ERA20CA135

NTSB accident investigation · AugustaWestland AW119MKII · Philadelphia, PA · March 21, 2020

Accident · No injuriesData collectionFinal report
Date
March 21, 2020, 15:42 local (19:42 UTC)
Place
Philadelphia, PA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N982SSAugustaWestland AW119MKII
Defining event
Approach: Part(s) separation from AC
Weather
Visual (VMC) · Day
Status
Completed · report June 29, 2020
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Leonardo S.p.a, FAA/FSDO, ANSV, Agustawestland Philadelphia Corporation
FAA report
20200321009079A
Case key
101114

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 in-flight failure of the lower left side of the engine cowling due to the mechanic’s improper installation of the fasteners, which resulted in the cowling impacting all four main rotor blades.

Findings · 3

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.

Misc hardware: fastenersAircraft › Fluids/misc hardware · Incorrect service/maintenanceAgustawestland Philadelphia AW119MKII: 1 caseAll aircraft: 58 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelAgustawestland Philadelphia AW119MKII: 1 caseAll aircraft: 371 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 and the flight test engineer were completing a production test flight of the helicopter. A review of a surveillance video showed that, as they were preparing to land, the lower section of the left side of the engine cowling folded back and struck all four main rotor blades, which resulted in substantial damage to the blades. According to the operator/manufacturer, postaccident examination of the helicopter revealed that none of the fasteners on the left side of the cowling remained attached and that three of the fasteners were missing. No evidence of any preaccident discrepancies with the fasteners, the cowling, or the design and conformity of the helicopter structure was found. According to the manufacturer/operator, before the flight, the pilot reported to maintenance personnel that he had seen that the fasteners attaching the generator duct to the right side of the same cowling appeared long. Maintenance personnel then removed the one-piece engine cowling, and a mechanic then replaced the generator duct fasteners and reinstalled the cowling with the help of another mechanic. The mechanic said he specifically fastened each of the fasteners on the cowling himself and checked all the fasteners after the cowling was reinstalled. Once the cowling was reinstalled, a quality inspector visually inspected the engine cowling fasteners. He did not see any anomalies and signed off that the work had been completed. The flight test engineer performed another preflight inspection of the helicopter and did not note any issues with any of the cowling fasteners. It is likely that the mechanic did not properly install the cowling fasteners before the flight, which resulted in the cowling coming loose and striking the main rotor blades.

Factual narrative

The pilot and the flight test engineer had just completed a production test flight of the helicopter and were preparing to land when the lower section of the left side of the engine cowling folded back and struck all 4 main rotor blades and made contact with all 4 main rotor blades at some point prior to the rotor stopping, resulting in substantial damage. According to the operator/manufacturer, none of the fasteners on the left side of the cowling remained attached and 3 of the fasteners were missing.Prior to the flight, the pilot observed that the fasteners attaching the generator duct to the right side of the same cowling appeared long and reported it to maintenance. No anomalies were observed with the fasteners attaching the cowling tothe airframe. Maintenance then removed the one-piece engine cowling and a mechanic replaced the generator duct fasteners before reinstalling the cowling with the help of another mechanic. The mechanic said he specifically fastened each of the fasteners on the cowling himself and did a 100% check of each fastener after the cowling was installed. Once the cowling was reinstalled a quality inspector visually inspected the engine cowling fasteners. He did not observe any anomalies and signed off that the work had been completed. Prior to the accident flight, the flight test engineer performed another preflight inspection of the helicopter and did not observe any obvious issues with any of the cowling fasteners. The helicopter then departed and flew for about an hour before the cowling folded back. Postaccident examination of the cowling by the operator/manufacturer revealed no evidence of any preaccident discrepancies with the fasteners/cowling, or the design and conformity of the helicopter structure.

Aircraft

Registration
N982SS
Reported as
AugustaWestland AW119MKII
Category
Helicopter
Serial number
14962
Built
2020
Airframe hours
6.1
Engine
Pratt&Whitney PT6B-37A, 900 horsepower, turbo shaft
Damage
Substantial damage
Flight
Flight test · Part 91
Airworthiness certificate
Special, Special flight (Special)
Departed
PNE · Philadelphia, PA
Destination
PNE · Philadelphia, PA
Flight plan
VFR
Airport
PNE · Northeast Philadelphia
Equipment
ADS-B, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
53
Injuries
None
Certificates
Airline transport, Commercial, Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter
Medical
Class 1, With waivers/limitations
Last flight review
February 11, 2020
Seat
Right
Restraint
4-point
Flight hours
4,629 total · 902 in this make and model · 2,337 as pilot in command · 33 in the last 90 days · 5 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 4 knots, gusting 16
Visibility
10 statute miles
Lowest ceiling
None
Temperature
55 °F, dew point 25 °F
Altimeter
30.01 inHg
Observed at
PNE

Docket · 3

The files NTSB released with the investigation on December 9, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.5 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.