# NTSB ERA20CA135: AugustaWestland AW119MKII, N982SS, Philadelphia, PA, March 21, 2020 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: March 21, 2020, 15:42 local (19:42 UTC) - Place: Philadelphia, PA - Coordinates: 40.083332, -75.001388 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.0833&lon=-75.0014&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338) - Highest injury: No injuries - Injuries: 2 uninjured - 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 - NTSB case key (mKey): 101114 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20CA135 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101114/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101114 - Page: https://openairdocs.org/ntsb/ERA20CA135 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Misc hardware: fasteners](https://openairdocs.org/ntsb-findings/01071430): Aircraft › Fluids/misc hardware · Incorrect service/maintenance (probable cause); cases with it: [Agustawestland Philadelphia AW119MKII, 1 case](https://openairdocs.org/ntsb-findings/01071430/cases.md?model=0260401), [All aircraft, 58 cases](https://openairdocs.org/ntsb-findings/01071430/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Agustawestland Philadelphia AW119MKII, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=0260401), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Engine (turbine/turboprop)](https://openairdocs.org/ntsb-findings/01057200): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Agustawestland Philadelphia AW119MKII, 1 case](https://openairdocs.org/ntsb-findings/01057200/cases.md?model=0260401), [All aircraft, 67 cases](https://openairdocs.org/ntsb-findings/01057200/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Agustawestland Philadelphia AW119MKII, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=0260401), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Approach: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338) (defining event); cases with it: [Agustawestland Philadelphia AW119MKII, 1 case](https://openairdocs.org/ntsb-events/338/sequence.md?model=0260401), [All aircraft, 563 cases](https://openairdocs.org/ntsb-events/338/sequence.md) ## 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](https://openairdocs.org/deregistered/N982SS-2020-10-28), registration cancelled 2020-10-28, S/N 14962, built 2020 (OpenAirDocs) - Reported make and model: AugustaWestland AW119MKII - Registry model: [Agustawestland Philadelphia AW119MKII](https://openairdocs.org/model/agustawestland-philadelphia-aw119mkii) (registry code 0260401) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6B-37A](https://openairdocs.org/engine/pratt-whitney-canada-pt6b-37a) (registry code 52179, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 14962 - Year built: 2020 - Airframe hours: 6.1 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: none; 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 ## 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 20200321009079A](https://openairdocs.org/incident/20200321009079A), Mar 21, 2020: Leonardo AW119MKII, Philadelphia, PA, Substantial damage. During hover and shutdown, the aircraft engine cowling flapped open due to a cowling fastener becoming unlocked. The cowling contacted the main rotor blades… ## Docket (3 files) The files NTSB released with the investigation on December 9, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101114. 4.5 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9383434&FileExtension=pdf&FileName=NTSB%206120-1%20for%2014962%20Signed_Redacted-Rel.pdf - NTSB summary of findings (item 2, PDF, 1 page, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9662698&FileExtension=pdf&FileName=NTSB%20Summary%20of%20Findings-Rel.pdf - Photos (item 3, PDF, 3 pages, 3 photos, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9641758&FileExtension=pdf&FileName=Photos%20of%20Damage%20(Courtesy%20of%20AugustaWestland)-Rel.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.