LAX02LA121

NTSB accident investigation · Rotorway Exec 165F · Chandler, AZ · April 1, 2002

Accident · Serious injuriesLimited investigationFinal report
Date
April 1, 2002, 09:55 local (16:55 UTC)
Place
Chandler, AZ
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N21901Rotorway Exec 165F
Weather
Visual (VMC) · Day
Status
Completed · report February 5, 2004
Report
Approved by Office Director
Parties
Federal Aviation Inspector
FAA report
20020401005029A
Case key
54436

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 tail rotor drive system failure as a result of incorrect installation procedures by the manufacturer's 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.

Airframe/component/system failure/malfunctionApproach - vfr pattern - final approach
Maintenance,installation - improperManufacturerCause
Rotor drive system,tail rotor drive shaft - failureCause
Loss of control - in flightApproach - vfr pattern - final approach
Tail rotor/anti-torque control - not availableCause
Directional control - not possiblePilot in command
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The helicopter collided with the ground following a loss of tail rotor drive during a steep approach. After performing various maneuvers, the certified flight instructor (CFI) and the student began traffic patterns to a landing zone (LZ). On short final, approximately 40 feet agl, and 40 mph, the helicopter yawed left slowly. When the helicopter had reached a 45-degree left yaw, the CFI took the controls. As the helicopter approached a 90-degree left yaw, the CFI had applied full right pedal. Simultaneously, he lowered the collective and reduced power. The helicopter rotated 360 degrees about 3 times before impact. Post accident inspection revealed incorrect installation of the forward end of the intermediate drive belt on the intermediate pulley group. The tail rotor drive system uses three belts, interconnected via pulleys at various points within the tail boom, to drive the tail rotor. The forward and aft belts and pulleys were normal. The intermediate belt was found shredded, burned, and separated. The aft end of the intermediate belt was positioned correctly on the rear pulley; however, the forward end was around the wrong pulley, the one meant for the forward belt, which induced a large misalignment of the intermediate belt and consequent rub between it and the pulley side. All pulleys were installed with specified tightness and with fore/aft play as stated in the maintenance manual. Maintenance records for the helicopter indicated that the belts were replaced twice in the past 8 months, both times by the manufacturer. The first time was in August 2001, for a heavy maintenance rebuild. The second time was in November 2001 following a tail rotor strike. The belts had about 200 hours operating time since their last replacement in November.

Factual narrative

On April 1, 2002, at 0955 mountain standard time, a Rotorway Exec 165F helicopter, N21901, collided with the ground following a loss of tail rotor drive during a steep approach near Chandler, Arizona. The helicopter, owned and operated by Rotorway International under 14 CFR Part 91, was on a local area instructional flight. The helicopter sustained substantial damage. The commercial pilot/flight instructor sustained serious injuries, and an airline transport pilot student sustained minor injuries. Visual meteorological conditions prevailed and no flight plan was filed. The flight departed from Stellar Airpark, Chandler, about 0900.

The CFI reported that after performing various maneuvers, he and the student began traffic patterns to a landing zone (LZ). On short final, approximately 40 feet, and 40 miles per hour (mph), the helicopter yawed left slowly. When the helicopter had reached a 45-degree left yaw, the CFI took the controls. As the helicopter approached a 90-degree left yaw, the CFI had applied full right pedal. Simultaneously, he lowered the collective and reduced power. The helicopter rotated 360 degrees about 3 times before impact. The helicopter impacted the ground, collapsing the right skid, and coming to rest on its right side.

The helicopter was examined at Rotorway International in Chandler under the auspices of the Federal Aviation Administration (FAA) inspector. He reported that the tail rotor drive system uses three belts, interconnected via pulleys at various points within the tail boom, to drive the tail rotor. The forward and aft belts and pulleys were normal. The intermediate belt was found shredded, burned, and separated. The aft end of the intermediate belt was positioned correctly on the rear pulley; however, the forward end was around the wrong pulley, the one meant for the forward belt, which induced a large misalignment of the belt and consequent rub between it and the pulley side. All pulleys were installed with specified tightness and with fore/aft play as stated in the maintenance manual. The engine, clutch, drive belt system, and transmission were found in working order.

Maintenance records for the helicopter indicated that the belts were replaced twice in the past 8 months. The first time was in August 2001, for a heavy maintenance rebuild. The second time was in November 2001 following a tail rotor strike. The belts had about 200 hours operating time since their last replacement in November.

On April 4, 2002, Rotorway International issued a Mandatory Compliance Bulletin M-20 that required immediate inspection to verify proper routing of tail rotor drive belts through the tail boom. Any belt not properly routed into the correct idler pulley groove required immediate replacement.

Aircraft

Registration
N21901
Reported as
Rotorway Exec 165F
Category
Helicopter
Serial number
6035
Airframe hours
1,776
Engine
Rotorway 162F, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Registered owner
Cobb International, Inc.
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Continuous airworthiness · March 18, 2002 · 12 hours before
Departed
P19 · Chandler, AZ

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
47
Injuries
Serious
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
April 30, 2000
Seat
Right
Flight hours
1,600 total · 800 in this make and model · 1,500 as pilot in command
Role
Student pilot
Age
55
Injuries
Minor
Certificates
Flight engineer, Flight instructor, Airline transport, Commercial
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
November 17, 2001
Seat
Left
Flight hours
17,000 total · 1 in this make and model · 13,000 as pilot in command · 180 in the last 90 days · 60 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
0° at 0 knots
Visibility
35 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 34 °F
Altimeter
29.87 inHg
Observed at
KCHD, 8 nm away

Docket · 8

The files NTSB released with the investigation on November 25, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.4 MB in all.

FAA reports on this event · 1

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

Other investigations on N21901 · 1

Matched to the same aircraft by N-number and date.