ERA17LA126

NTSB accident investigation · Eurocopter AS 350 · San Juan, PR · February 21, 2017

Accident · No injuriesLimited investigationFinal report
Date
February 21, 2017, 10:15 local (14:15 UTC)
Place
San Juan, PR
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Emergency descent
Aircraft
N413LPEurocopter AS 350
Defining event
Autorotation: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed · report January 25, 2018
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20170221001339A
Case key
94847

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

The flight instructor's incorrect manipulations of the twist grip throttle control during a practice autorotation, which resulted in an engine overspeed and subsequent fire.

Findings · 2

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.

Engine fuel and control: fuel controlling systemAircraft › Aircraft power plant · Incorrect use/operationEurocopter AS 350 B3: 1 caseAll aircraft: 59 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · Instructor/check pilotEurocopter AS 350 B3: 4 casesAll aircraft: 1,386 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/owner of the turbine helicopter was practicing autorotations with a flight instructor. After completing several autorotations uneventfully, the instructor asked if he could perform one, and the pilot agreed. Near the flare at the end of the maneuver, the pilot heard the engine overrev, followed by an Nr (rotor speed) aural warning, followed by a fire warning light illumination on the instrument panel. After landing, the pilot exited the helicopter with a fire extinguisher and attempted to extinguish an engine fire. Review of data downloaded from a vehicle-engine multifunction display and digital engine control unit revealed that the first failure recorded during the flight indicated that the gas generator rotation speed (N1) reached an out-of-limit value. At that time, the fuel regulation was in mixed mode, as the collective twist grip throttle control was out of the "flight" detent and the pilot was manually controlling the throttle. A second failure was recorded 2 seconds later, which indicated that the free turbine rotation speed (N2) reached an out-of-limit value. The failure was triggered by the maximum recorded value of 545 rpm, which equated to a turbine speed (Nr) of 140%. The engine's freewheeling turbine was designed to separate turbine blades at 150% Nr in order to prevent the turbine disc separating at 170% Nr. It is likely that the flight instructor excessively opened the fuel metering unit via the twist grip throttle manual control, which resulted in an engine overspeed, turbine blade separation, and subsequent engine fire.

Factual narrative

On February 21, 2017, about 1015 Atlantic standard time, an Airbus Helicopters (Eurocopter) AS 350 B3, N413LP, operated by the commercial pilot, was substantially damaged during a practice autorotation at Fernando Luis Ribas Dominicci Airport (TJIG), San Juan, Puerto Rico. The flight instructor and commercial pilot were not injured. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the flight that originated from TJIG about 0900.According to the flight instructor's written statement, he was the pilot-in-command for the flight and the commercial pilot/owner of the helicopter was practicing autorotations. During recovery from the last 180° autorotation, the flight instructor noticed that the engine rpm continued to increase and exceeded limitations, followed by a vibration in the helicopter. He then immediately landed on a grass area near a runway. After the landing, a mechanic told him that the helicopter's engine was on fire. The flight instructor completed the engine fire procedure and exited the helicopter. According to the commercial pilot's written statement, he had completed several training maneuvers and autorotations uneventfully. The flight instructor then asked if he could perform an autorotation and the commercial pilot agreed. During the flare at the end of the autorotation, the commercial pilot heard the engine overrev, followed by an Nr (rotor speed) aural warning, followed by a fire warning light illumination on the instrument panel. After landing, the commercial pilot exited the helicopter with a fire extinguisher and attempted to extinguish an engine fire. Review of airport security video revealed that the helicopter was descending to a grass area adjacent to the runway. About 30 feet above ground level, smoke began emitting from the helicopter and it climbed out of the video frame. It then descended back into the video frame and landed on the grass while smoke continued to emit from the helicopter. Examination of the helicopter by a Federal Aviation Administration inspector revealed that the fire resulted in damage to the engine deck support structure and a portion of the tail rotor drive shaft. A vehicle and engine multifunction display (VEMD), digital engine control unit (DECU), hydromechanical unit (HMU), and assembly valve were retained for examination and data download at the manufacturers' facilities under the supervision of the Bureau d'Enquetes et d'Analyses (BEA) in France. Examination and testing of the HMU and assembly valve did not reveal any anomalies that would have precluded normal engine operation. Review of data downloaded from the VEMD and DECU revealed that during the accident flight, the first failure recorded by both computers was an NG/N1 failure, respectively. The failure was recorded at 1 hour, 13 minutes, 18 seconds (1:13:18) into the 1-hour, 14-minute flight by the VEMD and1:13:27 by the DECU. The recorded failure indicated that the gas generator rotation speed (N1) reached an out of limit value. At that time, the fuel regulation was in mixed mode as the collective twist grip throttle control was out of the "flight" detent and the pilot was manually controlling the throttle. A second failure was recorded 2 seconds later, which indicated that the free turbine rotation speed (N2) reached an out of limit value. The failure was triggered by the maximum recorded value of 545 rpm, which equated to an Nr of 140%. According to a representative from the engine manufacturer, the engine's freewheeling turbine was designed for its turbine blades to separate at 150% turbine speed. The design was to prevent the turbine disc from separating at a turbine speed of 170%. During his examination of the engine, the representative observed evidence consistent with the turbine blades separating, resulting in an engine fire.

Aircraft

Registration
N413LP
Reported as
Eurocopter AS 350 (B3)
Category
Helicopter
Serial number
3228
Built
1999
Airframe hours
1,846
Engine
Turbomeca Arriel 2B, 871 horsepower, turbo shaft
Damage
Substantial damage
Fire
In-Flight
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 9, 2016 · 59 hours before
Departed
TJIG · San Juan, PR
Destination
TJIG · San Juan, PR
Airport
TJIG · Fernando Luis Ribas Dominicci
Equipment
Electronic multifunction display

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
37
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 1, Without waivers/limitations
Last flight review
September 20, 2016
Seat
Left
Restraint
3-point
Flight hours
6,250 total · 950 in this make and model · 5,500 as pilot in command · 280 in the last 90 days · 40 in the last 30 days · 3 in the last 24 hours
Role
Pilot
Age
74
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 1, With waivers/limitations
Last flight review
January 1, 2016
Seat
Right
Restraint
3-point
Flight hours
8,467 total · 5,200 in this make and model · 8,467 as pilot in command · 31 in the last 90 days · 12 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 6 knots, gusting 12
Visibility
8 statute miles
Lowest ceiling
5,500 ft broken
Temperature
73 °F, dew point 66 °F
Altimeter
29.95 inHg
Observed at
TJIG

Docket · 10

The files NTSB released with the investigation on October 30, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.1 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.

Other investigations on N413LP · 1

Matched to the same aircraft by N-number and date.