ERA10LA379

NTSB accident investigation · Garlick Helicopters OH-58A+ · Newport, TN · July 28, 2010

Accident · Minor injuriesLimited investigationFinal report
Date
July 28, 2010, 09:00 local (13:00 UTC)
Place
Newport, TN
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Standing
Aircraft
N48LAGarlick Helicopters OH-58A+
Defining event
Standing-engine(s) operating: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report June 20, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Bell Helicopter
FAA report
20100728039219A
Case key
76780

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

Inadequate maintenance inspections of the main rotor blade inertia screw holes, which resulted in a main rotor blade failure due to fatigue. Contributing to the accident was the pilot's inadequate preflight inspection of the main rotor blades.

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.

Main rotor system: main rotor blade systemAircraft › Aircraft propeller/rotor · Fatigue/wear/corrosionGarlick Helicopters OH-58A+: 1 caseAll aircraft: 60 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelGarlick Helicopters OH-58A+: 1 caseAll aircraft: 167 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotGarlick Helicopters OH-58A+: 1 caseAll aircraft: 551 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 pilot completed a preflight inspection and found no problems with the helicopter. He then completed a normal start procedure and increased the rpm to 100 percent flight idle. He was about to increase the collective, when he felt a violent shake, heard a loud noise, and the helicopter began to come apart. A postaccident examination of the wreckage revealed that an outboard 2-foot section of main rotor blade had separated. Metallurgical examination of the separated blade revealed that a fatigue crack originated from an inertia screw hole, located at the bottom surface of the spar portion of the main rotor blade. That crack propagated more than 50 percent of the spar cross section, before fracturing consistent with overstress. A manufacturer alert bulletin instructed operators to visually inspect the inertia screw hole locations on the blade spar with a 10X magnifying glass for cracks and corrosion every 8 hours of flight, or 32 cumulative flights. The outboard section of main rotor blade was secured with eight inertia screws. Although the inertia screw holes were supposed to receive a maintenance inspection every 8 flight hours, they were also a preflight inspection item for the pilot. Review of the helicopter's maintenance logbooks revealed an entry stating that the inertia screw holes had been inspected within the past 8 flight hours; however, corrosion was present in the inertia screw hole that failed. The corrosion and fatigue was most likely present for more than 8 flight hours.

Factual narrative

On July 28, 2010, about 0900 eastern daylight time, an experimental Garlick Helicopters OH-58A+, N48LA, operated by B & S Air Inc., was substantially damaged while standing in a field, with the engine operating, near Newport, Tennessee. The certificated commercial pilot incurred minor injuries. The aerial application flight was conducted under the provisions of 14 Code of Federal Regulations Part 137. Visual meteorological conditions prevailed and no flight plan was filed for the planned flight to Jackson, Tennessee. According to the pilot's written statement, he performed a normal preflight inspection and found no problems with the helicopter. He then completed a normal start procedure and increased rpm to 100 percent flight idle. The pilot was about to increase collective, when he felt a violent shake, heard a loud noise, and the helicopter began to come apart. He then saw the transmission and rotor blades on the ground in front of helicopter. He subsequently shut off the engine and exited the helicopter. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that an outboard 2-foot section of main rotor blade had separated. The transmission had also separated, which resulted in substantial damage to the fuselage. The separated section of main rotor blade was forwarded to the NTSB Materials Laboratory, Washington, DC, for further examination. Metallurgical examination revealed that a fatigue crack originated from an inertia screw hole, located at the bottom surface of the spar portion of the main rotor blade. That crack propagated more than 50 percent of the spar cross section, before fracturing consistent with overstress. The helicopter was manufactured in 1970 and delivered to the U.S. Army. In 1995, it was transferred from the U.S. Army to state law enforcement. The helicopter was subsequently equipped for agricultural application and issued an FAA experimental airworthiness certificate in 2005. According to maintenance records and the pilot, the helicopter's most recent 100-hour inspection was completed on June 15, 2010. At that time, the helicopter had accumulated approximately 6,704 total hours of operation. The helicopter had accumulated about 76 additional hours of operation, from the time of the last 100-hour inspection, until the accident. According to a representative from the helicopter manufacturer, Bell Military Alert Bulletin USA-OH-58-87-1 was issued on June 12, 1987, requesting military operators to visually inspect the inertia screw hole locations on the blade spar with a 10X magnifying glass for cracks and corrosion. The inspection should be done at every 8 hours of flight, or 32 cumulative flights. Subsequently, on April 12, 2007, Bell Operations Safety Notice OSN-GEN-07-38 was issued to all OH-58 operators and referenced the Bell Military Alert Bulletin. According to the FAA inspector, the outboard section of main rotor blade was secured with eight inertia screws. Although the inertiascrew holes were supposed to receive a maintenance inspection every 8 flight hours, they were also a preflight inspection item for the pilot. Review of the helicopter's maintenance logbooks revealed an entry stating that the inertia screw holes had been inspected within the past 8 flight hours with no anomalies noted; however, the inspector observed corrosion present in the inertia screw hole that failed.

Aircraft

Registration
N48LA
Reported as
Garlick Helicopters OH-58A+
Category
Helicopter
Serial number
70-15130
Engine
Allison C250-C20C, 420 horsepower, turbo shaft
Damage
Substantial damage
Flight
Aerial application · Part 137
Operator
B & S Air Inc
Registered owner
B & S Air Inc
Airworthiness certificate
Special, Experimental (Special)
Last inspection
100 hour · June 15, 2010 · 76 hours before
Departed
NONE · Newport, TN
Destination
NONE · Jackson, TN
Airport
NONE · None

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
22
Injuries
None
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
February 8, 2010
Seat
Right
Flight hours
400 total · 210 in this make and model · 380 as pilot in command · 4 in the last 90 days · 4 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 73 °F
Altimeter
30.12 inHg
Observed at
TYS, 30 nm away

Docket · 9

The files NTSB released with the investigation on May 5, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.4 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.