LAX04TA052

NTSB accident investigation · Eurocopter France AS 350 B3 · Yuma, AZ · November 25, 2003

Accident · No injuriesFinal report
Date
November 24, 2003, 19:00 local (Nov 25, 2003, 02:00 UTC)
Place
Yuma, AZ
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N846BPEurocopter France AS 350 B3
Weather
Visual (VMC) · Night/bright
Status
Completed · report December 28, 2004
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20031124031279A
Case key
58399

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 malfunction of the rotor drive system due to improper maintenance, which resulted in the uncoupling of the drive shaft during takeoff-initial climb. A factor associated with the accident is the undertorqued drive system bolts.

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/malfunctionTakeoff - initial climb
Miscellaneous,bolt/nut/fastener/clamp/spring - undertorquedFactor
Miscellaneous,bolt/nut/fastener/clamp/spring - not safetiedCause
Miscellaneous,bolt/nut/fastener/clamp/spring - failure,totalCause
Maintenance - improperCompany maintenance personnelCause
Forced landingEmergency landing after takeoff
Hard landingEmergency landing

Analysis

The helicopter encountered a total loss of drive to the rotor system a few seconds after takeoff, about 20 feet above the ground. The helicopter touched down hard and was substantially damaged. Company mechanics had performed maintenance on the helicopter that involved handling of the rotor drive shaft and a flex coupling. The flex coupling is normally secured with three bolts and self locking nuts. The manufacturer's maintenance procedure requires that during installation, the nuts are torqued and then cotter pins are inserted. During the wreckage examination, the bolts were found sheared, and no evidence of cotter pins were found. According to the manufacturer, even if the cotter pins are not installed, if the bolts are adequately torqued, they should not become loose.

Factual narrative

On November 24, 2003, about 1900 mountain standard time, a Eurocopter AS 350 B3, N846BP, made a hard forced landing at the Yuma MCAS International Airport, Yuma, Arizona. The commercial pilot and a crewmember (observer) sustained no injuries. The helicopter was owned and operated by the United States Border Patrol (USPB), Air Operations, El Paso, Texas, and it was substantially damaged during the public-use flight. Visual meteorological conditions prevailed during the nighttime patrol flight that was performed under the provisions of 14 CFR Part 91. A company flight plan was filed. The flight was originating at the time of the accident.

The operator indicated that a few seconds after taking off, a mechanical malfunction occurred about 20 feet above ground level. The pilot made a forced landing during which the helicopter touched down hard.

During the subsequent examination of the helicopter, the flex coupling between the engine drive shaft and the main gear box drive was found separated. The three bolts in the flex coupling assembly were found sheared. A further examination of the bolts revealed that they were devoid of three required cotter pins.

The American Eurocopter Corporation's U.S. manager of accident investigation reported to the National Transportation Safety Board investigator that company records indicated that the accident helicopter was delivered to the USPB with the cotter pins installed. A subsequent examination of the broken components in the wreckage revealed evidence that at some point in time cotter pins had been installed in the bolts. However, no cotter pins were found in the wreckage.

American Eurocopter’s accident investigation manager opined that the component examination performed by Eurocopter France's materials laboratory indicated that both sides of the flats on the recovered nuts revealed evidence of marks consistent with mechanical damage (see attached report).

Maintenance records indicated that, following the helicopter's sale to the USBP, USBP mechanics performed a module 1 change. In addition, other maintenance was performed such as installation of an air conditioner. This maintenance may have involved manipulation of the drive.

Maintenance or handling of the drive, if performed in accordance with Eurocopter's maintenance manual, would have required removing the three cotter pins and unscrewing (untorquing) the self locking flex coupling bolts.

Regarding the effect of having the flex coupling disconnect, according to American Eurocopter's manager of accident investigation, when the bolts sheared, their disconnection from the drive shaft to the coupling flange link resulted in a total loss of drive to the rotors. The manager further reported that when properly installed, the subject self locking nuts are torqued, and then they are cotter pinned. Even if the cotter pins are not installed, when properly torqued the nuts should not unscrew.

Aircraft

Registration
N846BP
Reported as
Eurocopter France AS 350 B3
Category
Helicopter
Serial number
3542
Airframe hours
813
Engine
Turbomeca Arriel A2, 847 horsepower, turbo shaft
Damage
Substantial damage
Flight
Public aircraft · Public use
Registered owner
U.S. Border Patrol, Air Operations
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · November 20, 2003 · 13 hours before
Departed
YUM · Yuma, AZ
Destination
YUM
Flight plan
Company VFR
Airport
YUM · Yuma MCAS International

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
45
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
July 10, 2003
Seat
Right
Flight hours
6,273 total · 202 in this make and model · 4,921 as pilot in command · 250 in the last 90 days · 60 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/bright
Wind
40° at 6 knots
Visibility
10 statute miles
Lowest ceiling
12,000 ft broken
Temperature
61 °F, dew point 19 °F
Altimeter
29.88 inHg
Observed at
YUM

Docket · 3

The files NTSB released with the investigation on November 4, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.4 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.