DCA12MA020

NTSB accident investigation · Eurocopter France AS350B2 · Las Vegas, NV · December 8, 2011

Accident · FatalClass 1 · MajorFinal report
Date
December 7, 2011, 16:30 local (Dec 8, 2011, 00:30 UTC)
Place
Las Vegas, NV
Injuries
5 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N37SHEurocopter France AS350B2
Defining event
Enroute-cruise: Part(s) separation from AC
Weather
Visual (VMC) · Dusk
Status
Completed · report February 20, 2013
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
20111207028539A
Case key
82479

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

Sundance Helicopters’ inadequate maintenance of the helicopter, including (1) the improper reuse of a degraded self-locking nut, (2) the improper or lack of installation of a split pin, and (3) inadequate postmaintenance inspections, which resulted in the in-flight separation of the servo control input rod from the fore/aft servo and rendered the helicopter uncontrollable. Contributing to the improper or lack of installation of the split pin was the mechanic’s fatigue and the lack of clearly delineated maintenance task steps to follow. Contributing to the inadequate postmaintenance inspection was the inspector’s fatigue and the lack of clearly delineated inspection steps to follow.

Findings · 8

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.

Rotorcraft flight control: rotorcraft servo systemAircraft › Aircraft propeller/rotor · Incorrect service/maintenanceEurocopter France AS350B2: 1 caseAll aircraft: 6 casesProbable cause
Misc hardware: fastenersAircraft › Fluids/misc hardware · Incorrect service/maintenanceEurocopter France AS350B2: 1 caseAll aircraft: 58 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelEurocopter France AS350B2: 1 caseAll aircraft: 371 casesProbable cause
Inspection: post maintenance inspectionPersonnel issues › Task performance · Maintenance personnelEurocopter France AS350B2: 1 caseAll aircraft: 57 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleEurocopter France AS350B2: 3 casesAll aircraft: 1,269 casesProbable cause
Alertness/FatiguePersonnel issues › Physical · Maintenance personnelEurocopter France AS350B2: 1 caseAll aircraft: 48 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 Safety Board’s full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-13/01. On December 7, 2011, about 1630 Pacific standard time, a Sundance Helicopters, Inc., Eurocopter AS350-B2 helicopter, N37SH, operating as a “Twilight tour” sightseeing trip, crashed in mountainous terrain about 14 miles east of Las Vegas, Nevada. The pilot and four passengers were killed, and the helicopter was destroyed by impact forces and postimpact fire. The helicopter was registered to and operated by Sundance as a scheduled air tour flight under the provisions of 14 Code of Federal Regulations (CFR) Part 135. Visual meteorological conditions with good visibility and dusk light prevailed at the time of the accident, and the flight operated under visual flight rules. The helicopter originated from Las Vegas McCarran International Airport, Las Vegas, Nevada, about 1621 with an intended route of flight to the Hoover Dam area and return to the airport. The helicopter was not equipped, and was not required to be equipped, with any on board recording devices.

Factual narrative

The Safety Board’s full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Report number is NTSB/AAR-13/01. On December 7, 2011, about 1630 Pacific standard time, a Sundance Helicopters, Inc., Eurocopter AS350-B2 helicopter, N37SH, operating as a “Twilight tour” sightseeing trip, crashed in mountainous terrain about 14 miles east of Las Vegas, Nevada. The pilot and four passengers were killed, and the helicopter was destroyed by impact forces and postimpact fire. The helicopter was registered to and operated by Sundance as a scheduled air tour flight under the provisions of 14 Code of Federal Regulations (CFR) Part 135. Visual meteorological conditions with good visibility and dusk light prevailed at the time of the accident, and the flight operated under visual flight rules. The helicopter originated from Las Vegas McCarran International Airport, Las Vegas, Nevada, about 1621 with an intended route of flight to the Hoover Dam area and return to the airport. The helicopter was not equipped, and was not required to be equipped, with any on board recording devices.

Aircraft

Registration
N37SH
Reported as
Eurocopter France AS350B2
Category
Helicopter
Serial number
2300
Engine
Turbomeca ARRIEL 1SER, 681 horsepower, turbo shaft
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Operator
Sundance Helicopters Inc
Registered owner
Sundance Helicopters Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · December 6, 2011 · 4 hours before
Departed
LAS · Las Vegas, NV
Destination
LAS · Las Vegas, NV
Flight plan
Company VFR
Airport
LAS · Las Vegas McCarren

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.

Weather

Conditions
Visual (VMC) · Dusk
Wind
200° at 4 knots
Visibility
10 statute miles
Temperature
54 °F, dew point 10 °F
Altimeter
30.13 inHg
Observed at
KLAS, 14 nm away

Docket · 94

The files NTSB released with the investigation on June 15, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 159 MB in all.

Operations 2 - Factual Report of Group ChairmanItem 1 · .PDF · 2.1 MBOperations 2 - Attachment 1 Pilot Operator Report NTSB Form 6120Item 2 · .PDF · 7.0 MBOperations 2 - Attachment 2 Twilight Tour Description with Flight Track OverlayItem 3 · .PDF · 245 KBOperations 2 - Attachment 3 Spidertrack Raw Data for Accident Flight (N37SH)Item 4 · .PDF · 149 KBOperations 2 - Attachment 4 National Park Service Incident Record of Telephone InterviewsItem 5 · .PDF · 2.3 MBOperations 2 - Attachment 5 Sundance Pilot StatementsItem 6 · .PDF · 1.8 MBOperations 2 - Attachment 6 Sundance Chief Pilot StatementItem 7 · .PDF · 462 KBOperations 2 - Attachment 7 Pilot's Training RecordsItem 8 · .PDF · 3.7 MBOperations 2 - Attachment 8 Pilot's Flight and Duty Time RecordsItem 9 · .PDF · 3.3 MBOperations 2 - Attachment 9 Pilot's Archived Flight TracksItem 10 · .PDF · 868 KBOperations 2 - Attachment 10 Weight and Balance Sheet for the Accident Flight (N37SH)Item 11 · .PDF · 181 KBOperations 2 - Attachment 11 Sundance Approved Operations Specifications (OpsSpecs)Item 12 · .PDF · 2.7 MBOperations 2 - Attachment 12 Sundance General Operations Manual (GOM) Chapter 6 Flight OperationsItem 13 · .PDF · 4.7 MBOperations 2 - Attachment 13 AS350B2 Rotorcraft Flight Manual (RFM) Section 4 Normal ProceduresItem 14 · .PDF · 581 KBOperations 2 - Attachment 14 AS350B2 Rotorcraft Flight Manual (RFM) Section 8-4 Daily Operating ChecksItem 15 · .PDF · 582 KBOperations 2 - Attachment 15 AS350B2 Rotorcraft Flight Manual (RFM) Section 8-3 Flight Test SheetsItem 16 · .PDF · 581 KBOperations 2 - Attachment 16 AS350B2 Rotorcraft Flight Manual (RFM) Supplement 14Item 17 · .PDF · 373 KBOperations 2 - Attachment 17 Sundance Expanded External Checks ChecklistItem 18 · .PDF · 3.1 MBOperations 2 - Attachment 18 External Safety Audits (DOD and TOPS)Item 19 · .PDF · 2.1 MBOperations 2 - Attachment 19 Internal Safety Audit (SMS)Item 20 · .PDF · 1.1 MBOperations 2 - Attachment 20 Letter from Sundance Helicopters to NTSBItem 21 · .PDF · 1.2 MBOperations 2 - Attachment 21 Sundance Safety Memorandum Outlining Post Accident Safety InitiativesItem 22 · .PDF · 308 KBOperations 2 - Photo 1 Pilot Conducting a Preflight Inspection of the Left MGB AreaItem 23 · .PDF · 1.9 MBOperations 2 - Photo 2 Left MGB Inspection AreaItem 24 · .PDF · 1.9 MBOperations 2 - Photo 3 Fore-Aft Servo Connecting Hardware Visible through the Cutout of the Ice BootItem 25 · .PDF · 1.7 MBAirworthiness Factual Report of Group Chairman (with 7 embedded images)Item 26 · .PDF · 7 photos · 5.3 MBAirworthiness Factual Report of Group Chairman - Addendum 1 (with 2 embedded images)Item 27 · .PDF · 2 photos · 486 KBAirworthiness Factual Report of Group Chairman - Addendum 1 (with 2 embedded images)Item 28 · .PDF · 2 photos · 766 KBAirworthiness Factual Report of Group Chairman - Addendum 1 - Attachment 1 - Meggitt Materials Laboratory Report on Particle CompositionItem 29 · .PDF · 492 KBAirworthiness Factual Report of Group Chairman - Addendum 1 - Attachment 2 - Meggitt Control Systems Test Certificates for Fore/Aft Servo (RX187) and Tail Rotor (FE212) - REDACTEDItem 30 · .PDF · 2.7 MBAirworthiness Factual Report of Group Chairman - Addendum 1 - Attachment 3 - Photographs and X-Ray Mosaic Images of Removed MaterialsItem 31 · .PDF · 22 photos · 2.7 MBAirworthiness Factual Report of Group Chairman - Addendum 1 - Attachment 4 - Photographs of Input Linkage Connection for Servo Commande Actuators (with 4 embedded photographs)Item 32 · .PDF · 4 photos · 1.3 MBAirworthiness Factual Report of Group Chairman - Addendum 1 - Attachment 5 - Eurocopter Response to May 11 NTSB QuestionsItem 33 · .PDF · 223 KBAirworthiness Factual Report of Group Chairman - Addendum 1 - Attachment 6 - Meggitt Control Systems Response to NTSB Question 3Item 34 · .PDF · 80 KBComputed Tomography Specialist's Factual Report (with 31 embedded images)Item 35 · .PDF · 3.3 MBPowerplants 8 - Factual Report of Group Chairman with 19 embedded photographsItem 36 · .PDF · 19 photos · 1.3 MBPowerplants 8 - Attachment 1. Maintenance Records Excerpt Engine Life Limited PartsItem 37 · .PDF · 41 KBMaintenance 11 - Factual Report of Group ChairmanItem 38 · .PDF · 2 photos · 815 KBMaintenance 11 - Attachment 1 Eurocopter 100-hour RequirementsItem 39 · .PDF · 1.7 MBMaintenance 11 - Attachment 2 Eurocopter Standard Practices ManualItem 40 · .PDF · 403 KBMaintenance 11 - Attachment 3 Eurocopter Main Rotor Servo Installation ProceduresItem 41 · .PDF · 143 KBMaintenance 11 - Attachment 4 Statement of Party RepresentativesItem 42 · .PDF · 3.9 MBMaintenance 11 - Attachment 5 SDH GOM and Operations SpecificationsItem 43 · .PDF · 52.3 MBMaintenance 11 - Attachment 6 SDH General Maintenance ManualItem 44 · .PDF · 3.6 MBMaintenance 11 - Attachment 7 JDA AssessmentItem 45 · .PDF · 190 KBMaintenance 11 - Attachment 8 DOD AuditItem 46 · .PDF · 2.3 MBMaintenance 11- Attachment 9 DOD ResponseItem 47 · .PDF · 393 KBMaintenance 11 - Attachment 10 TOPS InspectionItem 48 · .PDF · 386 KBMaintenance 11 - Attachment 11 Cotter Pin ReferenceItem 49 · .PDF · 292 KBMaintenance 11 - Attachment 12 Malmrose Heli Services, Inc. Vendor QuestionnaireItem 50 · .PDF · 365 KBMaintenance 11 - Attachment 13 Report Showing Last Bolt Change N351WMItem 51 · .PDF · 144 KBMaintenance 11 - Attatchment 14 Eurocopter Flight Manual Section 8Item 52 · .PDF · 299 KBMaintenance 11 - Attachment 15 N37SH 100-hour Inspection RecordItem 53 · .PDF · 3.7 MBMaintenance 11 - Attachment 16 Torque Stripe TrainingItem 54 · .PDF · 4.6 MBMaintenance 11 - Attachment 17 Check Pilot TranscriptItem 55 · .PDF · 264 KBMaintenance 11 - Attachment 18 Day Mechanic TranscriptItem 56 · .PDF · 90 KBMaintenance 11 - Attachment 19 Engine Mechanic TranscriptItem 57 · .PDF · 72 KBMaintenance 11 - Attachment 20 Tail Rotor Area Mechanic TranscriptItem 58 · .PDF · 72 KBMaintenance 11 - Attachment 21 Main Rotor Area Mechanic Initial TranscriptItem 59 · .PDF · 76 KBMaintenance 11 - Attachment 22 Main Rotor Area Mechanic Follow-up TranscriptItem 60 · .PDF · 73 KB
All 94 files on NTSB’s docket

FAA reports on this event · 1

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