GAA16LA056

NTSB accident investigation · Airbus EC135 · Apple Valley, CA · November 19, 2015

Accident · No injuriesLimited investigationFinal report
Date
November 19, 2015, 11:50 local (19:50 UTC)
Place
Apple Valley, CA
Injuries
5 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N36RXAirbus EC135
Defining event
Landing: Airport occurrence
Weather
Visual (VMC) · Day
Status
Completed · report November 29, 2016
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA Riverside FSDO
Case key
92344

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The ingestion of a towel from an unsecured storage container at the landing site into the helicopter's fenestron during the landing.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Airport facilities/design: securityEnvironmental issues › Operating environment · Effect on equipmentEurocopter Deutschland EC 135 P2+: 1 caseAll aircraft: 4 casesProbable cause
Object/animal/substance: debris/dirt/foreign objectEnvironmental issues › Physical environment · Effect on equipmentEurocopter Deutschland EC 135 P2+: 2 casesAll aircraft: 101 casesProbable cause
Tail rotorAircraft › Aircraft propeller/rotor · Damaged/degradedEurocopter Deutschland EC 135 P2+: 3 casesAll aircraft: 23 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

According to the airline transport pilot, firefighting personnel were using the helicopter for training to simulate patient loading and unloading. The training consisted of multiple takeoffs and landings from the training center landing site. The pilot reported that, during the third landing, when the helicopter was between 2 and 3 ft above ground level, he felt it shudder unexpectedly. The pilot immediately landed and shut down the helicopter without further incident. The pilot reported that there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. A postflight examination revealed that a towel had been ingested into the fenestron, which resulted in substantial damage to the fenestron tail rotor blades, fenestron housing body, tailboom, and tail rotor drive shaft flex couplings. The pilot reported that the towel had migrated from an unsecured storage container near the landing site. The investigation revealed that, when the towel was ingested, the fenestron hub fairing detached from the hub body, which was then ingested by the fenestron tail rotor blades. The operator's director of maintenance reported that a postaccident examination revealed that all of the main rotor blades "received a small amount of [foreign object damage] FOD…at middle cord line near the tips" and that the "damage was the result of FOD from the Fenestron [hub fairing ingestion] after the towel was ingested." This evidence indicates that the hub fairing body becoming detached due to the ingestion of the towel contributed to the severity of the damage.

Factual narrative

On November 19, 2015, about 1150 Pacific standard time, an air ambulance Airbus EC-135P2+ helicopter, ingested foreign object debris (FOD) into the Fenestron during an approach to the Victor Valley College Regional Public Safety Training Center in Apple Valley, California. The commercial pilot and four passengers were not injured, and the helicopter sustained substantial damage. The helicopter was registered to and operated by Reach Air Medical Services LLC, Santa Rosa, California, under the provisions of 14 Code of Federal Regulations Part 135 as a day, visual flight rules passenger flight. Visual meteorological conditions prevailed and a company visual flight rules flight plan was filed. The flight originated from the Victor Valley College Regional Public Safety Training Center in Apple Valley, California. Note: Various photos and diagrams of the Airbus EC-135 Fenestron, including labeling of the various parts, is located in the public docket of this accident under the Airbus EC-135 Fenestron Hub Fairing Report. According to the pilot, the helicopter was being utilized for training with firefighting personnel to simulate patient loading and unloading. The training consisted of multiple takeoffs and landings from the training center landing site. He reported that during the third landing, between two to three feet above ground level, he felt the helicopter "shutter unexpectedly." The pilot immediately landed and shut down the helicopter without further incident. A postflight inspection revealed that a towel had been ingested into the Fenestron. The pilot reported that the towel migrated from an unsecured storage container near the landing site. The helicopter sustained substantial damage to the Fenestron tail rotor blades, the Fenestron housing body, the tail boom, and the tail rotor drive shaft flex couplings. During the course of the investigation, it was discovered that when the towel was ingested, the Fenestron hub fairing detached from the hub body and it was ingested by the Fenestron tail rotor blades. The director of maintenance (DOM) for the operator reported that the tail rotor gearbox was shipped to the manufacturer for an inspection. Additionally, the DOM reported that all of the main rotor blades, "received a small amount of FOD damage at middle cord line near the tips" and that the "damage was the result of FOD from the Fenestron [hub fairing ingestion] after the towel was ingested." The pilot reported there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. WRECKAGE AND IMPACT INFORMATION Photos supplied by the operator showed pieces of the towel attached to various stators in the Fenestron housing body. Large gouges in the Fenestron housing body were present, consistent with impact from FOD. Small gouges were also present on the various Fenestron tail rotor blades, consistent with impact from FOD. The Fenestron hub fairing was not attached in the photos. Aphoto of the Fenestron hub fairing displayed it in numerous pieces, consistent with being destroyed by the impact of the Fenestron tail rotor blades. ADDITIONAL INFORMATION Safety Recommendation NORW-2007-073 In 2007, the Accident Investigation Board Norway (AIBN) along with the European Aviation Safety Agency (EASA) filed a formal safety recommendation to Eurocopter (Airbus) regarding the design of the Fenestron hub fairing. This safety recommendation was based on an Airbus EC-135 accident (2007/35) that occurred in Liagardene, Norway in 2006, which sustained similar damage due to similar accident sequence events. This safety recommendation from the AIBN states in part; The accident has revealed that the hub cover of the Fenestron on EC-135 can loosen when the rotor tips are bent out. A loosened cover will be sucked through the Fenestron and cause extensive damage. AIBN recommends that Eurocopter consider whether the fixing mechanism between the cover and hub could be changed to prevent loosening. The response from EASA states in part; EASA agrees with this recommendation. Eurocopter Deutschland (ECD) has launched a technical review of possible design improvements to the Fenestron hub cap installation; this might lead to a future design change if deemed suitable. However, no unsafe design features have been identified so far. In-flight loss (as well as all other three events reported to ECD) was accompanied by contact of the Fenestron/tail boom with obstacles. This safety recommendation was closed out with no further action. After multiple requests, the manufacturer did not respond to inquiries from the National Transportation Safety Board investigator-in-charge concerning what actions have been taken regarding the inadequate design of the Fenestron hub fairing attachment. Airbus EC-135 Fenestron Hub Fairing Information The Fenestron hub fairing is attached to the hub body with six attachment hardware assemblies. These hardware assemblies are inserted inside of a lip in the hub body, which covers the entire hub body. Once the hardware assemblies are inserted inside of the lip in the hub body, the screws are then tightened by a mechanic. A bore is located at the center of the fairing to aid with detachment, and is sealed with a plastic plug. Various photos, diagrams, and historical Airbus Fenestron FOD ingestion accident/incident information is located in the public docket of this accident under the Airbus EC-135 Fenestron Hub Fairing Report.

Aircraft

Registration
N36RX
Reported as
Airbus EC135 (P2+)
Category
Helicopter
Serial number
0859
Built
2009
Airframe hours
2,812
Engines
Pratt and Whitney PW206B2, 447 horsepower, turbo shaftPratt and Whitney PW206B2, 447 horsepower, turbo shaft
Damage
Substantial damage
Flight
Part 135
Operator
Reach Air Medical Services, LLC
Registered owner
Reach Air Medical Services, LLC
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · October 22, 2015
Departed
Apple Valley, CA
Destination
Apple Valley, CA
Flight plan
Company VFR
Equipment
Satellite tracking device, Electronic multifunction display, Auto-pilot

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
64
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, With waivers/limitations
Last flight review
October 2, 2015
Seat
Front
Restraint
4-point
Flight hours
17,000 total · 580 in this make and model · 8,500 as pilot in command · 64 in the last 90 days · 33 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 21 °F
Altimeter
30.12 inHg
Observed at
KVCV, 10 nm away

Docket · 6

The files NTSB released with the investigation on March 10, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.8 MB in all.