DEN08LA138

NTSB accident investigation · Bell 206L-1 · Heber Springs, AR · August 11, 2008

Accident · No injuriesLimited investigationFinal report
Date
August 11, 2008, 15:30 local (20:30 UTC)
Place
Heber Springs, AR
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N832AHBell 206L-1
Defining event
Maneuvering: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report January 29, 2009
Report
Approved by Office Director
Parties
Federal Aviation Administration
Case key
68680

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 improper installation of the PC line on the engine which resulted in a partial loss of engine power. Contributing to the accident was the trees encountered during the forced landing.

Findings · 3

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.

Engine fuel and control: fuel controlling systemAircraft › Aircraft power plant · Incorrect service/maintenanceAll aircraft: 59 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelAll aircraft: 371 casesProbable cause
TerrainEnvironmental issues › Physical environment · Contributed to outcomeAll aircraft: 267 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 helicopter had been conducting external load operations on the day of the accident and had just departed after refueling. While transporting an empty container on the long line at 300 feet above ground level, the engine "spooled down". The pilot released the external load, executed a 180-degree turn and autorotation. During the forced landing, the helicopter landed hard in a tree farm and impacted trees, rolled over and came to rest on its right side. The pilot shut off the fuel and exited the helicopter. Examination of the engine showed the PC line B-nut was found disconnected. The last engine maintenance which involved the removal and reinstallation of the PC line was 67.1 hours prior, during a scheduled turbine change. No slippage marks (torque paint) were noted on the fitting. The engine manufacturer's maintenance manual procedures document the proper installation procedures, which include slippage markings.

Factual narrative

On August 11, 2008, approximately 1530 central daylight time, a Bell 206L-1 single-engine helicopter, N832AH, sustained substantial damage during a forced landing following a partial loss of engine power while maneuvering near Heber Springs, Arkansas. The airline transport pilot, who was the sole occupant, was not injured. The helicopter was registered to and operated by Hillsboro Aviation Inc., Hillsboro, Oregon. Visual meteorological conditions prevailed, and a flight plan was not filed for the Title 14 Code of Federal Regulations Part 133 external load flight. The flight departed a remote heli-spot location approximately 20 minutes prior the accident.

According to the operator, the helicopter had been conducting external load operations on the day of the accident and had just departed after refueling. While transporting an empty container on the long line at 300 feet above ground level, the engine "spooled down". The pilot released the external load, executed a 180-degree turn and autorotation. During the forced landing, the helicopter landed hard in a tree farm and impacted trees, rolled over and came to rest on its right side. The pilot shut off the fuel and exited the helicopter. Examination of the helicopter revealed the tail boom was separated, the main rotor blades were bent, and the right side of the fuselage was damaged.

A Federal Aviation Administration inspector, who spoke with a company mechanic, reported that a PC line B-nut was found disconnected on the Rolls Royce 250-C30P engine. The mechanic reported that the last engine maintenance which involved the removal and reinstallation of the PC line was 67.1 hours prior, during a scheduled turbine change. No slippage marks (torque paint) were noted on the fitting.

According to the Rolls Royce 250-C30 Series Operation and Maintenance manual, section 72-00-00, "Proper tightening of engine tubing connections is critical to flight safety...Tubing B-nuts used in installations exposed to a high degree of vibration and pressure surges are subject to torque relaxation when improperly tightened...Old slippage marks (torque paint) shall be completely removed, using torque paint remover, and reapplied each time the B-nut is tightened."

In 1990 (Revision 1, dated February 5, 2007), Rolls Royce issued an "Alert Commercial Service Letter: Maintenance Warning - External Lines". The letter background states that Rolls Royce continues to be involved in investigations of aircraft accidents and incidents which are attributed to improper alignment, clamping, and torquing of engine tubing during installation. The letter documents examples and causes of the failures of tube assemblies.

Aircraft

Registration
N832AH
Reported as
Bell 206L-1
Category
Helicopter
Serial number
45560
Airframe hours
9,504
Engine
Rolls-Royce 250-C30P, 726 horsepower, turbo shaft
Damage
Substantial damage
Flight
External load · Part 133
Registered owner
Hillsboro Aviation Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · August 1, 2008
Departed
Heber Springs, AR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
67
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
April 1, 2008
Seat
Right
Flight hours
21,000 total · 6,000 in this make and model · 228 in the last 90 days · 94 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
90° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 66 °F
Altimeter
29.90 inHg