DFW06LA057

NTSB accident investigation · Agusta A109E · Fort Worth, TX · January 19, 2006

Accident · No injuriesLimited investigationFinal report
Date
January 19, 2006, 15:15 local (21:15 UTC)
Place
Fort Worth, TX
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Taxi
Aircraft
N142CFAgusta A109E
Weather
Visual (VMC) · Day
Status
Completed · report August 29, 2006
Report
Approved by Office Director
Parties
CareFlight - Director of Operations, Agusta Westland, Federal Aviation Administration, CareFlight - Director of Maintenance
FAA report
20060119001589A
Case key
63130

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 pilot's inadvertent encounter with ground resonance which resulted in the destruction of the helicopter.

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 control - on ground/waterTaxi
Ground resonance - inadvertentPilot in commandCause

Analysis

The 6,500-hour commercial helicopter rated pilot inadvertently encountered ground resonance while ground taxiing. The pilot performed a normal startup and prepared for ground taxi. He moved the helicopter forward and then started the helicopter in a 90-degree ground taxi turn at 30-degree intervals. He pushed on the toe brakes to stop the helicopter to give right of way to an aircraft taxiing down the taxiway. At this time the helicopter started to shake and bounce. Before the pilot could get the aircraft shutdown, the aircraft executed an uncommanded 90-degree turn to the left. The helicopter's main rotors and transmission assembly separated from the airframe. The wind at the time of the accident was reported to be from 170 degrees at 17 knots, gusting to 23 knots.

Factual narrative

On January 19, 2005, approximately 1515 central standard time, a twin-engine Augusta A109E turbo-shaft helicopter, N142CF, registered to North Central Texas Services of Grand Prairie, Texas, and operated by CareFlight of Grand Prairie, Texas, was substantially damaged while taxiing at the Fort Worth Meacham International Airport (FTW) near Fort Worth, Texas. The commercial pilot, sole occupant of the aircraft, was not injured. Visual meteorological conditions prevailed, and a company visual flight rules flight plan was filed for the repositioning flight conducted under 14 Code of Federal Regulations Part 91.

The 6,500-hour pilot reported in the Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1) that he performed a "normal startup and prepared for ground taxi. I started the aircraft forward then started the aircraft in a 90-degree ground taxi turn in 30-degree intervals. I pushed on the toe brakes to stop the aircraft to give right away for aircraft taxiing down the taxiway. At this time the aircraft started to shake. Before I could get the aircraft shutdown, the aircraft did a 90 degree turn to the left."

According to several witnesses, the helicopter was taxiing to the south and then stopped just as a fixed wing airplane was taxiing to the east into the ramp area for a fixed base operator. The helicopter began to shake and bounce very rapidly from side to side as if it were trying to roll about its longitudinal axis. The helicopter then turned 90-degrees to its left followed by the separation of the rotor and mast components and part of the upper fueslage, from the airframe. One of the witnesses stated that "the whole event probably took no more than 5 to 10 seconds."

Examination of the helicopter by a Federal Aviation Administration (FAA) inspector, who responded to the accident site, revealed that the helicopters main rotors and transmission assembly separated from the airframe. The main rotor actuator attachment fitting had separated into three pieces ( a left leg, right leg and fitting). All three pieces were retained for further examination.

On March 22, 2006, at the NTSB's Material Laboratory in Washington, D.C., an examination of the main rotor actuator attachment fitting was conducted by an NTSB metallurgist and representatives from the FAA, Agusta, and CareFlight.

A bench binocular microscope examination of the fracture face from the left leg revealed that the fracture was largely on a flat plane and had two distinct fracture regions. One of the regions had a woody, matte appearance typical of an overstress fracture region. The remainder of the fracture was heavily damaged from contact with the mating fracture surface and contained fracture lines oriented primarily in the forward/aft direction.

A scanning electron microscope (SEM) examination of the fracture face on the left leg revealed the "damaged region" contained mechanical damage that resulted from shear stress. The damaged portion of the fracture at one isolated area showed a feature that appeared similar to striations, but this striation-like feature was not found in other areas of the fracture or on the fracture face of the other separated leg. The striation-like feature also resembled the highly textured fracture features in the overstress region. The fracture face did not contain any other features that are typical of a fatigue crack (such as radial marks that point to a fatigue origin, crack arrest bands, thumbnail shaped crack regions, or a terminus of a fatigue region). During the SEM examination, areas of undamaged features were found near the top of the fracture in the left leg. These areas contained a highly textured surface with features that were oriented parallel to the length of the leg and ductile dimple features typical of overstress separation.

The right leg portion showed fracture features that were similar to those found on the left leg.

At 1453, the automated surface observing system (ASOS) at FTW reported the wind from 170 degrees at 17 knots, gusting to 23 knots, visibility 10 statute miles, clear sky, temperature 73 degrees Fahrenheit, dew point 44 degrees Fahrenheit and a barometric pressure of 29.87 inches of Mercury.

Aircraft

Registration
N142CF
Reported as
Agusta A109E
Category
Helicopter
Serial number
11141
Airframe hours
1,766
Engines
Pratt & Whitney PW-206C, 950 horsepower, turbo shaftPratt & Whitney PW-206C, 950 horsepower, turbo shaft
Damage
Substantial damage
Flight
Positioning · Part 91
Registered owner
North Central Texas Services
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · January 1, 2006
Departed
KFTW · Fort Worth, TX
Destination
KGPM · Grand Prairie, TX
Flight plan
Company VFR
Airport
KFTW · Ft Worth International Airport

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
36
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
October 1, 2005
Seat
Right
Flight hours
6,500 total · 250 in this make and model · 5,500 as pilot in command · 40 in the last 90 days · 15 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 17 knots, gusting 23
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 45 °F
Altimeter
29.87 inHg
Observed at
KFTW

Docket · 3

The files NTSB released with the investigation on May 15, 2006, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.2 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 N142CF · 1

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