FTW03TA156

NTSB accident investigation · Bell 407 · Franklin, LA · May 19, 2003

Accident · No injuriesFinal report
Date
May 19, 2003, 09:55 local (14:55 UTC)
Place
Franklin, LA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N991SPBell 407
Weather
Visual (VMC) · Day
Status
Completed · report March 2, 2004
Report
Approved by Office Director
Parties
FAA FSDO
FAA report
20030519011429A
Case key
57020

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 effectiveness due to the inadequate maintenance performed by other company personnel.

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/malfunctionApproach
Rotorcraft flight control,tail rotor control - loss,total
Maintenance,installation - inadequateOther maintenance personnelCause
Rotorcraft flight control,pitch change rod/link - loose part/bolt/nut/clamp/etc
Loss of control - in flightApproach
Loss of tail rotor effectiveness
In flight collision with terrain/waterEmergency descent/landing
Terrain condition - ground

Analysis

When approaching a helipad for landing, the pilot realized that the anti-torque pedals were not effective. Due to obstacles, the pilot aborted his approach to the helipad and turned eastbound toward a sugar cane field. Subsequently, the helicopter started to rotate and the pilot realized he had no control of the tail rotor with the anti torque pedals. He then rolled the throttle to idle, and initiated an autorotation from approximately 75 feet AGL. The pilot reported that a high sink rate developed and the helicopter impacted the ground hard on the main landing skids. Inspection of the helicopter revealed that the pivot bolt (P/N: NAS6604D31), bushing (P/N: 206-011-726-005), nut (P/N: MS14144l4), and cotter pin (P/N: MS24665-155), that connects the rotor control idler assembly (P/N: 406-012-127-101) to the tail rotor control housing assembly was not found. Examination of the aircraft logbooks indicated that there was an annual maintenance inspection preformed on the helicopter 7 days hours prior to the accident. The helicopter accumulated 4.9 hours of flight time since time of inspection.

Factual narrative

On May 19, 2003, at 0955 central daylight time, a Bell 407 helicopter, N991SP, registered to and operated by the Louisiana Department of Public Safety, was substantially damaged during a precautionary following a loss of tail rotor pitch control near Franklin, Louisiana. The commercial pilot and his passenger were not injured. Visual meteorological conditions prevailed and a Company VFR flight following plan was filed for the 14 Code of Federal Regulations Part 91 Public Use flight. The local flight originated from Baton Rouge Airport (BTR), Baton Rouge, Louisiana, at 0900, and was destined for Franklin, Louisiana.

The pilot reported in the Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2) that while he was approaching a helipad for landing, he realized that the anti-torque pedals were not effective. Due to obstacles he aborted his approach to the helipad and turned eastbound toward a sugar cane field. Subsequently, the helicopter started to rotate and he realized he had no control of the tail rotor with the anti torque pedals. He then rolled the throttle to idle, and initiated an autorotation from approximately 75 feet agl. The pilot further reported that a high sink rate developed and the helicopter impacted the ground hard on the main landing skids.

An FAA inspector, who examined the helicopter at the accident site, reported that the main landing skids were compressed nearly flat. Further inspection revealed that the pivot bolt (P/N: NAS6604D31), bushing (P/N: 206-011-726-005), nut (P/N: MS14144l4), and cotter pin (P/N: MS24665-155), that connects the rotor control idler assembly (P/N: 406-012-127-101) to the tail rotor control housing assembly was not found. All part numbers were verified with the Bell Helicopter Textron 407 Illustrated Parts Bulletin (BHT-407-IPB).

Examination of the aircraft logbooks indicated that there was an annual maintenance inspection preformed on the helicopter 7 days prior to the accident. The helicopter accumulated 4.9 hours of flight time since time of inspection. The company who preformed the maintenance inspection on the helicopter provided the NTSB investigator-in-charge with a written statement from the mechanic and supervisor who worked on the helicopter. The mechanic who was working on tail rotor gearbox area requested his supervisor inspect the area and double-check that the work was complete. It was discovered that the "pitch channel trunnion attach bolt was installed, but not tight or safety wired." The supervisor requested this be complied with. Later that day, the supervisor asked the mechanic if the work was complete, but did not verify it visually. The tail rotor gearbox cowling was then installed.

Aircraft

Registration
N991SP
Reported as
Bell 407
Category
Helicopter
Serial number
53518
Airframe hours
203.4
Engine
Rolls-Royce 250-C47B, 800 horsepower, turbo shaft
Damage
Substantial damage
Flight
Public aircraft · Public use
Registered owner
Louisiana Department of Public Safety
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 12, 2003 · 4.9 hours before
Departed
BTR · Baton Rouge, LA
Destination
Franklin

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
Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
March 14, 2002
Seat
Left
Flight hours
13,096 total · 305 in this make and model · 20 in the last 90 days · 12 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 72 °F
Altimeter
29.95 inHg

FAA reports on this event · 1

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