ERA21LA023

NTSB accident investigation · Bell 206 · Zephyrhills, FL · October 16, 2020

Accident · No injuriesClass 3 · LimitedFinal report
Date
October 16, 2020, 15:15 local (19:15 UTC)
Place
Zephyrhills, FL
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N777CPBell 206
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Rolls Royce
FAA report
20201016015159A
Case key
102161

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

Improper torquing of the “B” nut at the fuel control unit, which led to a total loss of engine power and subsequent autorotation that resulted in substantial damage.

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 service/maintenanceBell 206B: 2 casesAll aircraft: 59 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelBell 206B: 4 casesAll aircraft: 320 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

While in cruise flight, the pilot heard a binding sound and felt a reduction in engine power. The low rotor rpm aural alarm then sounded, and he initiated an autorotation to swampy terrain. The helicopter came to rest amongst pine trees and undergrowth. The tailboom was impact separated and the main rotors were fractured about midspan. During a detailed examination of the helicopter, the “B” nut at the engine fuel control unit was found loose with no thread engagement. During a test run of the engine, the “B” nut was tightened and torqued to proper specification. The engine ran smoothly and continuously at all power settings. A review of the helicopter’s maintenance records revealed the last annual inspection was completed about 75 hours prior to the accident. The pilot, who also holds an airframe and powerplant certificate, was the last person to perform maintenance on the engine. According to the Rolls-Royce maintenance manual, torque paint must be applied to all the rigid tube “B” nuts to ensure proper tightening. According to the maintenance manual, “failure to properly install, align, and tighten fuel, oil, and air fittings could result in an engine failure.”

Factual narrative

On October 16, 2020, about 1515 eastern daylight time, a Bell 206B, N777CP, was substantially damaged when it was involved in an accident near Zephyrhills, Florida. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, about 15 minutes after departure, he heard a “binding sound” and felt a reduction in engine power and a slight nose left yaw. He checked his engine instruments and noted no illumination of annunciator lights or engine warnings. The low rotor rpm aural alarm then sounded, and he initiated an autorotation to swampy terrain. According to the Federal Aviation Administration inspector who responded to the accident site, the helicopter came to rest among pine trees and undergrowth. The tailboom was impact separated, and the main rotors were fractured about midspan. A detailed examination revealed the “B” nut at the engine fuel control unit was loose with no thread engagement. The nut was also missing the torque stripe markings on the line as required by the Rolls-Royce maintenance manual. During a test run of the engine, the “B” nut was tightened and torqued to proper specification. The engine ran smoothly and continuously at all power settings. A review of the helicopter’s maintenance records revealed the last annual inspection was completed about 75 hours prior to the accident. At that time, the Nos. 1 and 2 turbine wheels were replaced. The pilot also holds an airframe and powerplant certificate and was the last person to perform maintenance on the engine. According to the Rolls-Royce maintenance manual, torque paint must be applied to all the rigid tube “B” nuts and reapplied each time the nut is loosened and tightened. The manual states that “Proper tightening of the engine tubing connections is critical to flight safety. Failure to properly install, align, and tighten fuel, oil, and air fittings cold result in an engine failure.”

Aircraft

Registration
N777CP
Reported as
Bell 206 (B)
Category
Helicopter
Serial number
3429
Built
1981
Airframe hours
12,582
Engine
Rolls Royce 250 C20-B, 420 horsepower, turbo shaft
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 8, 2020 · 74.2 hours before
Departed
Plant City, FL
Destination
KCRG · Jacksonville, FL
Flight plan
Company VFR
Equipment
Onboard weather, Handheld GPS, Electronic flight bag or handheld device, ADS-B, Satellite tracking device

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
57
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
November 23, 2018
Seat
Front
Restraint
Lap only
Flight hours
6,860 total · 2,400 in this make and model · 6,600 as pilot in command · 80 in the last 90 days · 30 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
10° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 68 °F
Altimeter
29.98 inHg
Observed at
ZPH, 12 nm away
METAR
KZPH 161915Z AUTO 01009KT 10SM CLR 31/20 A2998 RMK A02 T03060196

Docket · 9

The files NTSB released with the investigation on June 10, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.2 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.