# NTSB ERA14LA248: Bell Helicopter Textron Canada 206 L4, N55SL, Beverly, MA, May 21, 2014 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: May 21, 2014, 10:11 local (14:11 UTC) - Place: Beverly, MA - Coordinates: 42.584167, -70.916114 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.5842&lon=-70.9161&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report October 19, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: TSB, Rolls-Royce Corporation, Bell Helicopter, FAA FSDO - NTSB case key (mKey): 89241 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA248 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89241/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89241 - Page: https://openairdocs.org/ntsb/ERA14LA248 ## Probable cause Maintenance personnel’s inadequate inspection of the engine’s outer combustion case, which resulted in the failure of the case due to fatigue cracks that initiated on the inside surface of the case and the subsequent total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (turbine/turboprop): compressor section](https://openairdocs.org/ntsb-findings/01057230): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Bell Helicopter Textron Canada 206L-4, 1 case](https://openairdocs.org/ntsb-findings/01057230/cases.md?model=1181455), [All aircraft, 53 cases](https://openairdocs.org/ntsb-findings/01057230/cases.md) - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Bell Helicopter Textron Canada 206L-4, 1 case](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=1181455), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) - [Maintenance/inspections: scheduled maint checks](https://openairdocs.org/ntsb-findings/01010520): Aircraft › Aircraft handling/service · Inadequate inspection (probable cause); cases with it: [Bell Helicopter Textron Canada 206L-4, 1 case](https://openairdocs.org/ntsb-findings/01010520/cases.md?model=1181455), [All aircraft, 76 cases](https://openairdocs.org/ntsb-findings/01010520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Bell Helicopter Textron Canada 206L-4, 1 case](https://openairdocs.org/ntsb-events/050/sequence.md?model=1181455), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Bell Helicopter Textron Canada 206L-4, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=1181455), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Autorotation: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Bell Helicopter Textron Canada 206L-4, 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1181455), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Bell Helicopter Textron Canada 206L-4, 3 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=1181455), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis The pilot reported that, shortly after the helicopter lifted off, the engine abruptly lost all power. The pilot attempted an autorotation to a taxiway but chose to land in the grass adjacent to it when it became apparent that the helicopter would not reach the taxiway. During the flare and landing, the main rotor blades contacted the tail boom, severing it just aft of the horizontal stabilizer. The helicopter then came to rest on its skids. An initial examination of the engine revealed that the outer combustion case was ruptured in one of the two elbow areas. Subsequent examination revealed that the combustion case failed due to fatigue cracks that had initiated on the inside surface of the case along an aft horizontal butt weld line. The fractured weld line was located where a wire mesh reinforcement patch was brazed to the case. The fracture extended outward along the weld line toward the neighboring flanges and progressed along a portion of the flange joints; the fracture surface outside the case butt weld exhibited overstress tearing. A review of maintenance log entries revealed that the most recent 150-hour inspection, which included a procedure to detect outer combustion case cracks, was performed on the engine about 41.5 hours (engine operating time) before the accident when the engine had 11,142 total flight hours, and no anomalies were noted. It is likely that maintenance personnel did not adequately inspect the engine at that time, which resulted in their failure to detect the fatigue cracks in the combustion case. ## Factual narrative On May 21, 2014, about 1011 eastern daylight time, a Bell 206L-4, N55SL, landed hard following a total loss of engine power during initial climb at Beverly Municipal Airport (BVY), Beverly, Massachusetts. The commercial pilot and one passenger were not injured, and the helicopter was substantially damaged. The helicopter was operated by Helicopters, Inc. under the provisions of Title 14 Code of Federal Regulations Part 91. Day, visual meteorological conditions prevailed for the aerial observation flight, and no flight plan was filed. The local flight was originating at the time of the accident.According to the pilot, he was assigned to fly a photographer with a local news station to the Watertown, Massachusetts area to respond to a truck accident. The helicopter was parked on a trailer and the preflight and engine start portions of the flight were normal. After checking the local wind conditions, the flight was cleared to depart by air traffic control tower personnel. Shortly after takeoff, the engine "suddenly and abruptly" lost all power. The pilot attempted an autorotation to a taxiway, but chose to land in the grass adjacent to the taxiway when it became apparent the he would not make the taxiway. During the flare and landing, the main rotor blades contacted the tail boom, severing it just aft of the horizontal stabilizer. The helicopter came to rest on the landing gear skids and the pilot and passenger exited the aircraft. An inspector with the Federal Aviation Administration responded to the accident site and examined the wreckage. The engine examination revealed that the combustion section outer case (OCC) was ruptured in one of two elbow, or "armpit" areas. A review of maintenance logbook entries revealed that the most recent 150-hour inspection was performed on the engine on April 12, 2014. About 41.5 hours had accrued on the engine since this inspection. The total time on the engine at the time of this inspection was 11,142 hours. The inspection included a detailed visual inspection followed by a Leak-Teck or fluorescent penetrant inspection. A general condition inspection of the OCC was also required as part of the post-flight inspection. No anomalies were noted. The OCC was removed from the engine and forwarded to the NTSB Materials Laboratory for examination. The OCC contained a rupture aft of the left armpit. The rupture was manifested as case material protruding outward, with the mating fracture surfaces located along a horizontal butt weld line of the case. This fractured weld line was located where a wire mesh reinforcement patch was brazed to the case. The fracture extended into the braze joint around the left connecting flange and the butt weld of the center connecting flange. Much of the fracture surface along the flange joints outside the case butt weld exhibited a 45-degree slant consistent with overstress fracture. The fracture surface along the case weld exhibited a relatively flat orientation. The weld fracture surfaceexhibited crack arrest marks and ratchet marks consistent with progressive fracture. In the progressive regions, the fracture surface appeared dark with visible crack arrest marks, which were more visibly evident towards the periphery. The portions of the fracture surface outside the butt weld exhibited a brighter luster, but still exhibited crack arrest features. Using a measurement standard for comparison, the thickness of the case was measured along the progressive regions of the fracture surface. The thickness of the case averaged 0.027 inches. An examination of the opposite braze patch revealed small cracks present on the outside surface. These were consistent with smaller versions of outer surface defects observed on the fractured braze patch. Examination of the initiation area revealed the fatigue cracks started on the inside face of the case weld at multiple crack initiation sites. No material defects, such as pores or inclusions were found at these initiation sites. At the end of the fatigue crack in the weld, features that appeared to represent transition to other failure modes were also found to contain fatigue striations microscopically. Fatigue striations were present outside the main weld line. Outside the fatigue regions, dimple rupture, which was indicative of overstress failure, was observed. ## Aircraft - Registration: [N55SL](https://openairdocs.org/aircraft/N55SL), registered now, S/N 52347, built 2007 (OpenAirDocs) - Reported make and model: BELL HELICOPTER TEXTRON CANADA 206 L4 - Registry model: [Bell Helicopter Textron Canada 206L-4](https://openairdocs.org/model/bell-helicopter-textron-canada-206l-4) (registry code 1181455) (OpenAirDocs) - Registry engine: [Allison 250-C30P](https://openairdocs.org/engine/allison-250-c30p) (registry code 03099, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 52347 - Year built: 2007 - Airframe hours: 3162 - Engines: ALLISON 250-C30P 650 horsepower turbo shaft - Damage: Substantial damage - Flight: Aerial observation, Part 91 - Operator: Helicopters Inc - Registered owner: Helicopters Inc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, April 14, 2014, 41 hours before - Departed: BVY, Beverly, MA - Destination: Watertown, MA - Airport: BVY, Beverly Municipal Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: none; commercial, flight instructor; instrument ratings: helicopter; medical: class 2, without waivers/limitations; last flight review November 21, 2013; seat: right; restraint: 3-point; flight hours: 14,431 total, 10,555 in this make and model, 14,121 as pilot in command, 115 in the last 90 days, 35 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 52 °F - Altimeter: 29.98 inHg - Observed at: BVY ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20140521007809A](https://openairdocs.org/incident/20140521007809A), May 21, 2014: Bell Helicopter Textron Canada 206L-4, Beverly, MA, Substantial damage. At approximately 1011 local time on may 21, 2014, N55SL a Bell 206 L4 (serial number 52347) was scheduled to operate as a news gathering flight in the… ## Docket (10 files) The files NTSB released with the investigation on September 23, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89241. 16.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 5.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431962&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Excerpts – Maintenance Records (item 2, .PDF, 693 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431963&FileExtension=.PDF&FileName=Excerpts%20%E2%80%93%20Maintenance%20Records-Redacted.PDF - Excerpts – Rolls-Royce Maintenance Manual (item 3, .PDF, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431964&FileExtension=.PDF&FileName=Excerpts%20%E2%80%93%20Rolls-Royce%20Maintenance%20Manual-Master.PDF - Rolls-Royce Commercial Service Letter (item 4, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431965&FileExtension=.PDF&FileName=Rolls-Royce%20Commercial%20Service%20Letter-Master.PDF - Certification of Party Representatives (item 5, .PDF, 318 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431966&FileExtension=.PDF&FileName=Certification%20of%20Party%20Representatives-Redacted.PDF - Materials Laboratory Factual Report (item 6, .PDF, 21 photos, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431967&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report-Master.PDF - Evidence Control (item 7, .PDF, 394 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431968&FileExtension=.PDF&FileName=Evidence%20Control-Redacted.PDF - Comments from TSB and Transport Canada (item 8, .PDF, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431969&FileExtension=.PDF&FileName=Comments%20from%20TSB%20and%20Transport%20Canada-Master.PDF - Photo 1 –Main Wreckage (Photo Courtesy of FAA) (item 9, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431970&FileExtension=.PDF&FileName=Photo%201%20%E2%80%93Main%20Wreckage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 2 – OCC Damage (Photo Courtesy of FAA) (item 10, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431971&FileExtension=.PDF&FileName=Photo%202%20%E2%80%93%20OCC%20Damage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.