ERA14LA223

NTSB accident investigation · Messerschmitt-Bolkow-Blohm BK 117 · Hamburg, NY · May 4, 2014

Accident · No injuriesLimited investigationFinal report
Date
May 4, 2014, 17:40 local (21:40 UTC)
Place
Hamburg, NY
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N504TJMesserschmitt-Bolkow-Blohm BK 117
Defining event
Enroute-cruise: Part(s) separation from AC
Weather
Visual (VMC) · Day
Status
Completed · report February 3, 2016
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA, Airbus Helicopters, Airbus Helicopters Inc.
FAA report
20140504008879I
Case key
89167

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

Wear in the left cabin door assembly parts, which resulted in the door partially opening in flight, dislodging from the lower door track assembly, and then separating from the helicopter.

Findings · 4

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.

Doors: passenger/crew doorsAircraft › Aircraft structures · Fatigue/wear/corrosionAll aircraft: 86 casesProbable cause
Doors: passenger/crew doorsAircraft › Aircraft structures · Incorrect service/maintenanceAll aircraft: 86 casesProbable cause
Doors: passenger/crew doorsAircraft › Aircraft structures · FailureAll aircraft: 86 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelAll aircraft: 167 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 reported that, during a repositioning flight of the emergency medical services helicopter and while at cruise altitude, the flight nurse notified him and the paramedic that the left cabin door had partially opened. As the flight nurse and paramedic were attempting to close the door, it dislodged from the lower track assembly, pivoted up, and struck the main rotor system; the door subsequently separated from the helicopter. The pilot then initiated a forced landing to a field. Examination of the door assembly revealed that both of the lower door's bracket guides and the aft lower catcher and guide assemblies were worn and that the door's upper sliders were worn down to their minimum tolerances. The Airplane Maintenance Manual states that, if one of the two sliders does not meet the minimum tolerance, "both sliders must be replaced with new ones." A review of the maintenance logbook revealed that the door assembly had been inspected 127 hours before the accident in accordance with an alert service bulletin but that no anomalies with the door assembly were noted at that time.

Factual narrative

On May 4, 2014, about 1740 eastern daylight time, a BK-117 A-4, N504TJ, was substantially damaged while in cruise flight near Hamburg, New York, after a cabin door separated from the helicopter and struck the main rotor blades. The commercial pilot and the two passengers were not injured. The helicopter was registered to and operated by Mercy Flight Incorporated under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Visual meteorological conditions prevailed and no flight plan was filed. The flight departed Women and Children's Hospital Heliport (7NK9), Buffalo, New York, at 1730. According to the pilot, the helicopter was in cruise flight at an altitude of 3,000 feet mean sea level (msl). The flight nurse alerted the pilot and flight paramedic that the left sliding door had opened several inches. The flight nurse and the flight paramedic then attempted to close the door, but as the pilot reduced the forward airspeed the lower portion of the door dislodged from the lower track assembly and pivoted up, striking the main rotor system. Upon contact with the main rotor system the door departed the airframe. The pilot initiated a forced landing to a baseball field, and the door was recovered for further examination. The pilot reported that the flight paramedic completed the walk-around and inspected doors for closure prior to sitting in the co-pilot seat and securing that door. The door caution lights were extinguished prior to takeoff and did not illuminated until the left sliding door opened at cruise altitude. A cursory examination of the door assembly by the operator revealed that the door was broken into several pieces. The airframe latch assembly did not reveal any anomalies. The door latch and spring assembly was examined and it was questioned by the operator that it may have failed. The operator also stated that they did not have engineers on staff to examine the door assembly latch. The left cabin door and the main rotor blades were examined at Airbus Helicopters Incorporated under supervision of the Federal Aviation Administration. The examination revealed that the main rotor blades were substantially damaged and the doors upper sliders exhibited excessive wear. Both lower door bracket guide assemblies were damaged from impact, and partially separated from the composite door structure. Both guide brackets on the door assembly were worn. The aft lower catcher and guide assemblies revealed impact damage, and were partially separated from the door structure. The catcher and guide assemblies revealed a 45 degree worn away section at the forward catch. Although the door latch was impact damaged, it appeared to operate properly. In accordance with Chapter 21, page 16B, of the Maintenance Manual MBB-BK117, the caution sections states, "if the minimum measure of 1.0 + 0.5 mm is not reached on one of the two sliders, both sliders must be replaced with new ones." The sliders were at the minimum tolerance level of 0.5mm. A review of the logbook excerpts revealed that the door assembly was inspected 127 hours prior to the accident in accordance with Alert Service Bulletin MBB-BK117 No. ASB-MBB-BK117-20-111. No anomalies were noted with the door assembly at the time of that inspection.

Aircraft

Registration
N504TJ
Reported as
Messerschmitt-Bolkow-Blohm BK 117 (A-4)
Category
Helicopter
Serial number
7138
Built
1971
Airframe hours
11,735
Engines
Honeywell LTS-101-650B1, 550 horsepower, turbo shaftHoneywell LTS-101-650B1, 550 horsepower, turbo shaft
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
Mercy Flight Inc
Registered owner
Mercy Flight Inc
Airworthiness certificate
Standard, Transport
Last inspection
100 hour · April 14, 2014
Departed
7NK9 · Buffalo, NY
Destination
5NK4 · Olean, NY
Flight plan
Company VFR
Equipment
Unknown

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
45
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
April 21, 2014
Seat
Right
Restraint
3-point
Flight hours
3,310 total · 365 in this make and model · 3,260 as pilot in command · 32 in the last 90 days · 12 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 10 knots
Visibility
10 statute miles
Lowest ceiling
4,200 ft overcast
Temperature
50 °F, dew point 37 °F
Altimeter
29.84 inHg
Observed at
BUF, 15 nm away

Docket · 10

The files NTSB released with the investigation on December 21, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.7 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.