CHI08LA211

NTSB accident investigation · Bell 47G-4A · Mayville, WI · July 24, 2008

Accident · FatalLimited investigationFinal report
Date
July 24, 2008, 06:52 local (11:52 UTC)
Place
Mayville, WI
Injuries
1 fatal
Damage
Minor damage
Phase of flight
Standing
Aircraft
N24HMBell 47G-4A
Defining event
Standing-engine(s) operating: AC/prop/rotor contact w person
Weather
Visual (VMC) · Day
Status
Completed · report September 30, 2009
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20080724850309A
Case key
68659

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 pilot's failure to maintain clearance with the rotating rotor blades after he exited the helicopter after landing.

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.

Attention/monitoringPersonnel issues › Psychological · PilotBell 47G-4A: 1 caseAll aircraft: 18 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

A witness heard the engine running rough when the agricultural application helicopter took off, adjacent to the field that was going to be sprayed. The pilot then landed the helicopter in the field which had tall vegetation and uneven terrain. The left skid separated during landing resulting in the helicopter resting left side low. The pilot then exited and walked around the helicopter when he was struck by the rotating main rotor blades and was fatally injuried. Examination of the engine revealed an exhaust valve that displayed excessive wear which would result in the engine running rough due to the valve sticking. Logbook records show that the engine and parts manufacturer approval (PMA) manufacturer's recommended maintenance had not been performed.

Factual narrative

On July 24, 2008, about 0652 central daylight time, the pilot of a Bell 47G-4A, N24HM, received fatal injuries when he was stuck by the main rotor blade while exiting the helicopter near Mayville, Wisconsin. The pilot had shut down the engine and exited to inspect the helicopter. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 137 agricultural application flight was not operating on a flight plan.

The ground loader heard the engine running rough when the helicopter took off next to the field that was going to be sprayed. The helicopter flew in a southerly direction for about 200 yards before landing. During landing, the left skid became entangled in the surrounding vegetation and the helicopter turned towards the north breaking off the left skid. The helicopter landed in a field about 3/8 mile from the loading site and was resting left side low. The pilot exited and walked around the helicopter with the main rotor blades still rotating. The pilot was then fatally injured when he was struck by the rotating blades.

Aircraft information

The helicopter was powered by a Lycoming VO-540-B1B3 engine, serial number L-2450-43, that had a total time in service of 3,378.6 hours and a total time since overhaul of 395 hours. There were no markings identifying all the cylinder heads and barrels as Parts Manufacturer Approval (PMA) parts. The return to service tags associated with the engine cylinder assemblies were not received by the National Transportation Safety Board or Federal Aviation Administration (FAA).

Textron Lycoming Mandatory Service Bulletin 388 calls for 300-hour interval inspections if engine valve sticking is suspected. Also, Engine Components, Inc. (ECI) Service Instruction 03-11, which references Textron Lycoming Service Bulletin 388 also calls for similar inspections on ECI Titan Cylinder assemblies. There were no engine logbook entries showing that such inspections were performed.

The maximum gross weight of the helicopter was 3,200 lbs and the operator reported weight at the time of the accident was 3,100 lbs. The helicopter was loaded with 80 lbs of chemical applicant.

Medical and pathological informaton

An autopsy of the pilot was conducted by the Dodge County Medical Examiner on July 24, 2008. The cause of death was listed as blunt force trauma.

The FAA's Final Forensic Toxicology Fatal Accident Report on the pilot states that no carbon monoxide was detected in blood, no cyanide was detected in blood, no ethanol was detected in blood, metoprolol was detected in blood and urine, and naproxen was detected in urine.

Tests and research

A compression check of the engine revealed that the number one cylinder had a compression ratio of 45/80 with an exhaust valve leak. The number one cylinder assembly contained Superior Air Parts, Inc. Nimonic exhaust valve, part number SL16470AK, and Engine Components, Inc. (ECI) exhaust valve guide, part number AEL 75838 P030. The exhaust valve exhibited four fractures and a relative burnt appearance. The valve guide displayed excessive wear (bell-mouthing). The exhaust valve had an outside diameter of 0.496 inch; the exhaust valve guide interior diameter was 0.540 inch, and a clearance 0.044 inch (0.006 inch nominal).

Comparative examination of the number three cylinder exhaust valve also showed a burnt and worn appearance but to a lesser degree than the number one cylinder. No visible cracks of the exhaust valve were noted.

Aircraft

Registration
N24HM
Reported as
Bell 47G-4A
Category
Helicopter
Serial number
7688
Airframe hours
10,775
Engine
Textron Lycoming VO-540-B1B3, 300 hp, reciprocating
Damage
Minor damage
Flight
Aerial application · Part 137
Operator
Reabe Flying Service
Registered owner
McCraw Enterprises Inc.
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · November 1, 2007
Departed
Mayville, WI
Destination
Mayville, WI

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
70
Injuries
Fatal
Certificates
Commercial, Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
January 21, 2008
Seat
Left
Toxicology
Performed
Flight hours
24,000 total · 16,000 in this make and model · 24,000 as pilot in command · 56 in the last 90 days · 56 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 2 knots
Visibility
10 statute miles
Lowest ceiling
4,000 ft overcast
Temperature
61 °F
Altimeter
30.05 inHg

Docket · 4

The files NTSB released with the investigation on August 5, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.7 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.

Other investigations on N24HM · 1

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