- 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.
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.