FTW97FA330

NTSB accident investigation · Southwest Florida SW204 · Manila, AR · August 27, 1997

Accident · FatalField investigationFinal report
Date
August 27, 1997, 10:10 local (15:10 UTC)
Place
Manila, AR
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N482SASouthwest Florida SW204
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 1998
Report
Approved by Office Director
FAA report
19970827024169A
Case key
20055

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

Fatigue failure of the main rotor blade resulting in the in-flight separation of the main rotor system due to the use of an unairworthy blade, and failure of the maintenance personnel who modified the rotor blade and the mechanic who complied with the Airworthiness Directive to locate the unapproved repair. A factor was the unapproved repair of the main rotor blade.

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/malfunctionManeuvering - aerial application
Rotor system,main rotor blade - previous damage
Maintenance,major repair - not approvedUnknownFactor
Maintenance,modification - inadequateOther maintenance personnelCause
Maintenance,compliance with ad - inadequateOther maintenance personnelCause
Rotor system,main rotor blade - fatigueCause
Rotor system,main rotor blade - separationCause
Rotor system,main rotor - separation
Loss of control - in flightManeuvering - aerial application
Aircraft control - not possiblePilot in command
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The pilot was applying pesticide to a cotton field when the outboard 9 feet of one main rotor blade separated in flight, resulting in the main rotor system separating from the main transmission mast. The in-flight separation of the main rotor blade was due to fatigue cracks emanating from a puncture through the lower surface of the blade in the leading edge area. The shape of the puncture, the crater mark above the puncture, and surrounding areas containing heavy deposits of lead residue indicated a bullet had entered the blade. The puncture had been repaired; however, manufacturer's specifications stated that this type damage is nonrepairable and the blade should be scrapped. In July 1995, the rotor blade was modified. During the modification process, the blade was inspected for damage. In April 1997, an AD requiring inspection of the blade was complied with.

Factual narrative

History of flight

On August 27, 1997, approximately 1010 central daylight time, a SW Florida Aviation SW204 helicopter, N482SA, was destroyed following an in-flight separation of a main rotor blade while maneuvering, near Manila, Arkansas. The helicopter was registered to and operated by the pilot, DBA Buffalo Island Flying Service, as a Title 14 CFR Part 137 aerial application flight. Visual meteorological conditions prevailed, and a flight plan was not filed for the local flight. The commercial pilot, sole occupant of the helicopter, was fatally injured. The flight originated from the pilot's private airstrip near Manila, Arkansas, about 5 minutes prior to the accident.

The pilot was applying the pesticide Karate to a nearby cotton field. There were no reported eyewitnesses to the helicopter crash; however, one witness reported hearing the sound of the engine RPM rapidly increasing followed by the sudden termination of the engine sound. Subsequently, the witness heard the sound of the helicopter impacting the ground.

Personnel information

The non-instrument rated commercial pilot added a helicopter rating to his commercial certificate on November 25, 1979. According to the pilot's flight logbook, he had accumulated a total of 15,457.7 flight hours in all aircraft, of which 1,775.5 hours were in helicopters, with 85.3 hours in the Southwest Florida Aviation SW204 helicopter (converted military Bell UH-1B). The pilot's last biennial flight review (BFR) was completed in a Maule airplane on January 29, 1997.

Aircraft information

According to Bell Helicopter, the original manufacturer of the helicopter, the aircraft was delivered to the United States Army on January 20, 1964, as a UH-1B helicopter with a serial number of 63-8534. FAA records indicate that on February 9, 1993, the accident aircraft was assigned the registration number of N482SA after being imported back into the United States. On March 8, 1993, the aircraft was registered to Southwest Florida Aviation, Inc., of Punta Gorda, Florida.

On June 1, 1995, Southwest Florida Aviation, Inc., completed a conversion of the UH-1B to a Southwest Florida Aviation SW204 helicopter under the type certificate No. H6SO. The Southwest Florida Aviation SW204 helicopter, serial number 756, was issued a Special Airworthiness Certificate on June 22, 1995, in the restricted category.

During a personal interview conducted by the NTSB IIC, a representative from Hillcrest Aircraft Company, Inc., of Lewiston, Idaho, reported that they acquired the helicopter from Southwest Florida Aviation in July 1996. The helicopter was not in flyable condition. According to FAA records, on March 4, 1997, the Southwest Florida Aviation SW204 helicopter, serial number 756, was registered to the Hillcrest Aircraft Company, Inc., as a UH-1B helicopter, serial number 63-8534.

The representative from Hillcrest Aircraft Company, Inc., further reported that they sold the helicopter "as is" to the pilot, Sidney R. Atkison, about February 1997. According to FAA records, on March 25, 1997, the aircraft was registered to the pilot, Sidney R. Atkison, dba Buffalo Island Flying Service.

The pilot contracted Tamarack Helicopters, Inc., of Stevensville, Montana, to put the aircraft into an airworthy condition. On April 20, 1997, Tamarack completed the re-assembly of the helicopter from its storage and shipping condition. According to the aircraft's maintenance records, the helicopter was certified in airworthy condition on April 20, 1997, with 4,972.9 hours total airframe time. Airworthiness directive (AD) 75-26-05, inspection of main rotor blades, was also complied with on April 20, 1997. See the enclosed copy of AD 75-26-05 and the related Bell Helicopter service bulletin for inspection requirements.

According to the pilot's flight logbook, on April 17, 1997, the pilot received a check ride in the helicopter at Hamilton, Montana. His pilot flight logbook also showed that he ferried the aircraft from Hamilton, Montana, to Manila, Arkansas, on April 18, 1997. According to a packing slip from Tamarack Helicopters, the helicopter's maintenance logbooks were shipped to the pilot on May 16, 1997.

Wreckage impact information

The aircraft wreckage was located in a cotton field approximately 2 miles north of Manila, Arkansas, at latitude 35 degrees 56.6 minutes north and longitude 90 degrees 11.3 minutes west. Examination of the accident site revealed that the helicopter came to rest on its top right side. Its final resting heading was measured at 320 degrees magnetic.

The cabin roof was crushed inward and the main transmission was only attached to the fuselage by the lift link. The tail boom was partially separated from the fuselage, and the tail rotor was partially attached to the vertical stabilizer by its pitch change chain/cable.

The main rotor system was separated from the main transmission mast, and the main rotor was found approximately 110 feet southeast of the main wreckage. The main rotor hub and blade assembly was found separated from the mast near the bottom of the hub, and the fracture surface displayed evidence of shear overload. The outboard 5 feet of one main rotor blade, serial number RB0154, was separated and found near the hub and blade assembly. The other main rotor blade, serial number RB0156, had the outboard 9 feet separated, and it was not located in the area of the wreckage. This portion of the rotor blade was located on or about November 10, 1997, across a creek to the northwest of the main wreckage. The fractured fragments of main rotor blade RB0156 were sent to the NTSB Materials Laboratory in Washington D.C., for examination.

The engine was found in position on the engine deck; however, its mounts were fractured. Complete engine continuity could not be establish at the accident site, therefore the engine was sent to the engine manufacturer's facility in Phoenix, Arizona, for further examination and testing.

Medical and pathological information

The autopsy was performed by pathologist Steven A. Erickson, M.D., at the Arkansas State Crime Laboratory, in Little Rock, Arkansas. Toxicological findings were negative.

Tests and research

A teardown inspection of the Allied Signal Lycoming T53-L-11D turboshaft engine, serial number LE-13147, was conducted at the AlliedSignal Product Safety and Integrity Investigation Laboratory on October 28, 1997, under the supervision of the NTSB investigator-in-charge. According to the manufacturer's teardown report, "there was evidence of rotation and operation at the time of impact with the ground." Additionally, the report states that "no pre-existing conditions were found that would have interfered with normal operation of the engine." See the enclosed AlliedSignal report for details of the examination.

The fractured fragments of main rotor blade RB0156 were examined at the NTSB Materials Laboratory in Washington D.C., on November 13 and 14, 1997. Examination of the fragments revealed a chordwise fracture that intersected a puncture in the lower surface of the blade. The puncture was located approximately 5 inches aft of the leading edge and 108.5 inches from the outboard end of the blade. The puncture shape was circular with an approximate diameter measuring between 0.27 and 0.31 inch. The puncture penetrated the three bottom metal layers of the blade: the abrasion strip, doubler, and lower portion of the box beam (spar). The upper inside surface of the box beam in a position located almost directly above the central axis of the puncture displayed an impact crater. The surface of the crater, the area surrounding the crater, and the forward upper corner of the aft inboard wall of the box beam were covered with a gray-white deposit. Energy dispersive X-ray spectrographic (EDS) spectra of these gray-white deposits contained large peaks of the element lead. The puncture, crater, and lea

Aircraft

Registration
N482SA
Reported as
Southwest Florida SW204
Category
Helicopter
Serial number
756
Airframe hours
5,152
Engine
Lycoming T53-L-11D, 1,100 horsepower, turbo shaft
Damage
Destroyed
Flight
Aerial application · Part 137
Registered owner
Sidney R. Atkison
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · April 20, 1997 · 179 hours before
Departed
NONE

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
51
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
15,458 total · 85 in this make and model · 15,376 as pilot in command · 132 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 7 knots
Visibility
7 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 68 °F
Altimeter
30.00 inHg
Observed at
JBR, 24 nm away

Docket · 71

The files NTSB released with the investigation on September 2, 1998, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.5 MB in all.

Supplement AItem 1 · .PDF · 274 KBSupplement BItem 2 · .PDF · 369 KBSupplement GItem 3 · .PDF · 111 KBSupplement KItem 4 · .PDF · 434 KBInterview with Rotor Blades Modification, Inc. RepresentativeItem 5 · .PDF · 88 KBMetallurgist's - Factual Report of Group ChairmanItem 6 · .PDF · 429 KBMetallurgist's Figure 1. (2 Photos)Item 7 · .PDF · 28 KBMetallurgist's Figures 2 and 3. (2 Photos)Item 8 · .PDF · 31 KBMetallurgist's Figures 4 and 5. (3 Photos)Item 9 · .PDF · 36 KBMetallurgist's Figure 6. (2 Photos)Item 10 · .PDF · 27 KBWreckage DiagramItem 11 · .PDF · 49 KBReport from Party to the Investigation: Bell Helicopter/TextronItem 12 · .PDF · 250 KBBell Helicopter/Textron Photograph #1Item 13 · .PDF · 32 KBBell Helicopter/Textron Photograph #2Item 14 · .PDF · 35 KBBell Helicopter/Textron Photograph #3Item 15 · .PDF · 47 KBBell Helicopter/Textron Photograph #4Item 16 · .PDF · 53 KBBell Helicopter/Textron Photograph #5Item 17 · .PDF · 48 KBBell Helicopter/Textron Photograph #6Item 18 · .PDF · 49 KBBell Helicopter/Textron Photograph #7Item 19 · .PDF · 31 KBBell Helicopter/Textron Photograph #8Item 20 · .PDF · 28 KBBell Helicopter/Textron Photograph #9Item 21 · .PDF · 30 KBBell Helicopter/Textron Photograph #10Item 22 · .PDF · 32 KBBell Helicopter/Textron Photograph #'s 11 and 12.Item 23 · .PDF · 32 KBBell Helicopter/Textron Photograph #'s 13 and 14Item 24 · .PDF · 36 KBBell Helicopter/Textron Photograph #'s 15 and 16Item 25 · .PDF · 30 KBReport from Party to the Investigation: Allied Signal AerospaceItem 26 · .PDF · 444 KBAllied Signal- Figures 1 and 2 (2 Photos)Item 27 · .PDF · 29 KBAllied Signal- Figures 3 and 4 (2 Photos)Item 28 · .PDF · 30 KBAllied Signal- Figures 5 and 6 (2 Photos)Item 29 · .PDF · 38 KBAllied Signal- Figures 7 and 8 (2 Photos)Item 30 · .PDF · 30 KBAllied Signal- Fihures 9 and 10 (2 Photos)Item 31 · .PDF · 33 KBAllied Signal- Figures 11 and 12 (2 Photos)Item 32 · .PDF · 38 KBAllied Signal- Figures 13 and 14 (2 photos)Item 33 · .PDF · 41 KBAllied Signal- Figures 15 and 16 (2 photos)Item 34 · .PDF · 37 KBAllied Signal- Figures 17 and 18 (2 Photos)Item 35 · .PDF · 29 KBAllied Signal- Figures 19 and 20 (2 Photos)Item 36 · .PDF · 28 KBAllied Signal- Figures 21 and 22 (2 Photos)Item 37 · .PDF · 35 KBAllied Signal- Figures 23 and 24 (2 Photos)Item 38 · .PDF · 33 KBAllied Signal- Figures 25 and 26 (2 Photos)Item 39 · .PDF · 39 KBAllied Signal- Figures 27 and 28 (2 Photos)Item 40 · .PDF · 30 KBAllied Signal- Figures 29 and 30 (2 Photos)Item 41 · .PDF · 25 KBAllied Signal- Figures 31 and 32 (2 Photos)Item 42 · .PDF · 35 KBAllied Signal- Figures 33 and 34 (2 Photos)Item 43 · .PDF · 32 KBAllied Signal- Figures 35 and 36 (2 Photos)Item 44 · .PDF · 22 KBAllied Signal- Figures 37 and 38 (2 Photos)Item 45 · .PDF · 29 KBAllied Signal- Figures 39 and 40 (2 Photos)Item 46 · .PDF · 28 KBAllied Signal- Figures 41 and 42 (2 photos)Item 47 · .PDF · 29 KBExcerpts from Army's Technical Manuals TM 55-1520-219-23-1 TM 55-1520-210-20 & Bell Helicopter Manual BHT-204B-M&OItem 48 · .PDF · 29 KBAircraft RecordsItem 49 · .PDF · 2.5 MBRotors Blades Modification, Inc. Prodecures and Policies for Modification of Rotor Blades.Item 50 · .PDF · 855 KBExcerpts from Army's Depot Maintenance Work Requirement. DMWR 55-1560-198Item 51 · .PDF · 1.1 MBType Certificate Data Sheet No. H65OItem 52 · .PDF · 672 KBAD 75-26-05Item 53 · .PDF · 200 KBBell Helicopter Service Bulletin 205-75-5Item 54 · .PDF · 614 KBExcerpts from Pilot's Flight LogbookItem 55 · .PDF · 2.9 MBStatement of Party Representatives to NTSB InvestigationItem 56 · .PDF · 81 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 57 · .PDF · 126 KBToxicological ReportItem 58 · .PDF · 95 KBPhotograph #1: Front view of the main wreckage after it was uprighted.Item 59 · .PDF · 45 KBPhotograph #2: Right side view of main wreckage after it was uprighted.Item 60 · .PDF · 43 KB
All 71 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.