FTW03LA104

NTSB accident investigation · Bell 206L-3 · Kingsland, TX · March 6, 2003

Accident · No injuriesLimited investigationFinal report
Date
March 6, 2003, 16:15 local (22:15 UTC)
Place
Kingsland, TX
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N793CABell 206L-3
Weather
Visual (VMC) · Day
Status
Completed · report August 26, 2003
Report
Approved by Office Director
Parties
Bell Helicopter Textron, FAA FSDO, Critical Air
FAA report
20030306005039A
Case key
56589

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 loss of tail rotor drive as a result of a blanket coming in contract with the tailrotor blades, after the aft cargo door was left unsecured. Contributing factors were the lack of suitable terrain for the forced landing, and the failure of the medical crewmember to properly secure the aft cargo door.

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.

Rotor failure/malfunctionCruise
Procedures/directives - not followedFlightcrewFactor
Door,cargo/baggage - not securedCause
Rotor system,tail rotor blade - blade strike
Object - other
Rotor drive system,tail rotor drive shaft - shearedCause
Forced landingDescent - emergency
Autorotation - performedPilot in command
Hard landingLanding - flare/touchdown
Terrain condition - none suitableFactor
Terrain condition - soft
Object - tree(s)
Misc rotorcraft,tail boom - separation

Analysis

The pilot started the engine of the helicopter prior to the two medical crewmembers boarding. One medical crewmember opened the aft cargo door, removed medical equipment, and then closed the door. He then checked the auxiliary power unit (APU) door and boarded the helicopter. During this time the second medical crewmember had boarded the helicopter. The pilot reported that the takeoff was normal. Ten minutes after takeoff, the helicopter was in cruise flight at 700 feet agl (8 miles from the destination) when a loud bang was heard. The helicopter yawed right and the nose dipped. The pilot lowered the collective and moved the throttle to flight idle. Subsequently, the helicopter landed hard on soft terrain, amongst pecan trees, and came to rest upright. Examination of the accident site and helicopter revealed that a medical blanket had exited from the aft cargo compartment and contacted the tailrotor blades severing the tailrotor drive shaft. Examination of the aft cargo door revealed that its locking mechanism was not damaged, and operated normally.

Factual narrative

On March 6, 2003, at 1615 central standard time, a Bell 206L-3 helicopter, N793CA, was substantially damaged following a loss of tail rotor drive during cruise flight near Kingsland, Texas. The helicopter was registered to and operated by Critical Air Medicine, Inc., of San Diego, California. The airline transport pilot, and the two medical crewmembers were not injured. Visual meteorological conditions prevailed, and a company visual flight rules (VFR) flight plan was filed for the 14 Code of Federal Regulations Part 91 positioning flight. The cross-country flight originated from a private helipad in Marble Falls, Texas, at 1604, and was destined for Llano, Texas.

According to the pilot and the two medical crewmembers, they were dispatched to a hospital in Llano to pick up a patient. The pilot walked to the helicopter and started the engine. Prior to boarding the helicopter, one medical crewmember opened the aft cargo door, removed medical equipment, and then closed the door. He then checked the auxiliary power unit (APU) door and boarded the helicopter. During this time the second medical crewmember had boarded the helicopter.

The pilot reported that the takeoff was normal, "except for a notable vertical [vibration] in cruise flight." Ten minutes after takeoff, while in cruise flight at 700 feet agl (8 miles from Llano) a loud bang was heard. The helicopter yawed right and the nose dipped. The pilot lowered the collective and moved the throttle to flight idle. The pilot then began searching for an area to land; however, within the surrounding area there was a river with rocks, a green sloping field with trees and stumps, and an orchard of pecan trees. Subsequently, the helicopter landed hard on soft terrain, amongst the pecan trees, and came to rest upright. The pilot applied the rotor brake to stop the main rotor blades and the pilot and medical crewmembers exited the helicopter. During the landing, the tailboom separated from the helicopter.

According to an FAA inspector, who examined the helicopter and the accident site, a medical blanket, which was in the aft cargo compartment, was found in a tree upstream along the helicopters flight path. Additionally, a section of the tailrotor drive shaft, and other items, which were in the aft cargo compartment were located between the tree that the blanket was in and the accident site.

The helicopter and blanket that was in the tree was examined by the NTSB Investigator-In-Charge. The examination revealed that the aft cargo compartment door and its locking mechanism was not damaged and operated normally. The blanket was torn in multiple areas and contained a dark area, which was consistent with the size of the surface of a tailrotor blade. One tailrotor blade and the blanket were sent to and examined by the Bell Helicopter Engineering Laboratory in Hurst, Texas. The examination revealed that the tailrotor blade was buckled aft and to the inside (as positioned on the helicopter). Imprints of the blanket's weave pattern were observed on the sooty surface of the tailrotor blade. The soot and dirt was also observed on the surface of the blanket. Two areas of the blanket contained an amber colored grease. A comparison of the grease (using FTIR spectroscopy) found on the inboard end of the tailrotor blade and on the blanket, showed it to be of similar composition. Additionally, two fibers, one polyester and one non-mercerized cotton, were found on the tailrotor blade. These fibers are similar to the fibers that comprise the blanket; 82% cotton and 18% polyester.

Aircraft

Registration
N793CA
Reported as
Bell 206L-3
Category
Helicopter
Serial number
51476
Airframe hours
5,266.2
Engine
Allison 250-C30P, 525 horsepower, turbo shaft
Damage
Substantial damage
Flight
Positioning · Part 91
Registered owner
Critical Air Medicine, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · February 28, 2003 · 2.1 hours before
Departed
NONE · Marble Falls, TX
Destination
NONE · Llano, TX
Flight plan
Company VFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
62
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
January 20, 2003
Seat
Right
Flight hours
20,000 total · 8,000 in this make and model · 19,450 as pilot in command · 35 in the last 90 days · 12 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 43 °F
Altimeter
29.88 inHg
Observed at
BMQ, 15 nm away

FAA reports on this event · 1

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