DFW06FA083

NTSB accident investigation · Bell 206L-1 · Patterson, LA · March 14, 2006

Accident · FatalField investigationFinal report
Date
March 14, 2006, 07:40 local (13:40 UTC)
Place
Patterson, LA
Injuries
2 fatal, 2 minor
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N370RLBell 206L-1
Weather
Visual (VMC) · Day
Status
Completed · report March 26, 2007
Report
Approved by Office Director
Parties
Bell Helicopter, Rolls Royce, Federal Aviation Administration, RotorCraft Leasing LLC
FAA report
20060314005549A
Case key
63337

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 improper installation of an engine fuel line fitting by other maintenance personnel, which resulted in a loose fitting and a loss of engine power during cruise flight. Factors associated with the accident are a tailwind, and the lack of a suitable site for a forced 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 powerCruise
Maintenance,installation - improperOther maintenance personnelCause
Fuel system,line fitting - looseCause
Forced landingEmergency descent/landing
Hard landingEmergency landing
Autorotation - performedPilot in command
Terrain condition - none suitable
Terrain condition - high vegetation
Weather condition - tailwindFactor

Analysis

Approximately 5 minutes after departing on a Title 14, CFR Part 135 air taxi cross-country flight, the helicopter had a loss of engine power while in cruise flight. The commercial helicopter pilot subsequently made a hard forced landing at an off-airport site comprised of tall vegetation and soft terrain. The helicopter came to rest in an upright position, and the two rear seat passengers were able to egress unassisted. Moments later, the helicopter was engulfed in flames. The wreckage path was oriented on a magnetic heading of 225 degrees, and the wind was reported as from 020 degrees at 12 knots. An examination of the engine at the accident site revealed that the fuel line to fuel nozzle "B" nut could be turned by hand, and did not contain a lock wire as required. All other fittings and nuts on the engine were found to be secure. A review of the helicopter's maintenance records revealed that a 50-hour fuel nozzle inspection was performed the evening prior to the accident flight. This inspection required the removal, disassembly, cleaning, inspection, reassembly, and reinstallation of the fuel nozzle. An interview with maintenance personnel revealed that fuel nozzle installation procedures found in the engine manufacturer's maintenance manual had not been followed. A tear down examination of the engine was performed. The engine examination revealed no preimpact anomalies. Investigators conducted operational tests on an engine of the same make and model. The tests were performed in an effort to determine what effect a loose fuel nozzle "B" nut would have on the engine's operation. The test revealed that the engine would experience a substantial loss of power that could conclude in a flame out. Testing further revealed that conditions would have been conducive for an in-flight fire. Investigators could not determine if the fire originated in-flight, or during the ground impact.

Factual narrative

History of flight

On March 14, 2006, about 0740 central standard time, a single-engine Bell 206L-1 helicopter, N370RL, was destroyed when it impacted terrain following a loss of engine power while in cruise flight near Patterson, Louisiana. The commercial pilot and one passenger were fatally injured and the two remaining passengers sustained minor injuries. The helicopter was registered to and operated by Rotorcraft Leasing Company (RLC), LLC, of Broussard, Louisiana. Visual meteorological conditions prevailed and a flight plan was not filed for the 14 Code of Federal Regulations Part 135 on-demand passenger flight. The 75-nautical mile cross-country flight originated from the Harry P Williams Memorial Airport (PTN) near Patterson, Louisiana, at 0735 and was destined for offshore platform Ship Shoal 216, located in the Gulf of Mexico.

According to a passenger who had been seated in the left rear seat of the helicopter, the pilot performed a preflight engine check before takeoff. The passenger stated that the takeoff appeared normal and they departed south from the airport at an approximate altitude of 500-700 feet above ground level (agl).

The passenger reported that as they began their flight to the south, the helicopter "dropped" several times. Each time the helicopter regained the lost altitude; however, it appeared to do so slowly as if "he, [the pilot], didn't have the power to keep it up." Moments later while over a wooded area, the front seat passenger looked back and said, "brace yourself." The pilot then made a descending right turn, of approximately 90 degrees, towards an open field. As they approached the ground, the pilot brought the nose of the helicopter up as if he was attempting to "slow down." The helicopter impacted the ground on the front left side and came to an abrupt stop in an upright position.

The passenger further reported that he unbuckled his lap belt and exited the left aft door of the helicopter into vegetation that was 7-8 feet tall. Once out of the helicopter he observed a small fire by the baggage compartment. A brief time later the helicopter was fully engulfed in flames. The passenger further reported that before ground impact "everything sounded normal and he didn't smell anything unusual."

The second surviving passenger was not available for an interview and did not provide a statement to the NTSB investigator-in-charge (IIC).

Pilot information

The pilot held a commercial pilot certificate with ratings for airplane single-engine land, helicopter, instrument airplane, and instrument helicopter ratings. His last Federal Aviation Administration (FAA) second-class medical was issued on September 19, 2005, with the limitation of "MUST HAVE AVAILABLE GLASSES FOR NEAR VISION."

The operator submitted a Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2). This report indicated the pilot had accumulated a total flight time of 12,545 hours. The pilot accumulated 213 hours in the last 90 days, and 91 hours in the last 30 days. He had 11,070 hours in this make and model of helicopter. His last recorded flight review was completed February 11, 2006.

Aircraft information

The 1980-model Bell 206L-1, serial number 45370, was powered by a 650-shaft horsepower Rolls-Royce Allison 250-C30P turbo shaft engine, serial number CAE 860171, driving a two-bladed main rotor system and a two-bladed tail rotor. There was no flight data recorder, cockpit voice recorder, or fire detection system installed on the helicopter, nor was there a requirement for them.

The helicopter was maintained in accordance with Aircraft Type Certificate Data Sheet number H2SW and the appropriate Bell model Maintenance Manual. The Bell model 206 series of RLC's Approved Aircraft Inspection Program (AAIP) requirements were:

1. 200-hour tail rotor gearbox and transmission oil change.

2. 600-hour hydraulic and facet filter bypass.

3. 7-day airframe inspection.

4. 3-month emergency equipment inspection.

5. 6-month float inspection.

6. 12-month main rotor mast internal inspection.

7. 24-month flight control bolt inspection.

In addition, the following airframe inspections were to be accomplished on RLC's Bell 206L-1:

1. Daily preflight inspection.

2. 100-hour airframe inspection.

3. 300-hour airframe inspection.

4. 1200-hour airframe inspection.

The AAIP further required that the Allison Model 250-C30P engine be maintained in accordance with Engine Type Certificate Data Sheet number E1GL, and engine life-limited parts be replaced in accordance with Allison Operation and Maintenance Manual 16W2. Engines parts that require overhaul were to be overhauled in accordance with Allison Overhaul Manual 14W3.

The engine inspections consisted of the following:

1. 50-hour fuel nozzle inspection

2. 150-hour engine inspection

3. 300-hour engine inspection

4. 300-hour engine oil change.

The maintenance records for N370RL were reviewed by the accident investigation team. No anomalies or unusual events were noted, and no open discrepancies or deferred items were listed in maintenance records at the time of the accident. From maintenance records, the airframe was estimated to have accumulated a total of 10,622 hours at the time of the accident, and the engine had accumulated a total of 20,614 hours.

The weight and balance was computed for the NTSB's investigator-in-charge (IIC), with estimated weight for crew, cargo, and fuel for determining center of gravity (CG). The result of the computation was that the aft, forward, and lateral CG ranges were within the limits.

Fueling records at Harry P Williams Memorial Airport established that the helicopter was last fueled on March 14, 2006, with the addition of 25 gallons of Jet A aviation fuel. A fuel sample was taken from the helicopter before the accident flight. Investigators found the fuel to be clear and bright with no anomalies noted. The fuel tested negative for water.

Meteorological information

At 0755, the weather observation facility at PTN, reported wind from 020 degrees at 12 knots, visibility 10 statute miles, clear of clouds, temperature 61 degrees Fahrenheit, dew point 37 degrees Fahrenheit, and a barometric pressure of 30.16 inches of Mercury.

Communications

There were no reported radio communications from the pilot after he departed PTN.

Wreckage and impact information

On site documentation of the wreckage was conducted by investigators from the National Transportation Safety Board, Federal Aviation Administration, Bell Helicopter, Rolls Royce, and Rotorcraft Leasing Company.

The wreckage was located in a soft field of tall "Roosevelt Cane", approximately three miles south of PTN. The Global Positioning System (GPS) coordinates recorded at the accident site were 29 degrees 39.625 minutes north latitude and 091 degrees 19.473 minutes west longitude, at a field elevation of approximately -12 feet mean sea level (msl). All major components were accounted for at the accident site.

The wreckage path was about 125 feet long, approximately 20 feet wide, and oriented along a measured heading of 225 degrees. The first point of ground impact was about 150 feet west of a line of deciduous trees. About five feet beyond the first impact scar was a six inch deep ground imprint, which resembled the shape of the helicopter's lower fuselage. Within this imprint were stubs of cane that were pushed over in the westerly direction. The partially burned remains of a landing gear cross tube and the right skid tube were found in this area.

The tail rotor blades, tail rotor gear box, tail cone, vertical stabilizer and various small pieces were found along the wreckage path in the area between the first ground impact and the main wreckage.

The main wreckage, consisting of the fuselage, engine, main rotor head, mast, transmission pylon, and the surviving sections of the main rotor blades, came t

Aircraft

Registration
N370RL
Reported as
Bell 206L-1
Category
Helicopter
Serial number
45370
Airframe hours
10,622
Engine
Allison 250-C30P, 650 horsepower, turbo shaft
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Registered owner
Rotorcraft Leasing Company LLC
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · March 1, 2006 · 30 hours before
Departed
PTN · Patterson, LA
Destination
Ship Shoal 216, GM
Airport
PTN · Harry P Williams Memorial

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
47
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, With waivers/limitations
Last flight review
February 1, 2006
Seat
Right
Toxicology
Performed
Flight hours
12,545 total · 11,070 in this make and model · 12,545 as pilot in command · 213 in the last 90 days · 91 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 37 °F
Altimeter
30.15 inHg
Observed at
PTN, 3 nm away

Docket · 17

The files NTSB released with the investigation on December 20, 2006, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.6 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.