LAX00FA130

NTSB accident investigation · Bell 212 · Snelling, CA · March 19, 2000

Accident · FatalField investigationFinal report
Date
March 19, 2000, 15:45 local (23:45 UTC)
Place
Snelling, CA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N415BBell 212
Weather
Visual (VMC) · Day
Status
Completed · report November 25, 2003
Report
Approved by Office Director
Parties
Pratt & Whitney, Bell Helicopter, Federal Aviation Administration
FAA report
20000319009389A
Case key
48837

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 in-flight separation of the main rotor mast while in cruise flight following a mast bumping event. The reason for the mast bumping event was not determined.

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/malfunctionCruise
Rotor drive system,main rotor mast(drive shaft) - bumpedCause
Rotor drive system,main rotor mast(drive shaft) - separationCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The twin-engine helicopter impacted terrain following a mast bumping event and subsequent the loss of control. The helicopter was the second in a flight of two and trailed the lead helicopter by a short distance. The lead pilot noticed the second helicopter wreckage after the pilot did not receive a radio response from the accident pilot; he reported receiving no distress transmissions from the accident pilot. The first helicopter pilot reported they were in cruise flight between 400 - 500 feet agl at 100 knots. He said that he encountered a large bird about 1 mile before the accident. A 12-foot section of one of the main rotor blades was found early on in the wreckage debris path, which equaled approximately 1,000 feet in length and was oriented along the flight's course. Cut portions of the left skid, battery door, and the left elevator were found early on in the debris path. The separated main rotor blade underwent an overhaul approximately 8.3 hours prior to the accident. The main rotor mast displayed evidence of a mast bumping event, with indentations corresponding to the blade stops. The mast separated at the blade stop area. The commercial helicopter pilot was wearing a cast on his right leg, which extended from below his knees to his toes. The pilot received a check-out flight after not flying for 3 months. According to the pilot who provided the check-out flight, the accident pilot performed a few traffic pattern operations and was found to be able to fly. A mechanic who flew with the accident pilot during the first legs of the flight indicated the pilot was able to fly with no problems. Though there was evidence of a mast bumping event, the initiating event is unknown. Examination of the wreckage disclosed no anomalies that would have prevented normal system operation and the engines displayed evidence of rotation at the time of ground impact. The main rotor blade with the separated section was examined and it was noted that its failure was a result of overload separation and did not delaminate in flight.

Factual narrative

History of flight

On March 19, 2000, at 1545 Pacific standard time, a Bell 212 helicopter, N415B, was destroyed after impacting terrain following a loss of control while in cruise flight near Snelling, California. The commercial pilot, who was the sole occupant, received fatal injuries. The aircraft was being operated as a positioning flight by Aviation International Rotors (A.I.R.), Inc., Apple Valley, California, under 14 CFR Part 91 when the accident occurred. The flight originated from Fresno, California, at 1515, and was destined for Sacramento, California. Visual meteorological conditions prevailed at the time and a company visual flight rules (VFR) flight plan had been filed.

The accident helicopter was second in a flight of two en route to Sacramento. Both helicopters departed Apple Valley, made fuel stops in Bakersfield, California, and Fresno before continuing on to their final destination of Sacramento. The lead pilot reported that they were cruising about 800 feet mean sea level (msl), or 400 to 500 feet above ground level (agl), over rolling terrain. The pilot estimated that the accident aircraft was echelon right, and about eight rotor disks to the rear, with cruise airspeed of about 100 knots. Both aircraft were on a common air-to-air frequency and had been communicating previously with no reported difficulties.

As the flight neared the Snelling Highway northeast of Merced, the lead pilot called the accident pilot, asking about his fuel consumption rate. When he did not receive a reply, he turned his helicopter 180 degrees to look for the other helicopter. As he did, he saw a column of black smoke. He flew toward the smoke, and as he neared, he realized the second helicopter had crashed and was nearly engulfed with flames.

He immediately landed his helicopter, deplaned, and approached the burning wreckage to aid the pilot, but was driven back by the heat and flames. Realizing that there was nothing further he could do, he got back into his helicopter and flew to Castle Airport (located in Atwater, California, approximately 11 miles southwest of the accident site), where he reported the accident to authorities and the operator.

The lead pilot reported he had an encounter with a large bird about a mile back along the flight path from the accident site.

Personnel information

The non-instrument rated commercial helicopter pilot had accumulated 6,200 total flight hours, of which approximately 500 hours were in the same make and model as the accident helicopter. He obtained a second-class medical certificate, which was issued on May 11, 1999, with a limitation for corrective lenses, and a waiver for blood pressure.

The pilot underwent surgery in December 1999, to adjust for flat feet. As a result of the surgery, the pilot wore a cast on his right lower leg that extended from just below his knee to his toes.

The pilot did not fly after the surgery until the day of the accident. He received a check-out flight from the pilot of the lead helicopter before they departed on their trip. The purpose of the flight was to see if the cast would inhibit the pilot's ability to fly the helicopter. According to the chief pilot, both the lead and accident pilots determined that the accident pilot would be able to fly.

According to the lead pilot, the accident pilot was mentally ready and excited to fly. The accident pilot assured the lead pilot that his personal doctor had released him to work and he was ready to fly. The check-out flight lasted less than 30 minutes and included operations in the traffic pattern. He reported noting no problems with the accident pilot's ability to fly the helicopter.

Aircraft information

The twin-engine helicopter (serial number 30613) was powered by two Pratt & Whitney PT-6-3 engines. The helicopter's main rotor group included a two-blade, semi-rigid type rotor, and a stabilizer bar with dampers. The rotor hub yoke was underslung on its mounting trunnion through two pillow blocks, which provided a flapping axis. The all metal blades were attached through grips, which rotated on yoke spindles to change blade pitch. The helicopter's paint scheme (from the skid crossover tubes to the transmission/engine area) consisted of horizontal bands of red, blue, white, blue, and white.

Review of helicopter maintenance records revealed that the helicopter underwent its last annual inspection on March 15, 2000, at an airframe total time of 15,184.8 hours. According to the maintenance log, the following work was conducted during the annual inspection:

Inspection of Hangar Assemblies

Overhaul of Tail Rotor Hub Assembly

Overhaul Main Drive Shaft

Overhaul Pylon Assembly

Main Rotor Head Strap Change

Overhaul Main Transmission

At the time of the annual inspection, one of the two blades (the white blade, P/N 212015501-115, S/N A-2991) was removed for rework and repair. The total time on the blade since manufacture was 1,861 hours. The Historical Service Record for the blade indicated that on December 20, 1999, it underwent the following actions: "Inspected I.A.W. [in accordance with] 204-099-223 vol. XI, repaired the lower surface skin at station 70 to 74.5 per IAC-8110-0386, repaired the upper and lower surfaces spar doublers at the tip, installed a full chord skin repair on the upper and lower surface at the tip, replaced the abrasion strip, replaced the inboard leading edge splice cover, replaced the forward tip cap, replaced the main attachment bushing, refinished the paint and static balanced per BHT [Bell Helicopter Textron] spec[ifications]." The blade had accumulated 8.3 hours at the time of the accident since its reinstallation.

A mechanic flew with the accident pilot on the Apple Valley to Bakersfield, and Bakersfield to Fresno legs of the flight. According to the mechanic's written statement, he performed the daily preflight inspections along with the pilot on the morning of the accident. The pilot requested approximately 2 cups of oil in the combined gearbox, to which the mechanic complied and added the oil. The mechanic reported they departed for the first leg of flight and during the takeoff climb, the accident pilot radioed the lead pilot alerting him of a torque split of approximately 30 percent. The lead pilot asked if the accident pilot had verified the number 2 throttle was "full open with friction?" The accident pilot responded that he would verify. The mechanic added the lead pilot was correct and the engine torque indications were then "matched perfectly," and they continued to Bakersfield. The mechanic reported the remainder of the flight to Bakersfield, and the flight to Fresno, were uneventful, and the pilot flew "perfectly."

Meteorological information

According to the lead pilot, the weather at the time of the accident was described as unlimited visibility, with clear skies, and wind from 330 degrees at 20 knots gusting to 30 knots.

Wreckage and impact information

Merced county sheriff's deputies reported when rescue personnel reached the scene, about 2 hours after the crash, the fire had burned itself out. The debris path extended along the approximate route of flight on a bearing of about 300 degrees covering a distance of nearly 1,000 feet. The main wreckage came to rest at 37 degrees 29.182 minutes north latitude and 120 degrees 21.038 west longitude.

One of the first pieces of debris found was a nearly 12-foot section of the honeycomb airfoil from the white blade. Its separation from the blade began outboard of the doublers, ran along the leading edge D-spar, and continued to within about 2 feet of the tip. The skin on the separated upper surface of the blade was rolled back toward the trailing edge. The outboard 2 feet of blade, excluding the leading edge spar, was located further along the debris path, but forward of the main wreckage.

The left skid and left step, with a corresponding gr

Aircraft

Registration
N415B
Reported as
Bell 212
Category
Helicopter
Serial number
30613
Airframe hours
15,190.8
Engines
Pratt & Whitney PT-6-3, 1,500 horsepower, turbo shaftPratt & Whitney PR-6-3, 1,500 horsepower, turbo shaft
Damage
Destroyed
Fire
On-Ground
Flight
Positioning · Part 91
Registered owner
Aviation International Rotors
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 1, 2000 · 7 hours before
Departed
FAT · Fresno, CA
Destination
SMF · Sacramento, CA
Flight plan
Company VFR

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
40
Injuries
Fatal
Certificate
Commercial
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
February 23, 1999
Seat
Left
Toxicology
Performed
Flight hours
6,200 total · 500 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 13 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
68 °F, dew point 45 °F
Altimeter
29.00 inHg
Observed at
MCE, 15 nm away

Docket · 35

The files NTSB released with the investigation on September 16, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 16.2 MB in all.

Materials Laboratory 15 - Factual Report of Group ChairmanItem 1 · .PDF · 710 KBOther Pertinent Forms and Reports - Bell HelicopterItem 2 · .PDF · 417 KBOther Pertinent Forms and Reports - Blade Deviation CalculationsItem 3 · .PDF · 73 KBOther Pertinent Forms and Reports - Pratt and WhitneyItem 4 · .PDF · 71 KBReceipt of Returned PartsItem 5 · .PDF · 73 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 6 · .PDF · 311 KBMaintenance Record ExcerptsItem 7 · .PDF · 812 KBToxicological ReportItem 8 · .PDF · 55 KBWitness StatementItem 9 · .PDF · 117 KBPhoto 1 - Separated section of white blade and section on left skidItem 10 · .PDF · 806 KBPhoto 2 - Section of left skid with main wreckage in backgroundItem 11 · .PDF · 778 KBPhoto 3 - Main wreckage viewed from main rotor bladesItem 12 · .PDF · 803 KBPhoto 4 - Main rotor bladesItem 13 · .PDF · 684 KBPhoto 5 - Another view of main rotor bladesItem 14 · .PDF · 691 KBPhoto 6 - Mast separationItem 15 · .PDF · 103 KBPhoto 7 - Main rotor mastItem 16 · .PDF · 113 KBPhoto 8 - White bladeItem 17 · .PDF · 111 KBPhoto 9 - Red bladeItem 18 · .PDF · 110 KBPhoto 10 - Tail rotor drive componentsItem 19 · .PDF · 1.2 MBPhoto 11 - Red blade drag braceItem 20 · .PDF · 101 KBPhoto 12 - Main wreckageItem 21 · .PDF · 89 KBPhoto 13 - Right seat and controlsItem 22 · .PDF · 120 KBPhoto 14 - Metallic deformation on elevator fracture surfaceItem 23 · .PDF · 629 KBPhoto 15 - Wreckage layoutItem 24 · .PDF · 1.1 MBPhoto 16 - Tail rotor bladeItem 25 · .PDF · 808 KBPhoto 17 - Layout of white bladeItem 26 · .PDF · 593 KBPhoto 18 - Tail rotor drive shaft layoutItem 27 · .PDF · 1.0 MBPhoto 19 - Tail rotorItem 28 · .PDF · 976 KBPhoto 20 - ElevatorItem 29 · .PDF · 1.1 MBPhoto 21 - Elevator barItem 30 · .PDF · 128 KBPhoto 22 - Nose compartment access doorItem 31 · .PDF · 1.0 MBPhoto 23 - Outboard trailing edge fo white bladeItem 32 · .PDF · 130 KBPhoto 24 - Elevator, tail boomItem 33 · .PDF · 113 KBPhoto 25 - Instrument panelItem 34 · .PDF · 100 KBPhoto 26 - Profile view of red bladeItem 35 · .PDF · 97 KB

FAA reports on this event · 1

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