FTW00LA137

NTSB accident investigation · Bell 206L3 · Salt Marsh · April 29, 2000

Accident · No injuriesLimited investigationFinal report
Date
April 29, 2000, 18:10 local (23:10 UTC)
Place
Salt Marsh
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N17237Bell 206L3
Weather
Visual (VMC) · Day
Status
Completed · report January 18, 2001
Report
Approved by Office Director
FAA report
20000429005689A
Case key
49210

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The company mechanic's failure to replace the bolt's cotter key properly and the subsequent loss of the nut, which then resulted in the tail rotor control disconnection and the pilot's inability to maintain aircraft control.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionApproach - vfr pattern - final approach
Miscellaneous,bolt/nut/fastener/clamp/spring - loss,totalCause
Maintenance,installation - improperCompany maintenance personnelCause
Loss of control - in flightApproach - vfr pattern - final approach
Rotorcraft flight control,tail rotor control - disconnected
Aircraft control - not possiblePilot in command
In flight collision with terrain/waterEmergency landing
Terrain condition - water

Analysis

The pilot reported that the helicopter lost tail rotor response while approaching an offshore platform. The pilot elected to make an autorotative emergency landing to the water. According to witnesses, the helicopter began the autorotation and proceeded to rotate to the left and 'pitch nose down.' The helicopter entered a steep descent, and the pilot reported that he could not control the helicopter. Prior to impacting the water, the helicopter assumed level flight and the emergency floats deployed. Upon impact with the water, the helicopter rolled right and came to rest inverted in the water. According to the operator's maintenance superintendent, a mechanic either omitted a bolt's cotter key or installed it improperly, which resulted in the disconnect of the tail rotor control rod assembly from the control lever located at the rear of the tail rotor gear box.

Factual narrative

On April 29, 2000, at 1810 central daylight time, a Bell 206L3 helicopter, N17237, sustained substantial damage during an emergency landing in the Gulf of Mexico near the Salt Marsh Island 61C offshore platform. The commercial pilot and his passenger were not injured. The helicopter was owned and operated by Chevron USA Inc., of New Orleans, Louisiana, under Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and a company VFR flight plan was filed for the local business flight. The helicopter departed the Salt Marsh Island 78B offshore platform at 1735.

The 15,672-hour pilot reported that the helicopter lost tail rotor response when turning final to 61C. The pilot reported the problem to the operator and was informed that a rescue boat was dispatched to their area for assistance. After circling in the area for about 25 minutes, the pilot elected to make an autorotative emergency landing to the water. According to witnesses, the helicopter began the autorotation and proceeded to rotate to the left and "pitch nose down." The helicopter entered a steep descent, and the pilot reported that he could not control the helicopter. At approximately 100 feet above the ocean, the helicopter assumed level flight, the emergency floats deployed, and the helicopter subsequently impacted the water. Upon impact, the right float "broke," and the helicopter rolled to the right, coming to rest inverted in the water.

According to the FAA inspector, a main rotor blade severed the tailboom. Both main rotor blades were shattered, and the fuselage sustained minor damage.

According to the operator's maintenance superintendent, the loss of tail rotor control was a result of "a bolt falling out of a control rod in the tail rotor control system." The bolt (part number 20-057-4-22D) connected the control rod assembly to the control lever located at the rear of the tail rotor gearbox. The cotter key and castellated nut were not recovered. The bolt was recovered and showed no signs of distress. The helicopter underwent an approved aircraft inspection between March 21st and April 1st, 2000, 63 hours prior to the accident. During the inspection, the bolt was removed to facilitate the removal of another control tube for repair. During the re-assembly process, the cotter key was either not properly installed or was accidentally omitted. The discrepancy was not noticed by the mechanic, who was working the inspection, or the supervisor, who was inspecting the mechanic's work.

Aircraft

Registration
N17237
Reported as
Bell 206L3
Category
Helicopter
Serial number
51478
Airframe hours
7,785
Engine
Allison 250-C30P, 500 horsepower, turbo shaft
Damage
Substantial damage
Flight
Business · Part 91
Registered owner
Chevron USA Inc.
Airworthiness certificate
Standard, Utility
Last inspection
AAIP · April 1, 2000 · 63 hours before
Departed
78B · Salt Marsh, GM
Destination
61C
Flight plan
Company VFR

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
55
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
15,672 total · 720 in this make and model · 12,892 as pilot in command · 85 in the last 90 days · 56 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
110° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.