance ground run and test flight were completed and the helicopter was returned to service. On July 12, the helicopter was flown from the maintenance facility in Langley Regional Airport (CYNJ), British Columbia, Canada, to Bellingham International Airport (KBLI), Bellingham, Washington. Helicopter total time was 13,248.3 hours. According to Rolls-Royce, the B-nut that was found loose is difficult to access when other tubes are installed. Rolls-Royce designed, developed, and released a special tool to access this B-nut. On October 24, 2016, it was released to the field via commercial service letter (CSL) 1273. The CSL provides details on how to manufacture the tool locally and the tool is also available for purchase. Operators are advised that torque paint/slippage indication is to be applied to all B-nuts per the Rolls-Royce operation and maintenance manual (OMM). Strict adherence to the specified manuals is essential to the safe and reliable operation of the engine. Failure to maintain the engine in accordance with the OMM and supporting customer publications can result in a decrease in airworthiness of the engine.

Aircraft

Registration
N169AA
Reported as
Bell Helicopter Textron 206B
Category
Helicopter
Serial number
990
Built
1973
Airframe hours
13,248
Engine
Rolls-Royce 250-C20, 420 horsepower, turbo shaft
Damage
Substantial damage
Fire
On-Ground
Flight
Aerial application · Part 137
Registered owner
Pierce Associates LLC
Airworthiness certificate
Standard, Normal
Last inspection
Unknown · July 10, 2022
Equipment
Unknown

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
78
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
July 21, 2020
Seat
Right

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 4 knots
Visibility
9 statute miles
Temperature
72 °F, dew point 66 °F
Altimeter
29.98 inHg
Observed at
KCIN, 11 nm away
METAR
KCIN 011415Z AUTO 03004KT 9SM FEW100 22/19 A2998 RMK AO2

Docket · 6

The files NTSB released with the investigation on June 20, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.4 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.