LAX06LA072

NTSB accident investigation · Eurocopter AS350BA · Hana, HI · January 10, 2006

Accident · Serious injuriesLimited investigationFinal report
Date
January 10, 2006, 08:45 local (18:45 UTC)
Place
Hana, HI
Injuries
1 serious, 4 minor
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N3607PEurocopter AS350BA
Weather
Visual (VMC) · Day
Status
Completed · report June 27, 2007
Report
Approved by Office Director
Parties
ACRO Helipro, Turbomeca USA, Sunshine Helicopters, American Eurocopter, Federal Aviaiton Administration
Case key
63017

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 total loss of engine power due to a fatigue failure of a turbine blade. A factor in the accident was the lack of a suitable forced landing site.

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.

Loss of engine power(total) - mech failure/malfCruise
Turbine assembly,turbine blade - fatigueCause
Turbine assembly,turbine blade - failure,totalCause
Forced landingEmergency descent/landing
Terrain condition - mountainous/hillyFactor
Terrain condition - high vegetationFactor
Terrain condition - none suitableFactor
Autorotation - performedPilot in command
In flight collision with objectEmergency landing
Object - tree(s)

Analysis

While flying a sightseeing tour over a dense tropical forest the helicopter experienced a total loss of engine power and autorotated into the forest canopy. Forty-four minutes into a 1-hour sightseeing tour the helicopter vibrated, shuddered, and the low rotor rpm warning horn sounded. The pilot entered an autorotation and tried to arrest the helicopter's forward velocity before settling into the treetops. The helicopter dropped nose first towards the forest floor, and came to rest on its right side suspended in the trees a few feet from the ground. During the subsequent engine examination it was determined that a turbine blade from the second stage gas producer turbine had separated from the turbine wheel. A material laboratory analysis determined that the turbine blade failure was a result of a fatigue fracture that was initiated at a corrosion/oxidation pit. As a result of the investigation into the engine failure, the engine manufacturer has reduced the life limit of the second stage turbine blades from 6,000 hours to 3,000 hours, and implemented additional turbine inspection criteria.

Factual narrative

History of flight

On January 10, 2006, at 0845 Hawaiian standard time, a Eurocopter AS350BA, N3607P, experienced a loss of engine power and autorotated into a dense tropical forest on a steep slope near Hana, Maui, Hawaii. Sunshine Helicopters, Inc., operated the helicopter as a scenic tour flight under the provisions of 14 CFR Part 135. The four passengers received minor injuries and the airline transport pilot was seriously injured. The helicopter was destroyed. Visual meteorological conditions prevailed, and a company flight plan had been filed. The sightseeing flight duration is about an hour and returns to the departure airport. The scenic tour flight departed Kahului Airport, Maui, at 0807.

The pilot stated that following a viewing of Haleakala Crater, they proceeded to enter the Manawainui Gulch to view the waterfalls there. The pilot maneuvered the helicopter to exit the gulch and proceeded north over the Maui rainforest. At this time the helicopter vibrated, shuddered, and the low rotor rpm warning horn sounded. The pilot entered an autorotation and attempted to arrest the helicopter's forward velocity before settling into the canopy of treetops. The helicopter dropped nose first towards the forest floor, and came to rest on its right side suspended in the trees a few feet from the ground. The four passengers and the pilot were able to lower themselves to the ground and called for assistance using a cell phone.

Aircraft information

The Eurocopter AS350BA helicopter is a six passenger, single pilot, single engine aircraft, with a traditional main rotor and tail rotor configuration. The operator reported a total airframe time of 14,007 hours at the time of the accident, and a 100-hour inspection had been completed on December 28, 2005.

The helicopter was equipped with a video recording system that could record images outside the helicopter and inside the cockpit. The video recording utilized VHS cassette tape and compact flash memory. The video recording system was operating at the time of the accident.

The engine was a Turbomeca Arriel 1B, serial number 4467. Examination of the engine logbook revealed that the engine had operated for 9,593 hours since new, and 1,764 hours since the last overhaul. The engine maintenance logbook documented that Module 3, the gas generator section, was removed, and replaced with an overhauled module on September 14, 2004. The overhaul on the replacement module had been completed by the ACRO Helipro Company on August 23, 2004. The overhaul included the replacement of the second stage turbine blades with overhauled turbine blades. Turbomeca specified the life limit of turbine blades for the Arriel 1B to be 6,000 hours. The overhauled blade set was documented to have 2,986.2 hours at the time of the turbine overhaul. The module had accumulated an additional 1,763.5 hours, and 1,712 cycles since the overhaul.

Wreckage & impact information

The wreckage was recovered to the Kahului Airport and examined by a National Transportation Safety Board investigator on January 13, 2006. An onboard video recording was removed from the wreckage and sent to the Safety Board Vehicle Recorders Laboratory, Washington, D.C., for further documentation and viewing. The engine was removed and crated, under the supervision of the Safety Board investigator, for shipment to the manufacturer in order to conduct a detailed teardown and examination.

Tests & research

On January 26, 2006, the engine was examined by representatives from Turbomeca USA, Sunshine Helicopters, ACRO Helipro, American Eurocopter, and the Federal Aviation Administration (FAA), under the supervision of the Safety Board investigator-in-charge (IIC), at the Turbomeca facility, Grand Prairie, Texas. Details of the examination are in the public docket of this report.

The engine was removed from the shipping crate and placed on an engine stand. The engine had localized sooting with no foreign debris observed. The exhaust duct exhibited a large amount of interior dents. Dents varied in size from 2 mm to 10 mm.

Upon disassembly of module 3, the gas generator high pressure turbine section, it was observed that the second stage turbine (T2) blade tips all exhibited fractures, and a single blade had separated at the blade platform flush with the disk circumference. The missing blade fir tree base was not displaced axially, the fracture surface was gray in color and granular in texture. The first stage turbine (T1) exhibited minor blade tip rubbing. All turbine blades and blade locks were present on the power (free) turbine. The blades exhibited substantial mechanical damage to all blade tips. The T2 turbine wheel and blades were removed from module 3 and sent to the Safety Board Materials Laboratory, Washington, D.C., for further metallurgical analysis.

Materials Laboratory Examination

The 2nd stage turbine disk with fractured blades was examined at the Safety Board Materials Laboratory. The disk face was labeled with part number 0292253250 and serial number ADE 2318YC. Engine records indicated that disk ADE2318YC was part of gas generator (module 3), s/n 4801TEC, and had accumulated 4,749.8 hours and 4,589 cycles since new. Module 3, 4801TEC, had accumulated 1,763.5 hours, and 1,712 cycles since its overhaul and installation in this engine, in September 2004. All blades were tight in the disk with the locks in-place and properly deformed.

All of the 2nd stage blades, except one, were fractured through the airfoil sections. The excepted blade was fractured through the "fir tree" area just below the platform. Microscopic examinations also uncovered a crack in the fir tree of another nearby blade. Each blade was marked with a sequence number 1 thru 27. However, the sequence numbers were not in order nor did they match the disk slot numbers. The fractured blade was marked 23 and the cracked blade was marked 25.

Examinations of the airfoil fractures revealed features indicative of overstress separations. Close inspection of the blade (23) fracture through the fir tree area uncovered a darker oxidized region which contained features consistent with fatigue propagation followed by overstress separation. The plane of the fracture was in the most outboard fir tree radius just below the blade platform.

The fatigue region was at the aft (trailing edge) side of the blade below the platform. Fracture marking indicated fatigue initiation at the aft trailing corner in the cutout portion of the fir tree. As viewed with the blade installed in the disk, the fatigue region of the blade was somewhat obscured by tan colored material consistent with "engine dust" and darker unidentified material. Blade 23 was removed from the disk and ultrasonically cleaned in acetone for further examinations.

The oxidized area of the blade showed three regions with differing fracture features. In the initial region, the fracture was relatively smooth and flat with marking typical of fatigue propagation in nickel based alloys. The area adjacent to the smooth region displayed a much rougher topography with some crack arrest marks. To the right (forward) of the rough region, the fracture was relatively clean with little oxidation, and contained features typical of overstress separations in cast high temperature alloys.

High magnification optical examinations revealed a shallow rounded pit on the trailing fir tree surface at the fatigue origin. The pit and fatigue initiation area were just outboard of the blade-to-disk contact area indicated by the fretting pattern on the blade.

The fracture face of blade 23 was further tape replica cleaned and examined on the scanning electron microscope (SEM). High magnification viewing uncovered finely spaced and oxidized fatigue striations throughout the initial fatigue region. Ratchet marks and striation orientations established that fatigue initiation was at multiple

Aircraft

Registration
N3607P
Reported as
Eurocopter AS350BA
Category
Helicopter
Serial number
1249
Airframe hours
14,007
Engine
Turbomeca Arriel 1B, 650 horsepower, turbo shaft
Damage
Destroyed
Flight
Part 135
Registered owner
Sunshine Helicopters, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · December 1, 2005
Departed
KOGG · Kahului, HI
Flight plan
Company VFR
Airport
KOGG · Kahului

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
59
Injuries
Serious
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2
Last flight review
April 1, 2005
Seat
Right
Flight hours
17,350 total · 5,920 in this make and model · 17,350 as pilot in command · 260 in the last 90 days · 98 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 10 knots
Visibility
15 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 70 °F
Altimeter
30.10 inHg
Observed at
PHHN, 5 nm away