# NTSB ERA19LA273: Robinson R44, N827JE, Sardis, GA, September 17, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: September 17, 2019, 12:30 local (16:30 UTC) - Place: Sardis, GA - Coordinates: 33.028057, -81.78778 - Nearby events: https://openairdocs.org/map.md?lat=33.0281&lon=-81.7878&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Lycoming Engines, FAA/FSDO - NTSB case key (mKey): 100282 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA273 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100282/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100282 - Page: https://openairdocs.org/ntsb/ERA19LA273 ## Probable cause Fatigue failure of the fasteners on the engine crankshaft, which resulted in a partial loss of engine power and a subsequent forced landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng rear section](https://openairdocs.org/ntsb-findings/01058540): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Robinson Helicopter R44, 2 cases](https://openairdocs.org/ntsb-findings/01058540/cases.md?model=7640120), [All aircraft, 42 cases](https://openairdocs.org/ntsb-findings/01058540/cases.md) - [Power plant](https://openairdocs.org/ntsb-findings/01057100): Aircraft › Aircraft power plant · Not serviced/maintained; cases with it: [Robinson Helicopter R44, 1 case](https://openairdocs.org/ntsb-findings/01057100/cases.md?model=7640120), [All aircraft, 198 cases](https://openairdocs.org/ntsb-findings/01057100/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel; cases with it: [Robinson Helicopter R44, 4 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=7640120), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Robinson Helicopter R44, 10 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7640120), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Autorotation: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Robinson Helicopter R44, 56 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7640120), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The helicopter was about 100 ft above ground level during an aerial application fight when the engine experienced a partial loss of power. The pilot performed an autorotation and the helicopter impacted trees and terrain. Postaccident examination of the engine revealed that the crankshaft idler gear flange, which should have been secured to the left half of the crankcase by a bolt and stud, had separated from its mounting location. Worn fragments of the bolt and stud were recovered from the oil sump. Metallurgical examination of the fasteners revealed that they failed due to rotating bending fatigue, which allowed the crankshaft idler gear to disengage and resulted in a loss of engine power. A review of maintenance records revealed that the engine had been in service for about 20 years and 1,900 operating hours since its last major overhaul, which is 8 years and 400 hours beyond the manufacturer recommended time between overhauls. ## Factual narrative On September 17, 2019, about 1230 eastern daylight time, a Robinson R44, N827JE, was substantially damaged when it was involved in an accident near Sardis, Georgia. The pilot was seriously injured. The helicopter was operated as Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot reported that he was flying about 100 ft above ground level, applying spray, when he heard a "pop," followed by alarms and lights activating in the cockpit. The helicopter then lost engine power and the pilot performed an autorotation. During the autorotation, the helicopter impacted trees and terrain. Examination of the helicopter by a Federal Aviation Administration inspector revealed that it came to rest on its left side. The inspector observed damage to the fuselage and the tail boom had separated. Subsequent teardown examination of the engine revealed that the left crankshaft idler gear was not engaged in the teeth of the crankshaft gear or the camshaft gear. The idler gear was removed and the idler gear shaft was observed not attached to its left crankcase half mounting location. According to an engine diagram, the idler gear shaft was supposed to secured to the left crankcase half by a bolt and a crankcase stud. Worn fragments of the bolt and crankcase stud, along with the stud nut and fragments of safety wire, were recovered from the oil sump. Metallurgical examination revealed evidence of wear on crankshaft idler gear, shaft flange, and gear shaft fasteners (bolt and stud). The worn gear shaft fasteners exhibited a rotating bending fatigue failure (for more information, see Materials Laboratory Factual Report in the public docket for this accident). According to maintenance records and information from the operator, the engine had been operated for about 1,900 hours over a 20-year-period since major overhaul. Review of Lycoming Service Instruction (SI) 1009BD, superseded by SI 1009BE, revealed a recommended time between overhauls as 12 calendar years or 1,500 hours of operation in the case of engines used in crop dusting or other chemical application, whichever occurs first. ## Aircraft - Registration: [N827JE](https://openairdocs.org/deregistered/N827JE-2022-05-09), registration cancelled 2022-05-09, S/N 0153, built 1995 (OpenAirDocs) - Reported make and model: Robinson R44 (Undesignat) - Registry model: [Robinson Helicopter R44](https://openairdocs.org/model/robinson-helicopter-r44) (registry code 7640120) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 0153 - Year built: 1995 - Airframe hours: 3700 - Engines: Lycoming O-540-F1B5 250 horsepower reciprocating - Damage: Substantial damage - Flight: Aerial application, Part 137 - Operator: Rowland Air Chem Llc - Registered owner: Rowland Air Chem Llc - Airworthiness certificate: Special, Restricted (Special) - Last inspection: Annual, May 4, 2020 - Departed: Sardis, GA - Destination: Sardis, GA - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: serious; commercial; medical: class 2, without waivers/limitations; last flight review April 20, 2019; seat: right; restraint: 3-point; flight hours: 4,000 total, 400 in this make and model, 4,000 as pilot in command, 150 in the last 90 days, 50 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 93 °F, dew point 63 °F - Altimeter: 29.97 inHg - Observed at: 2J5, 10 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 20190917021859A](https://openairdocs.org/incident/20190917021859A), Sep 17, 2019: Robinson Helicopter R44, Sardis, GA, Substantial damage. Pilot stated he was spraying edges of tract when the he heard a pop sound from the aircraft and alarms and lights went off. He stated he lost power and… ## Docket (7 files) The files NTSB released with the investigation on August 28, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100282. 5.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 470 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486390&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=40486391&FileExtension=.PDF&FileName=Interview%20Summary-Master.PDF - Excerpt From Maintenance Records (item 3, .PDF, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486392&FileExtension=.PDF&FileName=Excerpt%20From%20Maintenance%20Records-Master.PDF - Lycoming Service Instruction 1009BE (item 4, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486393&FileExtension=.PDF&FileName=Lycoming%20Service%20Instruction%201009BE-Master.PDF - Photo Array (item 5, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486394&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - 20-019 Materials Lab Factual Report for ERA19LA273 (item 6, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486395&FileExtension=.PDF&FileName=20-019%20Materials%20Lab%20Factual%20Report%20for%20ERA19LA273-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 310 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486396&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-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.