CHI93LA212

NTSB accident investigation · Enstrom F-28C · Buckner, MO · June 14, 1993

Accident · Serious injuriesLimited investigationFinal report
Date
June 14, 1993, 12:53 local (17:53 UTC)
Place
Buckner, MO
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N51717Enstrom F-28C
Weather
Visual (VMC) · Day
Status
Completed · report October 20, 1994
Report
Approved by Office Director
FAA report
19930614025209A
Case key
9222

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 nut backing off the connecting rod bolt resulting in rod failure. A factor involved in this accident was the lack of suitable terrain for the pilot in command to make a run on landing.

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.

Loss of engine power(total) - mech failure/malfCruise
Engine assembly,connecting rod bolt - separationCause
Forced landingDescent - emergency
Autorotation - performedPilot in command
Hard landingLanding
Terrain condition - none suitableFactor

Analysis

During an aerial observation flight to inspect the sibly-blue springs power line, the pilot and passenger reported hearing a 'clunk'/'pop' and felt a jolt. The pilot started an immediate auto rotation. With no place for a safe run on landing, the pilot made a hard emergency landing. The helicopter slide next to a corrugated metal and pole shed. Upon landing, the pilot noticed that a fire had started in the engine area. The pilot and passenger were able to evacuate the aircraft before it and the nearby pole shed were completely engulfed in flames. The engine teardown showed the no. 2 cylinder connecting rod was imbedded in the skirt of the cylinder. A connecting rod nut found in the crankcase was ovalized; however, the internal threads appeared to be free of substantial damage and were not stripped.

Factual narrative

On June 14, 1993, about 1253 central daylight time, an Enstrom, F-28C, helicopter, N51717, received substantial damage when it impacted a barn and the ground near Buckner, Missouri during an aerial observation flight for the operator, Missouri Public Service. The commercial pilot, and one other passenger were both seriously injured. The flight was operating in visual meteorological conditions under 14 CFR Part 91.

An interview with the pilot/owner of N51717 revealed that the flight was carrying a passenger, an employee of Missouri Public Service, for the purpose of inspecting power lines for damage. The pilot left Grain Valley, Missouri (3GV),picked up the passenger at Oakgrove, and then proceeded to fly segments of power lines before refueling at Lexington, Missouri airport. Upon departing, the flight headed southbound to inspect the Sibly-Blue Springs power line.

Approximately 45 to 50 minutes into the flight between Sibly and Blue Springs, the pilot and passenger reported hearing a "clunk"/"pop" and felt a jolt. The pilot stated he started an immediate auto rotation, lowering the collective to stabilize the aircraft, and made a left turn to clear the power lines and try to position the aircraft into the wind. With no place for a safe run on landing, the pilot made a hard emergency landing with a nose left attitude. The helicopter slid next to a corrugated metal and pole shed. Immediately upon landing, the pilot noticed that a fire had started in the engine area. The pilot and passenger were both able to evacuate the aircraft before it and the nearby pole shed were completely engulfed in flames.

Initial investigation found the forward portion of the aircraft, including the cabin, seats, instrument panel, and lower fuselage were consumed in the fire.

The tail rotor drive shaft and tail rotor gear box were checked and found the tail rotor to rotate freely and control of the blades to be satisfactory. However, the tail rotor drive shaft and shaft coupling were found separated. Metallurgical examination found the fracture features were consistent with a ductile overstress torsional separation and there was not any evidence of preexisting fracture areas.

The engine, viewed under the engine cooling shroud, revealed that the crankcase was damaged above the No. 2 cylinder in the area of the cam followers. An engine tear down showed the left crankcase half had a hole in the top and bottom by the No. 2 cylinder. A section of the case that contains the cam followers was loose, and upon its removal it was noted that the No. 2 cylinder connecting rod was imbedded in the skirt of the cylinder and had hit the crankcase.

The cylinder was removed and it was noted that portions of the large end of the rod were missing. The No. 1 cylinder was removed and a portion of a connecting rod bolt and a section of the connecting rod cap was found in the piston behind the connecting rod pin. Upon removal of the No. 4 cylinder, it was noted that a portion of a connecting rod bolt with a nut threaded on it and a connecting rod bolt nut had been wedged between the piston and cylinder walls.

The crankcase halves exhibited gouges and scars. The right crankcase half at No. 1 had an imprint of a nut in the aluminum. The cam sustained strike damage between lobes and in line with the No. 2 connecting rod.

The connecting rod bolt nut (item "c", figure 4 of NTSB Metallurgist\s Factual Report), disclosed the nut "was grossly deformed as a result of mechanical damage on the washer face. Even though the nut was ovalized, the internal threads appeared to be free of substantial damage and were not stripped. Examination of the connecting rod bolt pieces revealed fracture features typical of over stress separations.

The connecting rod cap was fractured adjacent to the cut-out for the connecting rod bolt head. The severe damage to the fracture from exposure to the fire obliterated the fracture features and prevented a positive determination of the fracture mode. The connecting rod bolts and cam follower contained over stress separations. The underside of the nut for a connecting rod bolt was heavily peened, resulting in distortion of the nut.

According to Bill Taylor from Enstrom Helicopter, the nose will turn to the left in the event of an engine failure. Both the pilot and the passenger's interview statement indicate the tail turned to the right after hearing the "clunk", and feeling the "jolt" in flight.

Aircraft records and the pilot report show the engine with 1520 to 1530 hours SMOH (since major overhaul). Recommended TBO (time between overhaul) for this engine from the manufacturer is 1500 hours TBO.

Aircraft

Registration
N51717
Reported as
Enstrom F-28C
Category
Helicopter
Serial number
418
Airframe hours
2,460
Engine
Lycoming HIO-360, 205 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Aerial observation · Part 91
Registered owner
Valley Helicopters
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 1, 1992 · 42 hours before
Departed
4K3 · Lexington, MO
Destination
Oak Grove, MO

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
34
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 2, Unknown
Seat
Left
Flight hours
825 total · 531 in this make and model · 741 as pilot in command · 11 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
10° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 57 °F
Altimeter
30.00 inHg
Observed at
MKC, 18 nm away

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 N51717 · 1

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