FTW03FA097

NTSB accident investigation · Bell 407 · Mi 700 · February 16, 2003

Accident · FatalField investigationFinal report
Date
February 16, 2003, 12:25 local (18:25 UTC)
Place
Mi 700
Injuries
2 fatal, 3 serious
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N407HHBell 407
Weather
Visual (VMC)
Status
Completed · report April 28, 2005
Report
Approved by Office Director
Parties
Houston Helicopters, Bell Helicopter, FAA, Rolls Royce
FAA report
20030216001569A
Case key
56497

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 catastrophic failure of the engine resulting from 1st stage turbine wheel blade failure due to type 1 hot corrosion (sulfidation). Contributing factors were the pilot's failure to brief the passengers on emergency safety equipment (life raft), the pilot's failure to deploy the skid-mounted emergency float system during the autorotation, the high wind conditions, and rough sea state.

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.

Loss of engine power(total) - mech failure/malfCruise
Turboshaft engine,free(power) turbine - failure,totalCause
Turbine assembly,turbine blade - failure,totalCause
Turbine assembly,turbine wheel - corrodedCause
Passenger briefing - not performedPilot in commandFactor
Forced landingDescent - emergency
Autorotation - performedPilot in command
DitchingEmergency landing
Roll overStanding
Emergency floats - not deployedPilot in commandFactor
Emergency equipment - not deployedFactor
Terrain condition - water,roughFactor
Weather condition - high windFactor

Analysis

The helicopter, flown by 19,000-hour pilot and transporting 4 passengers to an offshore oil platform, experienced a catastrophic engine failure and autorotated into open ocean water in the Gulf Of Mexico. Within a few seconds after landing on the water, the helicopter rolled inverted, the pilot and passengers exited, inflated their personal life vests, and waited for rescue. The pilot and one of the passengers drowned prior to rescue personnel arriving about 2 hours after the accident. Surviving passenger statements indicated that they were not aware of an emergency lift raft on-board the helicopter, and that the skid-mounted emergency float system was not inflated prior to landing. Rescue personnel reported high wind and rough seas in the area of the accident. Examination of the wreckage revealed that the float "ARM" switch was found in the disarmed position and its cover closed. The skid-mounted emergency floats were found inside their protective bags. The float system tested functional, and no anomalies were found during airframe component examinations. Download data from the ECU showed that engine performance prior to the loss of power was normal and the engine was operating in a steady state condition prior to the initial deterioration of NG. Detailed inspection of the engine revealed progressive turbine wheel damage throughout the power turbine. The damage varied from approximately 95% of the airfoil material missing on the 1st stage wheel to approximately 10% of the material missing on the 4th stage wheel. The damage observed in the gas producer turbine section was consistent with the separation of one or more of the first stage wheel airfoils. Mostly all of the fracture surfaces were obscured, typical of elevated turbine temperatures (according to the manufacturer, in excess of turbine and material limits). All 4 turbine wheels had evidence of solutioning and incipient melting was observed at the tips of the airfoil remnants. Fracture surfaces of the 1st stage wheel airfoils did not reveal the presence of fatigue. Detailed metallurgical examination revealed the presence of sulfides on the 1st and 2nd stage turbine wheel surfaces. According to the manufacturer, the presence of sulfides is evidence that sulfidation has occurred. Damage on the concave surface adjacent to the fractures near the leading edges of the airfoils was found consistent with type 1 hot corrosion (sulfidation) damage. Examination of radial cracks at the trailing edges of the airfoils revealed heavy oxidation consistent with thermal fatigue. According to Rolls Royce, that "thermal fatigue cracking at the airfoil base is not uncommon." Evidence of EPS 10649 (S1 Aluminide, which is a protective coating applied to the turbine wheel during manufacturing), was confirmed adjacent to the corrosive damage found on the wheels.

Factual narrative

History of flight

On February 16, 2003, approximately 1225 central standard time, a Bell 407 single-engine helicopter, N407HH, registered to and operated by Houston Helicopters, Inc., of Pearland, Texas, executed an emergency landing into open ocean water in the Gulf of Mexico following a loss of engine power. The pilot and his four passengers survived the initial landing, however, the pilot and one passenger later drowned after egress from the helicopter. The remaining three passengers received serious injuries. Visual meteorological conditions prevailed, and a company visual flight rules (VFR) flight plan was filed for the Title 14 Code of federal Regulations Part 135 on-demand air taxi flight. Approximately 1210, the helicopter departed Harbor Island (TeSoro Heliport), Ingleside, Texas, for a 26.1 nautical mile flight to offshore platform, Ensco Rig 84 (Matagorda 700 block offshore), with an estimated time of arrival of 1230.

According to recorded communication records provided by the operator, the pilot of N407HH had transmitted a "Mayday" call, approximately 1225, citing an engine failure, and that he was going to land the helicopter on the water. Sounds similar to an "engine-out" audio tone were heard in the background of the Mayday call. Upon reception of the Mayday call, the Coast Guard stationed at Aransas Pass, Texas, and Corpus Christi, Texas, were notified, and an immediate search and rescue was initiated by the operator, the Coast Guard, private water vessels, and other helicopter operators.

Two of the surviving passengers reported that they heard a loud "bang" at the time of the loss of engine power. The survivors also reported that the helicopter rolled inverted within a few seconds after the landing and began to submerge. They stated that the skid-mounted emergency float system were not inflated at the time of the landing. The pilot and passengers exited the helicopter, inflated their life vests, and awaited their rescue. Approximately 1425, the pilot and passengers were recovered by the Coast Guard. (See 'Survival Aspects' section for additional details). The operator, Coast Guard helicopter pilots, pilot's of other search helicopters, and two of the passengers reported the winds were from the north at 25-40 mph with 5-9 foot sea swells.

Personnel information

The 19,000-hour pilot-in-command, held a valid commercial pilot certificate, issued on May 25, 1964, with a rotorcraft-helicopter rating. The pilot also held a valid mechanic certificate, issued December 8, 1965, with airframe and power plant ratings. His most recent second class medical certificate was issued on June 12, 2002, with the limitation that he must have available glasses for near vision. On the Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2) the operator reported the pilot's total flight time in all aircraft was 19,339 hours, of which, 19,299 hours were in rotorcraft. The pilot's total accumulated flight time in the Bell 407 was151 hours. A review of company flight and duty records revealed the pilot flew 168.9 hours, 263.9 hours (27.9 Bell 407), and 232.8 hours (89.9 Bell 407) in years 2000, 2001, and 2002, respectively. His most recent flight experience was 57 hours, 21 hours, and 3.5 hours in the past 90 days, 30 days, and 24 hours, respectively. The pilot was off duty from February 6-10, 2003. Flight and duty records for February 11-16 were not recovered from the helicopter and are presumed destroyed. According to the aircraft's (N407HH) maintenance log for February 11-14, 2003, the pilot flew 1.2 hours on February 11, 1.2 hours on February 12, and 2.5 hours on February 14.

A review of company records revealed that the pilot satisfactory completed company training and the airman competency/proficiency testing requirements (FAA CFR Part 135.293 (a) (b) Part 299) to act as pilot-in-command (PIC) of Bell 407 helicopters on May 8, 2001. The pilot's most recent recurrent ground training records, dated March 20, 2002, certified the pilot-in-command had received ground training on life rafts, survival vests, ditching procedures, and water survival techniques. Underwater egress training for the pilot could not be verified. The pilot's most recent competency/proficiency check, conducted by the company check airman, for the Bell 407 helicopter was satisfactorily performed on May 31, 2002.

Aircraft information

The Bell 407 helicopter, serial number (SIN) 53460, helicopter was manufactured in 2000, and issued an airworthiness certificate on December 9, 2000, and was registered to Houston Helicopters, Inc., on February 1, 2001. Total airframe time at the time of the accident was approximately 612.7 hours since manufactured. The helicopter was equipped with a Full Authority Digital Electronic Control system (FADEC) and Electronic Control Unit (ECU) with version 7102 software, which includes incident recording capability. On December 12, 2002, the last annual inspection of N407HH, which was accomplished at a total time of 546.8 hours by the Houston Helicopter, Inc., FAA certificated repair station, encompassed the 50 hour, 100 hour and 300 hour airframe inspection and the 150 hour engine inspection. During the inspection, the electrical system functional test, inflation test, and float pneumatic system checks and bottle servicing were satisfactorily performed for the emergency float system. The helicopter was not equipped with a cockpit voice recorder (CVR) or a digital flight data recorder (DFDR).

The helicopter's power plant, installed new on October 28, 2000, was an 650-horsepower Allison/Rolls Royce 250-C47B turbo shaft engine, part number (PIN) 23063392, SIN CAE 847499. The last annual inspection engine inspection coincided with the last airframe inspection on December 12, 2002, at a total time of 546.8 hours. The turbine engine maintenance inspection was performed in accordance with the Rolls Royce/Allison Operations and Maintenance Manual. Total engine time at the time of the accident was 612.7 hours ( power cycles:1,679, start cycles:1,116).

In May 2001, the operator found (during an inspection) that the internal engine oil filter was not installed. The time on the engine was 97.0 hours. On September 7, 2001, two bearings (258.6 hours) PIN 407-340-339-103, SIN C00-2514 and D00-0027 were removed and replaced. The starter generator (164.7 hours) was removed and replaced on July 3, 2002. Maintenance records for January 4, 2003, stated the "floats circuit breaker pops when float switch armed/repaired wire." Time on the aircraft was 562.4 hours.

The last refueling of N407HH prior to the accident occurred on February 14, 2003, with a total of 90.2 gallons.

Wreckage and impact information

Recovery

On February 26, 2003, search for the submerged helicopter was initiated by the insurance company. Side scan sonar located the helicopter on February 27, 2003, at North 27 degrees 51 minutes 23.617 seconds; West 096 degrees 41 minutes 36.493 seconds (approximately 1,400 feet northeast of the last known position). According to divers, the helicopter was found inverted at a depth of 96 feet with 2 of the 4 main rotor blades embedded in sand and silt. The helicopter was raised on March 16, 2003. According to an FAA inspector, who was aboard the recovery vessel, the boat stabilizing pylon was inadvertently jacked down onto the wreckage, resulting crushing damage to the airframe and cabin. After the wreckage was raised, it was rinsed with fresh water on board the recovery vessel. The ECU and three instrument panel-mounted engine instruments (MGT, Torque, and Ng) were removed and placed in fresh water for preservation. The helicopter was brought to shore and transported via ground vehicle by Air Salvage of Dallas (ASOD), Lancaster, Texas, to the ASOD facility where is was secured for further examination by the Board.

Initial Wreckage Examination

Under the supervision of the NTSB IIC, the

Aircraft

Registration
N407HH
Reported as
Bell 407
Category
Helicopter
Serial number
53460
Airframe hours
546.8
Engine
Allison 250-C47B, 600 horsepower, turbo shaft
Damage
Destroyed
Flight
Part 135
Registered owner
Houston Helicopters, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · December 10, 2002 · 62.2 hours before
Departed
Ingleside, TX
Destination
Mi 700, GM
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
65
Injuries
Fatal
Certificates
Commercial, Flight instructor
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
May 31, 2004
Seat
Right
Toxicology
Performed
Flight hours
19,339 total · 151 in this make and model · 57 in the last 90 days · 21 in the last 30 days

Weather

Conditions
Visual (VMC)
Wind
360° at 20 knots, gusting 30
Visibility
10 statute miles
Lowest ceiling
None
Temperature
50 °F

Docket · 69

The files NTSB released with the investigation on January 20, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 62.4 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 247 KBMaterials Laboratory 15 - Factual Report 03-038 Rolls 250 engineItem 2 · .PDF · 8.7 MBWitness/Passenger StatementsItem 3 · .PDF · 667 KBMaps or Charts of Accident Area, Wreckage DiagramsItem 4 · .PDF · 1.5 MBUS Coast Guard Search & Rescue ReportItem 5 · .PDF · 1.8 MBReports from Parties to the Investigation (Bell)Item 6 · .PDF · 443 KBReports from Parties to the Investigation (NGPS-S)Item 7 · .PDF · 3.9 MBReports from Parties to the Investigation (Unison)Item 8 · .PDF · 564 KBReports from Parties to the Investigation (Goodrich)Item 9 · .PDF · 1.8 MBReports from Parties to the Investigation (Rolls Royce)Item 10 · .PDF · 304 KBReports from Parties to the Investigation (Rolls Royce Metallurgy)Item 11 · .PDF · 13.2 MBAnnual InspectionItem 12 · .PDF · 1.2 MBIncident Recorder Plot Summary (ECU)Item 13 · .PDF · 40 KBDaily Maintenance LogsItem 14 · .PDF · 2.9 MBWeight & Balance DataItem 15 · .PDF · 37 KBAircraft Status ReportItem 16 · .PDF · 195 KBPiolt RecordsItem 17 · .PDF · 603 KBPredelivery InspectionItem 18 · .PDF · 928 KBEngine RecordsItem 19 · .PDF · 1.1 MBStatement of PartiesItem 20 · .PDF · 269 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 21 · .PDF · 116 KBToxocologyItem 22 · .PDF · 154 KBDispatcher Daily LogItem 23 · .PDF · 196 KBGeneral Operations ManualItem 24 · .PDF · 660 KBCompany Radio LogItem 25 · .PDF · 1.7 MBRecorder DataItem 26 · .PDF · 424 KBLaboratory ResultsItem 27 · .PDF · 51 KBPhoto 01 Gas producer sectionItem 28 · .PDF · 543 KBPhoto 02 Turbine 3rd stage wheel Courtesy BellItem 29 · .PDF · 174 KBPhoto 03 Turbine 4th stage wheel-rotor assmeblyItem 30 · .PDF · 504 KBPhoto 04 Turbine 2nd stage nozzle and ringItem 31 · .PDF · 620 KBPhoto 05 Turbine 1st stage wheelItem 32 · .PDF · 613 KBPhoto 06 Turbine 1st stage nozzleItem 33 · .PDF · 673 KBPhoto 07 ImpellerItem 34 · .PDF · 608 KBPhoto 08 Turbine 2nd stage wheelItem 35 · .PDF · 646 KBPhoto 09 Turbine 3rd stage nozzleItem 36 · .PDF · 532 KBPhoto 10 Turbine 4th stage wheel-rotor assemblyItem 37 · .PDF · 503 KBPhoto 11 Fueling FacilityItem 38 · .PDF · 109 KBPhoto 12 Fueling facility filterItem 39 · .PDF · 128 KBPhoto 13 Wiring harnessItem 40 · .PDF · 591 KBPhoto 14 Tail rotor assemblyItem 41 · .PDF · 632 KBPhoto 15 Main rotor bladesItem 42 · .PDF · 762 KBPhoto 16 Emergency flotation cylinderItem 43 · .PDF · 464 KBPhoto 17 View of helicopterItem 44 · .PDF · 685 KBPhoto 18 View of helicopterItem 45 · .PDF · 668 KBPhoto 19 View of helicopterItem 46 · .PDF · 835 KBPhoto 20 View of helicopterItem 47 · .PDF · 631 KBPhoto 21 View of helicopterItem 48 · .PDF · 585 KBPhoto 22 View of collectiveItem 49 · .PDF · 576 KBPhoto 23 View of cockpitItem 50 · .PDF · 585 KBPhoto 24 View of exemplary helicopterItem 51 · .PDF · 686 KBPhoto 25 View of floatsItem 52 · .PDF · 628 KBPhoto 26 View of Ng, MGT, TRQ instrumentsItem 53 · .PDF · 488 KBPhoto 27 View of exhaustItem 54 · .PDF · 500 KBPhoto 28 View of exhaustItem 55 · .PDF · 496 KBPhoto 29 Wiring harness Courtesy BellItem 56 · .PDF · 129 KBPhoto 30 Inlet screen Courtesy BellItem 57 · .PDF · 189 KBPhoto 31 Map of accident site Courtesy BellItem 58 · .PDF · 168 KBPhoto 32 View of engine Courtesy BellItem 59 · .PDF · 202 KBPhoto 33 Main rotor blades Courtesy BellItem 60 · .PDF · 114 KB
All 69 files on NTSB’s docket

FAA reports on this event · 1

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