# NTSB GAA16CA039: Bell 407, N420PH, Cameron, LA, October 30, 2015

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Data collection · Final report
- Date: October 30, 2015, 12:20 local (17:20 UTC)
- Place: Cameron, LA
- Location: 29.7952° N, 93.2916° W: Placed by OpenAirDocs: center of Cameron, LA, within about 6 miles (OpenAirDocs)
- NTSB coordinates: 29.390556, -93.446113 (estimated), outside the stated state
- Nearby events: https://openairdocs.org/map.md?lat=29.7952&lon=-93.2916&mi=10
- Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping)
- Defining event: [Standing-engine(s) start-up: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338)
- Highest injury: No injuries
- Injuries: 1 uninjured
- Status: Completed, report February 8, 2016
- Report: Approved by Office Director
- NTSB office: General Aviation Accidents
- Parties: FAA Baton Rouge FSDO
- NTSB case key (mKey): 92283
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16CA039
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92283/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92283
- Page: https://openairdocs.org/ntsb/GAA16CA039

## Probable cause

The pilot's failure to remove a main rotor blade tiedown, which resulted in substantial damage to a main rotor blade when the engine was started.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Bell 407, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=1182206), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md)
- [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Bell 407, 1 case](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=1182206), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md)
- [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot; cases with it: [Bell 407, 2 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=1182206), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Bell 407, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=1182206), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md)
- [Standing-engine(s) start-up: Aircraft structural failure](https://openairdocs.org/ntsb-events/337); cases with it: [Bell 407, 2 cases](https://openairdocs.org/ntsb-events/337/sequence.md?model=1182206), [All aircraft, 290 cases](https://openairdocs.org/ntsb-events/337/sequence.md)
- [Standing-engine(s) start-up: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338) (defining event); cases with it: [Bell 407, 6 cases](https://openairdocs.org/ntsb-events/338/sequence.md?model=1182206), [All aircraft, 562 cases](https://openairdocs.org/ntsb-events/338/sequence.md)

## Analysis

The operator reported that the pilot landed and shutdown the helicopter on an offshore platform. He secured the main rotor system by attaching a tiedown to the forward left main rotor blade and he then attached this tiedown to the left front skid cross tube. Several hours later, the pilot entered the right front seat to begin the engine start sequence. The operator reported that the pilot proceeded to start the engine and noted a few seconds after initiating the engine start that the helicopter made an "unusual noise" and began to shake. The pilot then shut down the helicopter without further incident. A postflight inspection revealed substantial damage to the blue main rotor blade. The operator reported there were no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.

## Factual narrative

The operator reported that the pilot landed and shutdown the helicopter on an offshore platform. He secured the main rotor system by attaching a tiedown to the forward left main rotor blade and he then attached this tiedown to the left front skid cross tube. Several hours later, the pilot entered the right front seat to begin the engine start sequence. The operator reported that the pilot proceeded to start the engine and noted a few seconds after initiating the engine start that the helicopter made an "unusual noise" and began to shake. The pilot then shut down the helicopter without further incident. A postflight inspection revealed substantial damage to the blue main rotor blade. The operator reported there were no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. The Bell Helicopter 407 Rotorcraft Flight Manual lists the preflight check areas in Section 2 Normal Procedures. Regarding the exterior check, this manual states in part; 2-3-B-1. Fuselage – Cabin Right Side 1. All main rotor blades – tiedowns removed, condition. There is also a warning in this section that states, "Failure to remove rotor tiedowns before engine starting may result in severe damage and possible injury."

## Aircraft

- Registration: [N420PH](https://openairdocs.org/aircraft/N420PH), registered now, S/N 53747, built 2007 (OpenAirDocs)
- Reported make and model: BELL 407 (NO SERIES)
- Registry model: [Bell 407](https://openairdocs.org/model/bell-407) (registry code 1182206) (OpenAirDocs)
- Registry engine: [Rolls-Royce 250-C47B](https://openairdocs.org/engine/rolls-royce-250-c47b) (registry code 54585, turbo-shaft) (OpenAirDocs)
- Category: Helicopter
- Serial number: 53747
- Year built: 2007
- Airframe hours: 9015.86
- Engines: Rolls-Royce 250-C47B 630 horsepower turbo shaft
- Damage: Substantial damage
- Flight: Part 135
- Operator: Phi Inc.
- Registered owner: Phi Inc.
- Airworthiness certificate: Standard, Normal
- Last inspection: AAIP, December 17, 2014
- Departed: 149, Cameron, LA
- Destination: 167, Cameron, LA
- Airport: 167, West Cameron 167
- Equipment: Satellite tracking device

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 49; injuries: none; flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane, helicopter; medical: class 1, with waivers/limitations; last flight review June 21, 2015; seat: right; restraint: 4-point; flight hours: 3,104 total, 313 in this make and model, 1,918 as pilot in command, 150 in the last 90 days, 36 in the last 30 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 180° at 13 knots, gusting 20
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 75 °F, dew point 73 °F
- Altimeter: 29.92 inHg
- Observed at: KVBS, 11 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 (OpenAirDocs).

- [Accident 20151030019639A](https://openairdocs.org/incident/20151030019639A), Oct 30, 2015: Bell 407, Gulf Of Mexico, Substantial damage. On the morning of October 30, 2015 the pilot and aircraft began the operational day at high island a 264, an offshore platform located in the Gulf Of Mexico.…

## Docket (2 files)

The files NTSB released with the investigation on January 28, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92283. 2.2 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436183&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- Accident Photo (Courtesy of Operator) (item 2, .PDF, 1 photo, 311 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436184&FileExtension=.PDF&FileName=Accident%20Photo%20(Courtesy%20of%20Operator)-Master.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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