CHI03IA293

NTSB incident investigation · Bell 230 · Wilmington, IL · August 20, 2003

Incident · No injuriesIncident investigationFinal report
Date
August 19, 2003, 19:12 local (Aug 20, 2003, 00:12 UTC)
Place
Wilmington, IL
Injuries
3 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N880SFBell 230
Weather
Visual (VMC) · Dusk
Status
Completed · report December 3, 2004
Report
Approved by Office Director
Parties
Bell Helicopter Textron, Transportation Safety Board, Federal Aviation Administration
Case key
57882

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

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Probable cause

The material defect during the manufacture of the tail rotor counterweight bellcrank and the bellcrank's subsequent failure due to a fatigue fracture.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionCruise
Tail rotor/anti-torque control - inadequateManufacturerCause
Material defectManufacturerCause
Rotorcraft flight control,t/r bellcrank/quadrant - failure,totalCause
Rotorcraft flight control,t/r bellcrank/quadrant - fatigueCause
Forced landingEmergency descent/landing
Precautionary landing - performedPilot in command

Analysis

During a repositioning flight, the medical transportation helicopter executed a precautionary landing to a vacant parking lot after experiencing an in-flight vibration during cruise flight. The pilot stated that the flight time with the vibration was less than 90 seconds. An inspection of the helicopter revealed that the tail rotor counterweight bellcrank (p/n 222-012-727-003) used to hold counterweights had fractured in two pieces. A metallurgical examination of the bellcrank indicated that the bellcrank fractured as a result of a fatigue crack propagating from a casting discontinuity formed during manufacture. Three other occurrences of the same part number were found. The manufacturer issued an information letter to all owners and operators of Bell 222/230/430 helicopters advising them of the occurrences.

Factual narrative

On August 19, 2003, at 1912 central daylight time, a Bell 230 helicopter, N880SF, operated by OSF Aviation LLC, executed a precautionary landing to a vacant parking lot near Wilmington, Illinois, after the helicopter encountered an in-flight vibration during cruise flight. The pilot and two crewmembers were not injured. The 14 CFR Part 91 medical positioning flight departed Gary Regional Airport (GYY), Gary, Indiana, at 1858, and was en route to the St. Francis Hospital helicopter landing zone (LL37), Peoria, Illinois. Visual meteorological conditions prevailed at the time of the incident. A company visual flight rules (VFR) flight plan was filed.

The pilot stated that while returning to LL37 the crew noticed a "sudden increase in vibration." He reported that he decided to land immediately with minimum of control inputs. He reported that he landed and shut down the helicopter without further incident. The pilot stated that the flight time with the vibration was less than 90 seconds.

An inspection of the helicopter revealed that the tail rotor bellcrank (p/n 222-012-727-003) used to hold counterweights had fractured in two pieces. The part was installed on N880SF at the time of aircraft manufacture and had accumulated 1,570.6 hours since new. A review of the maintenance records indicated that the tail rotor assembly had been inspected as part of the 150 hour component inspection conducted on July 31, 2003. The helicopter had a total time of 1,522.2 hours at the time of the 150 hour inspection and no defects were noted during the inspection.

The tail rotor bellcrank was sent to the Engineering Branch Laboratory of the Transportation Safety Board of Canada (TSB) for examination. The TSB engineering report stated that the bellcrank fractured as a result of a fatigue crack propagating from a casting discontinuity. It further stated, "Cadmium was found on the wall of the cavity indicating that the defect was present in the part before plating. The defect was not detected by a penetrant inspection of the finished part." (See TSB Engineering Report LP092/2003 included with the docket material associated with this factual report)

Bell Helicopter Textron reviewed their database to check if there had been similar occurrences. Their records indicated three occurrences of tail rotor bellcrank counterweight arm fractures since March 1989. They reported, "In each case, the fracture occurred in the arm inboard of the weights and none of the fractures resulted in an accident." The number of hours accumulated by the three failed parts were:

1. March 1989: Fatigue originating in casting porosity. Total part hours - 3,946.

2. February 1998: Fatigue originating in a mechanical scrape. Total part hours - 800.

3. June 2003: Fatigue fracture with no discontinuity at origin, however, pivot bearings worn. Total part hours - 6,897.

Bell Helicopter Textron issued an Information Letter 222-03-18, 2224-03-13, 230-03-08, and 430-03-33 on November 11, 2003. The information letter was issued to advise all owners and operators of Bell 222/230/430 helicopters of "occurrences affecting the tail rotor counterweight bellcrank P/N 222-012-727-003." The letter stated, "Bell Helicopter Textron has received reports of in-flight fracture and subsequent loss of a weighted portion of the tail rotor counterweight bellcrank. In each occurrence, a severe vibration was felt in the aircraft and a precautionary landing was carried out." The letter further stated, "Bell Helicopter Textron is actively seeking a solution to resolve this issue and in the near future all owners/operators will be notified of the corrective action." The letter also reminded owners and operators to check the condition and security of the tail rotor pitch change linkage during aircraft preflight and during the 150-hour component inspection contained in the maintenance manual. (See Bell Helicopter Textron Information Letter dated November 11, 2003, included with the docket material associated with this factual report)

Aircraft

Registration
N880SF
Reported as
Bell 230
Category
Helicopter
Serial number
23024
Airframe hours
1,570
Engines
Allison C-30 G/2, 700 horsepower, turbo shaftAllison C-30 G/2, 700 horsepower, turbo shaft
Damage
Minor damage
Flight
Positioning · Part 91
Registered owner
OSF Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · July 31, 2003 · 48 hours before
Departed
GYY · Gary, IN
Destination
LL37 · Peoria, IL
Flight plan
Company VFR

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
35
Injuries
None
Certificates
Military, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
July 28, 2003
Seat
Right
Flight hours
4,487 total · 305 in this make and model

Weather

Conditions
Visual (VMC) · Dusk
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 66 °F
Altimeter
30.11 inHg
Observed at
IKK, 20 nm away

Other investigations on N880SF · 1

Matched to the same aircraft by N-number and date.