CEN23LA025

NTSB accident investigation · Bell 206 · Greenville, IL · November 3, 2022

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
November 2, 2022, 19:48 local (Nov 3, 2022, 00:48 UTC)
Place
Greenville, IL
Injuries
2 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N61KHBell 206
Defining event
Initial climb: Fuel starvation
Weather
Visual (VMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Rolls-Royce, Honeywell, Transportation Safety Board of Canada, Kash Helicopter Services, Bell Textron, FAA Springfield FSDO
FAA report
20221102020039A
Case key
106242

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The mechanic’s failure to inspect and clean the entire fuel nozzle assembly in accordance with the engine maintenance manual, which resulted in fuel starvation and a partial loss of engine power, an autorotation, and a hard landing.

Findings · 4

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.

Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelBell 206B: 4 casesAll aircraft: 320 casesProbable cause
Action: forgotten action/omissionPersonnel issues › Action/decision · Maintenance personnelBell 206B: 4 casesAll aircraft: 440 casesProbable cause
Attention/monitoring: task monitoring/vigilancePersonnel issues › Psychological · Maintenance personnelBell 206B: 7 casesAll aircraft: 330 casesProbable cause
Fuel system: fuel distributionAircraft › Aircraft systems · Incorrect service/maintenanceBell 206B: 1 caseAll aircraft: 141 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 aerial application helicopter completed operations for the day and stopped to refuel on the way back to the operator’s facility. After refueling and during the initial climb, the pilot reported that he was unable to maintain main rotor rpm. The pilot initiated a 180° autorotation and landed hard on a grass area near a hangar. During the landing, the right-side skid collapsed, the tail boom separated, and the helicopter came to rest upright. The helicopter sustained substantial damage to the fuselage, the tail boom, and the tail rotor system. Examination of the engine revealed that the fuel nozzle inlet screen was contaminated and partially blocked with a buildup of debris. The fuel nozzle assembly had been inspected, as part of the required 150-hour inspection interval, 25.9 hours before the accident. The director of maintenance (DOM) for the operator was interviewed for additional details on how the inspection had been performed. The DOM reported that he had cleaned the fuel nozzle, but not the fuel nozzle inlet screen. When asked specifically about the fuel nozzle inlet screen cleaning, the DOM reported that he, “has not had a chance to get to that yet.” A review of the engine maintenance records showed that the DOM had signed his initials indicating that the fuel nozzle assembly was inspected and cleaned at the required 150-hour inspection interval. The partially blocked fuel nozzle inlet screen with debris likely restricted fuel flow to the engine. The DOM’s failure to clean the entire fuel nozzle assembly, including the fuel nozzle inlet screen, likely resulted in a partial loss of engine power, an autorotation, and a hard landing. Based on the available evidence, it is likely the DOM did not clean the fuel nozzle inlet screen for undetermined reasons.

Factual narrative

On November 2, 2022, about 1948 central daylight time, a Bell 206B helicopter, N61KH, sustained substantial damage when it was involved in an accident near Greenville, Illinois. The pilot and one passenger sustained minor injuries and one passenger sustained no injury. The helicopter was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 business flight. The helicopter, which had a normal and a restricted airworthiness certificate, had completed 14 CFR Part 137 aerial application work during the day near Rushville, Illinois. The two passengers onboard were loaders employed by the operator. The helicopter was returning to the operator’s facility at the Mount Vernon Airport (MVN), Mount Vernon, Illinois, and stopped at the Greenville Airport (GRE), Greenville, Illinois, to refuel. After being refueled, the helicopter departed for MVN. During the initial climb, the pilot reported he was unable to maintain main rotor rpm. The pilot initiated a 180° autorotation to land back to the airport. The helicopter landed hard on a grass area near a hangar, the right-side skid collapsed, the tail boom separated, and the helicopter came to rest upright. The three occupants were able to egress from the helicopter without further incident. During the landing, the fuel system was damaged, and a large fuel leak occurred on the grass. The helicopter sustained substantial damage to the fuselage, the tail boom, and the tail rotor system. Postaccident examination of the airframe confirmed flight control continuity, and cockpit to engine control continuity was confirmed. Examination of the engine revealed that the fuel nozzle inlet screen was contaminated and partially blocked with a buildup of debris. The fuel nozzle assembly had been inspected, as part of the required 150-hour inspection interval, 25.9 hours before the accident. The DOM for the operator, who is an airframe and powerplant mechanic with inspection authorization, was interviewed for additional details on how the inspection had been performed. The DOM reported that he had cleaned the fuel nozzle, but not the fuel nozzle inlet screen. When asked specifically about the fuel nozzle inlet screen cleaning, the DOM reported that he, “has not had a chance to get to that yet.” The DOM further reported that he had never seen the fuel nozzle inlet screen before. A review of the engine maintenance records showed that the DOM had signed his initials indicating that the fuel nozzle assembly was inspected and cleaned at the required 150-hour inspection interval. Because of the smooth coated appearance of the debris on the fuel nozzle inlet screen as well as the highly variable color of fuel observed during the airframe examination, it was decided to perform testing on the fuel samples to determine if the fuel may have been contaminated with “apple jelly” or diesel exhaust fluid (DEF). The results of the testing found no “apple jelly” or DEF contamination with the helicopter’s fuel system. The Rolls-RoyceM250-C20 Series Operation and Maintenance Manual states that the fuel nozzle assembly is required to be removed, inspected, and cleaned at 150-hour intervals. The manual further states: NOTE: Operators can find it necessary to inspect and clean the fuel nozzle more often depending on past experience or operating conditions. The National Agricultural Aviation Association published the Fly Safe Message, Avoid Engine Fuel System Contamination, on May 1, 2023. This document discusses fuel system contamination with turbine-powered aircraft used for aerial application work and states in part: Contamination of an engine fuel system could result in either a partial or a complete loss of engine power. Turbine engine components that could be adversely affected by contamination include the fuel control unit and the fuel nozzles. Due to the nature of aerial application work, operators should consider increasing the inspection frequency of turbine engine fuel system components. Always follow the maintenance manual when performing your work. Consult with the airframe, the engine, and the engine accessory manufacturers on any additional service documents regarding the topic of fuel contamination.

Aircraft

Registration
N61KH
Reported as
Bell 206 (B)
Category
Helicopter
Serial number
2255
Built
1978
Airframe hours
15,537.9
Engine
Rolls-Royce 250-C20B, 317 horsepower, turbo shaft
Damage
Substantial damage
Flight
Business · Part 91
Operator
Kash Helicopter Services LLC, doing business as Kash Helicopter Services LLC
Registered owner
Kash Helicopter Services LLC
Airworthiness certificate
Standard, Normal; Special, Restricted (Special)
Last inspection
AAIP · September 30, 2022 · 25.9 hours before
Departed
Rushville, IL
Destination
Same as departure
Flight plan
Company VFR
Airport
GRE · Greenville, runway 36, 4,002 × 75 ft, grass/turf
Equipment
Handheld GPS, ADS-B

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
60
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 2, Without waivers/limitations
Last flight review
March 15, 2022
Seat
Right
Restraint
4-point
Flight hours
5,823 total · 1,800 in this make and model · 5,700 as pilot in command · 125 in the last 90 days · 25 in the last 30 days

Weather

Conditions
Visual (VMC) · Night
Wind
140° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 46 °F
Altimeter
30.17 inHg
Observed at
KBLV, 28 nm away
METAR
KBLV 030055Z 14006KT 10SM CLR 16/08 A3017 RMK AO2A PRESRR SLP220 T01560079 $

Docket · 22

The files NTSB released with the investigation on September 5, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 46.5 MB in all.

Pilot/operator aircraft accident report, NTSB form 6120.1Item 1 · PDF · 9 pages · 1.5 MBAccident photographsItem 2 · PDF · 7 pages · 2.8 MBVarious statements - occupants and witnessItem 3 · PDF · 5 pages · 953 KBStatement - director of maintenanceItem 4 · PDF · 1 page · 67 KBAdditional questions - operatorItem 5 · PDF · 2 pages · 202 KBN61KH - accident flight ADS-B data, google earth file (.kmz)Item 6 · KMZ · 295 KBN61KH - accident flight ADS-B data, microsoft excel file (.xlsx)Item 7 · XLSX · 11.8 MBN61KH - most recent airframe maintenance recordsItem 8 · PDF · 7 pages · 3.0 MBN61KH - most recent engine maintenance recordsItem 9 · PDF · 8 pages · 7.4 MBWreckage examination factual reportItem 10 · PDF · 11 pages · 7 photos · 689 KBPowerplants factual reportItem 11 · PDF · 26 pages · 2.7 MBAttachment I - KTS fuel nozzle testItem 12 · PDF · 4 pages · 1.5 MBAttachment ii - rolls royce M250-C20 omm nozzleItem 13 · PDF · 7 pages · 272 KBAttachment iii - SAIB AIR-21-08Item 14 · PDF · 8 pages · 497 KBAttachment iv - ptg test reportItem 15 · PDF · 3 pages · 1.8 MBAttachment v - fcu test reportItem 16 · PDF · 6 pages · 4.3 MBAttachment VI - fuel test reportItem 17 · PDF · 39 pages · 1.6 MBFuel informationItem 18 · PDF · 2 pages · 399 KBWeight and balance informationItem 19 · PDF · 8 pages · 2.0 MBNational agricultural aviation association, fly safe message - avoid engine fuel system contaminationItem 20 · PDF · 1 page · 159 KBRelease of aircraft wreckage, NTSB form 6120.15Item 21 · PDF · 3 pages · 257 KBNTSB party member forms - variousItem 22 · PDF · 5 pages · 2.3 MB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.