ERA11IA091

NTSB incident investigation · Eurocopter Deutschland MBB-BK 117 C-1 · Boston, MA · December 4, 2010

Incident · No injuriesIncident investigationFinal report
Date
December 4, 2010, 09:00 local (14:00 UTC)
Place
Boston, MA
Injuries
4 uninjured
Damage
Minor damage
Phase of flight
Approach
Aircraft
N271NEEurocopter Deutschland MBB-BK 117 C-1
Defining event
Approach: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed · report January 17, 2012
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, FAA/Rotorcraft Directorate
FAA report
20101204052739I
Case key
78008

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

On this page

Probable cause

Improper installation of wiring associated with a medical cabinet interior, which resulted in chafing and a subsequent in-flight fire. Contributing to the incident was inadequate maintenance procedures for continued airworthiness.

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.

Maintenance: modification/alterationPersonnel issues › Task performance · Maintenance personnelEurocopter Deutschland MBB-BK 117 C-1: 1 caseAll aircraft: 69 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

During the air ambulance flight, the helicopter was on final approach to land when smoke and flames were observed emanating from the suction control mounted on the left side of the cabin. The fire was subsequently extinguished, and the pilot landed the helicopter without further incident. Postincident examination revealed fire damage on the face of an overhead medical cabinet that was part of a medical interior installed about 7.5 years prior to the incident per a supplemental type certificate. A sheathed wiring bundle for a 120-volt alternating current power outlet mounted in the aft end of the cabinet displayed chafing damage and arcing consistent with rubbing on the metal housing for the vacuum control switch. The wiring was installed without adequate clearance or support to prevent it from chafing on the switch housing. The helicopter was maintained under an approved inspection program; however, review of the instructions for continued airworthiness associated with the medical cabinet installation did not reveal any required inspections of the associated wiring harnesses for general condition or chafing.

Factual narrative

On December 4, 2010, about 0900 eastern standard time, a Eurocopter Deutschland GMBH, MBB-BK117-C1, N271NE, sustained minor damage when it experienced an in-flight electrical fire, while on approach to the Brigham & Women's Hospital Heliport (MA39), Boston, Massachusetts. The helicopter was owned by New England Life Flight, doing business as Boston MedFlight, and operated by ERA Med LLC, as an air ambulance flight conducted under the provisions of 14 Code of Federal Regulations Part 135. The airline transport pilot, flight nurse, flight paramedic, and patient were not injured. Visual meteorological conditions prevailed and a company flight plan had been filed for the flight that departed from Oak Bluffs, Massachusetts. According to the flight nurse, the helicopter was on final approach to land, when she noticed "a smell" followed by smoke and flames emanating from the suction control mounted on the left side of the cabin. She notified the pilot and discharged a fire extinguisher, which extinguished the fire. The pilot landed the helicopter without further incident. He subsequently noted obvious fire damage on the left cabin wall near the suction device control switch and the liquid oxygen gauge. Post incident inspection by a Federal Aviation Administration (FAA) inspector revealed fire damage on the face of the overhead medical cabinet around the vacuum control switch. The cabinet was part of a medical interior that was installed per a supplemental type certificate (STC) during May 2003, and housed a vacuum regulator, vacuum pump switch, liquid oxygen quantity indicator and 120-volt alternating current (AC) electrical outlets. A sheathed wiring bundle for the 120-volt AC power outlet mounted in the aft end of the cabinet displayed chafing damage and arching consistent with rubbing on the metal housing for the vacuum control switch. In addition, an approximate 2-inch portion of composite material, which surrounded the switch, was consumed by fire. Additional examination was performed by an FAA inspector, who reported that the wiring was installed without adequate clearance or support to prevent it from chafing on the switch housing. The electrical power to the outlets was supplied by a KGS Electronics SPS-1607A medical inverter system, which was installed per an STC during June 2003. Review of the instructions for continued airworthiness associated with the medical cabinet installation did not reveal any required inspections of the associated wiring harnesses for general condition or chafing. The helicopter was maintained under an FAA approved inspection program and had been operated for approximately 254 hours since its most recent 300 hour/12 month inspection, which was performed on August 12, 2010. Item 24 on the inspection checklist included: "Visually inspect inverter and mounting for damage, security and electrical connections" and "Test medical inverter for proper operation," with a reference to the KGS-SPS-1607A Removal/InstallationManual. Review of the KGS-SPS-1607A Removal/Installation Manual revealed instructions for removal and installation. Under instructions for maintenance, the manual stated "No regular periodic maintenance is required for this product. Service is required only when a malfunction is detected. Maintenance consists of removal and replacement." An FAA check of service difficulty reports for the BK117 did not reveal any previous instances of fires associated with the medical cabinet installation. FAA Advisory Circular AC65-15A, Airframe and Powerplant Mechanics Airframe Handbook, Chapter 11, Aircraft Electrical Systems, Protection Against Chafing, stated in part: "Wires and wire groups should be protected against chafing or abrasion in those locations where contact with sharp surfaces or other wires would damage the insulation. Damage to the insulation can cause short circuits, malfunction, or inadvertent operation of equipment…."

Aircraft

Registration
N271NE
Reported as
Eurocopter Deutschland MBB-BK 117 C-1
Category
Helicopter
Serial number
7543
Airframe hours
4,959
Engines
Turbomeca Ariel 1E2, 738 horsepower, turbo shaftTurbomeca Ariel 1E2, 738 horsepower, turbo shaft
Damage
Minor damage
Fire
In-Flight
Flight
Part 135
Operator
ERA Med LLC, doing business as Boston MedFlight
Registered owner
New England Life Flight Inc
Airworthiness certificate
Standard, Utility
Last inspection
AAIP · December 1, 2010 · 254 hours before
Departed
Oak Bluffs, MA
Destination
MA39 · Boston, MA
Flight plan
Company VFR
Airport
MA39 · Brigham & Women's Hospital

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
35
Injuries
None
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 1, Without waivers/limitations
Last flight review
October 12, 2010
Seat
Right
Flight hours
4,465 total · 533 in this make and model · 4,121 as pilot in command · 47 in the last 90 days · 15 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 17 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
36 °F, dew point 19 °F
Altimeter
29.65 inHg
Observed at
BOS, 5 nm away

Docket · 13

The files NTSB released with the investigation on December 2, 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.