# NTSB ERA16LA265: Eurocopter Deutschland MBB BK 117 C-2, N145HN, Pittsburgh, PA, April 26, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 26, 2016, 15:00 local (19:00 UTC) - Place: Pittsburgh, PA - Coordinates: 40.461944, -79.944725 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.4619&lon=-79.9447&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: No injuries - Injuries: 5 uninjured - Status: Completed, report May 25, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 93663 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA265 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93663/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93663 - Page: https://openairdocs.org/ntsb/ERA16LA265 ## Probable cause Maintenance personnel’s failure to properly secure the left vertical fin cowling during recent maintenance, which resulted in its separation and subsequent contact with the tail rotor system during flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) - [Fuselage](https://openairdocs.org/ntsb-findings/01035300): Aircraft › Aircraft structures · Incorrect service/maintenance (probable cause); cases with it: [All aircraft, 4 cases](https://openairdocs.org/ntsb-findings/01035300/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) ## Analysis The accident flight, which was an on-demand air medical flight, was the second flight of the day following maintenance work that had been performed on the helicopter earlier that morning. The commercial pilot reported that the flight was uneventful but that, after landing, he noticed that the left vertical fin cowling had partially separated and contacted a tail rotor blade. Further examination of the helicopter revealed that the right vertical fin cowling remained secured but that 8 of the 11 fasteners on the left vertical fin cowling were unlocked, consistent with maintenance personnel not properly securing them following the maintenance work that was performed earlier that day. ## Factual narrative On April 26, 2016, about 1500 eastern daylight time, a Eurocopter Deutchland GMBH MBB-BK-117 C-2, N145HN, operated by Air Methods Corp, was substantially damaged during cruise flight to West Penn Hospital Heliport (PN80), Pittsburgh, Pennsylvania. The commercial pilot, three crewmembers and one patient were not injured. The on-demand air medical flight was conducted under the provisions of 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed and a company flight plan was filed for the flight that originated from Grafton City Hospital Heliport (22WV), Grafton, West Virginia, about 1430.The pilot reported that the patient transfer flight was the second flight of the day, following maintenance work that was performed on the helicopter earlier that morning. The patient transfer flight was uneventful; however, after landing the pilot noticed that the left vertical fin cowling had partially separated and came in contact with a tailrotor blade. The pilot added that 8 of the 11 fasteners on the left vertical fin cowling were unlocked. Examination of the tailrotor blade by representatives from the helicopter manufacturer revealed that the tailrotor blade had sustained substantial damage. Examination of the helicopter by a Federal Aviation Administration inspector revealed that the Dzus fasteners on the right vertical fin cowling remained secured while the Dzus fasteners on the left vertical fin cowling were unlocked, consistent with them not being properly secured by maintenance personnel following the maintenance work that was performed. Additionally, the operator reported that there were no mechanical failures or malfunctions with the helicopter. ## Aircraft - Registration: N145HN (not matched to a registry record) - Reported make and model: EUROCOPTER DEUTSCHLAND GMBH MBB BK 117 C-2 (C2) - Category: Helicopter - Serial number: 9302 - Year built: 2009 - Airframe hours: 3362 - Engines: Turbomeca Arriel 1E2 665 horsepower turbo shaft; Turbomeca Arriel 1E2 665 horsepower turbo shaft - Damage: Substantial damage - Flight: Part 135 - Operator: Air Methods Corp - Registered owner: Healthnet Aeromedican Services Inc - Airworthiness certificate: Standard, Transport - Last inspection: AAIP, April 22, 2016, 16 hours before - Departed: 22WV, Grafton, WV - Destination: PN80, Pittsburgh, PA - Flight plan: Company VFR - Airport: PN80, West Penn Hospital Heliport - Equipment: Satellite tracking device, Onboard weather, Electronic multifunction display, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: none; commercial; instrument ratings: helicopter; medical: class 2, without waivers/limitations; last flight review October 8, 2015; seat: right; restraint: 4-point; flight hours: 5,246 total, 478 in this make and model, 5,246 as pilot in command, 68 in the last 90 days, 28 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 16 knots - Visibility: 10 statute miles - Lowest ceiling: 5,000 ft broken - Temperature: 73 °F, dew point 55 °F - Altimeter: 29.73 inHg - Observed at: AGC, 8 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). - [Incident 20160426006189I](https://openairdocs.org/incident/20160426006189I), Apr 26, 2016: Eurocopter Deutschland Gmbh MBB-BK 117 C-2, Pittsburgh, PA, Minor damage. Pilot accomplished walk around prior to take off from west penn hospital, pilot discovered vertical fin cowling fasteners missing and damage on the tail rotor… ## Docket (3 files) The files NTSB released with the investigation on April 3, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93663. 2.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450607&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Interview Summary (item 2, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450608&FileExtension=.PDF&FileName=Interview%20Summary-Master.PDF - Photo Array (Courtesy of FAA) (item 3, .PDF, 3 photos, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450609&FileExtension=.PDF&FileName=Photo%20Array%20(Courtesy%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.