# NTSB ERA15LA280: MD Helicopter 369FF, N5842Z, Vega Baja, PR, July 24, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: July 24, 2015, 09:45 local (13:45 UTC) - Place: Vega Baja, PR - Coordinates: 18.483055, -66.347503 - Nearby events: https://openairdocs.org/map.md?lat=18.4831&lon=-66.3475&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Puerto Rico Electric Power Authority, FAA/FSDO, MD Helicopters, Inc., Rolls Royce Engines - NTSB case key (mKey): 91625 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA280 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91625/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91625 - Page: https://openairdocs.org/ntsb/ERA15LA280 ## Probable cause A total loss of engine power due to insufficient lubrication to the engine's No. 2 bearing, which resulted in the failure of the bearing and a subsequent forced landing. ## 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 · Failure (probable cause); cases with it: [MD Helicopters 369FF, 1 case](https://openairdocs.org/ntsb-findings/01057230/cases.md?model=3030002), [All aircraft, 53 cases](https://openairdocs.org/ntsb-findings/01057230/cases.md) - [Engine (turbine/turboprop): oil system](https://openairdocs.org/ntsb-findings/01057261): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [MD Helicopters 369FF, 1 case](https://openairdocs.org/ntsb-findings/01057261/cases.md?model=3030002), [All aircraft, 16 cases](https://openairdocs.org/ntsb-findings/01057261/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [MD Helicopters 369FF, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=3030002), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [MD Helicopters 369FF, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=3030002), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [MD Helicopters 369FF, 2 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=3030002), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis About 20 minutes into a flight, the helicopter's engine experienced a total loss of power while at an altitude of about 300 ft above ground level. The pilot then entered an autorotative descent, and during the landing attempt, the helicopter impacted an area of shallow water near a beach and the fuselage was substantially damaged. Postaccident examination of the engine revealed that the No. 2 bearing had failed most likely as the result of a reduction in oil flow to the bearing. Examination of the tube that fed oil to the bearing revealed that it was unremarkable; however, its design had been superseded with an improved design for new helicopters several months before the accident. The newly designed tube was implemented to "decrease the bearing temperature and improve the bearing performance." ## Factual narrative On July 24, 2015, about 0945 Atlantic standard time, an MD Helicopters Inc. 369FF, N5842Z, was substantially damaged when it impacted shallow water near Vega Baja, Puerto Rico. The commercial pilot, pilot-rated passenger, and another passenger were not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the flight, which originated from Luis Munoz Marin International Airport (SJU), San Juan, Puerto Rico and was destined for Antonio (Nery) Juarbe Pol Airport (ABO), Arecibo, Puerto Rico. The work use flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The helicopter was operated by the Puerto Rico Electric Power Authority and was assisting with electrical power distribution system construction. The helicopter departed from SJU and proceeded to the work site, cruising at an altitude of 300 feet along the northern coastline of Puerto Rico. About 20 minutes into the flight, the pilot heard a loud "bang" emanate from the area of the engine, followed by a second bang 2 to 3 seconds later. The engine then experienced a total loss of power and the pilot responded by entering an autorotative descent. During the descent, the pilot recalled hearing and observing the "low engine rpm" annunciations. The helicopter subsequently impacted an area of shallow water near a beach. During the landing, the main rotor struck the tail boom, separating it from the fuselage. Examination of the engine revealed that the power section was not free to rotate, and borescope examination revealed thermal damage to the first stage turbine blades. The engine oil was drained, and examination of the oil and oil filter element revealed slivers and chips of ferrous metal. Detailed examination of the engine revealed that the No. 2 bearing was damaged. The bearing displayed evidence of thermal distress, spalling of the balls and races, and the ball separator was fractured. The oil delivery tube (also referred to as a "piccolo tube") that serviced the bearing with oil was installed and undamaged. Metallurgical examination of the No. 2 bearing showed a thermal distress pattern consistent with a possible reduction in oil flow to the bearing. The bearing's metallurgical composition was consistent with the material types specified in its design. X-ray examination of the bearing's oil delivery tube revealed no evidence of obstruction or restrictions; the inlet screen was absent of debris. The oil delivery tube installed in the accident engine was subject to a Commercial Engine Bulletin published by the manufacturer (CEB-72-3299), which was effective for all engines built before November 30, 2014. The bulletin stated that the reason for the part replacement was to, "…improve oil delivery to the #2 thrust bearing. This change will decrease the bearing temperature and improve the bearing performance." The bulletin further stated that it should be complied with the next time the engine's gearbox was at an authorizedrepair/overhaul facility and was disassembled for any reason. ## Aircraft - Registration: [N5842Z](https://openairdocs.org/aircraft/N5842Z), registered now, S/N 0137FF (OpenAirDocs) - Reported make and model: MD HELICOPTER INC 369FF - Registry model: [MD Helicopters 369FF](https://openairdocs.org/model/md-helicopters-369ff) (registry code 3030002) (OpenAirDocs) - Registry engine: [Allison 250-C30 series](https://openairdocs.org/engine/allison-250-c30-series) (registry code 03015, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 0137FF - Year built: 1999 - Airframe hours: 4961.2 - Engines: Rolls-Royce 250-C30 650 horsepower turbo shaft - Damage: Substantial damage - Flight: Other work use, Part 91 - Operator: Puerto Rico Electric Power Authority - Registered owner: Puerto Rico Electric Power Authority - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, March 12, 2015 - Departed: SJU, SAN JUAN, PR - Destination: ABO, ARECIBO, PR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: none; commercial; instrument ratings: helicopter; medical: class 2, with waivers/limitations; last flight review March 28, 2014; seat: left; restraint: 4-point; flight hours: 6,021 total, 657 in this make and model, 5,671 as pilot in command, 163 in the last 90 days, 52 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 70° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 75 °F - Altimeter: 30.12 inHg - Observed at: TJSJ, 19 nm away ## 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 20150724015779A](https://openairdocs.org/incident/20150724015779A), Jul 24, 2015: Md Helicopters Inc 369FF, Vega Baja, PR, Substantial damage. The flight departed from luis muÑoz marin international airport (sju) to a facility in arecibo, PR. While enroute at 300FT in the vicinity of cerro gordo, Vega… ## Docket (6 files) The files NTSB released with the investigation on October 16, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91625. 11.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4859926&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Engine oil analysis results (item 2, PDF, 3 pages, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4860047&FileExtension=pdf&FileName=Oil%20Test%20Results_Redacted-Rel.pdf - Investigation photographs (item 3, PDF, 5 pages, 5 photos, 948 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4858879&FileExtension=pdf&FileName=Investigation%20Photographs-Rel.pdf - Rolls-royce engine examination report (item 4, PDF, 5 pages, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4860038&FileExtension=pdf&FileName=Engine%20Examination%20Report%20-%20RR-Rel.pdf - Statement of party representatives to NTSB investigation (item 5, PDF, 6 pages, 8.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4860468&FileExtension=pdf&FileName=Party%20Forms%20-%20Signed_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 6, PDF, 1 page, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11146964&FileExtension=pdf&FileName=Wreckage%20Release%20-%20Final-Rel.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.