LAX90DUJ05

NTSB accident investigation · Bell UH-1E · Mesa, AZ · November 4, 1989

Accident · No injuriesFinal report
Date
November 4, 1989, 09:15 local (16:15 UTC)
Place
Mesa, AZ
Injuries
2 uninjured
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N138USBell UH-1E
Weather
Visual (VMC) · Day
Status
Completed · report June 30, 1992
Report
Approved by Office Director
FAA report
19891104044199A
Case key
26544

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 inflight separation of the tail rotor due to improper maintenance procedures and the installation of incorrect attachment hardware on the tail rotor blade pitch change linkages.

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/malfunctionManeuvering - aerial application
Rotor system,tail rotor hub pitch link - separation
Maintenance,installation - improperCompany maintenance personnelCause
Maintenance,inspection - improperCompany maintenance personnelCause
In flight collision with terrain/waterDescent - uncontrolled
Aircraft control - not possiblePilot in command

Analysis

Investigation disclosed that the tail rotor separated from the helicopter in flight. The tail rotor assembly was sent to the manufacturer for analysis. On tail rotor blade 'a' the bolt, nut and associated hardware that attached the pitch change link to the blade grip were missing. The bolt bushing was worn beyond the service limits that mandated replacement. On blade 'b' the attaching bolt, nut and hardware were determined to be the wrong size. In addition, the wrong spacer was attached to the bolt. Four more washers than allowed were under the trailing edge blade retaining bolt nut. According to the preflight inspection requirements, the discrepancies on the blade 'a' bushing and the incorrect hardware on the blade 'b' pitch change link should have been detected during the daily inspection event.

Aircraft

Registration
N138US
Reported as
Bell UH-1E
Category
Helicopter
Serial number
154944
Airframe hours
6,866
Engine
Lycoming T5311, 1,100 horsepower, turbo shaft
Damage
Destroyed
Flight
Aerial application · Part 137
Operator
Gilman D. Christopher, doing business as Chris'S Aviation
Registered owner
Phillip D. Barnes
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · May 30, 1989 · 300 hours before
Departed
NONE · Queen Creek, AZ
Destination
NONE

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
46
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Flight hours
21,020 total · 580 in this make and model · 20,820 as pilot in command · 300 in the last 90 days · 100 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Lowest ceiling
None
Altimeter
29.00 inHg

FAA reports on this event · 1

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