LAX95LA282

NTSB accident investigation · Aerospatiale AS-355-F1 · Daggett, CA · August 8, 1995

Accident · No injuriesLimited investigationFinal report
Date
August 8, 1995, 15:45 local (22:45 UTC)
Place
Daggett, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Standing
Aircraft
N813CEAerospatiale AS-355-F1
Weather
Visual (VMC) · Day
Status
Completed · report April 29, 1996
Report
Approved by Office Director
FAA report
19950808026669A
Case key
29175

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 failure of the Starflex arm due to fatigue, and the manufacturer's inadequate maintenance procedure. The operator's maintenance personnel failure to understand the repair procedure was a factor in the accident.

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/malfunctionStanding - idling rotors
Rotor system,star flex arm - fatigueCause
Rotor system,star flex arm - failure,totalCause
Ground resonance - encounteredPilot in command
Maintenance,major repair - not understoodCompany maintenance personnelFactor
Procedure inadequateManufacturerCause

Analysis

The helicopter entered ground resonance before lift-off. The pilot was able to stop the main rotor blades before they struck the ground. Wreckage examination showed that all of the helicopter components that could cause ground resonance were serviceable. Examination of the broken starflex yellow arm disclosed that it fractured due to fatigue in an area where previous repairs have been made, and that its porosity level was high. Fatigue was also found in the red arm, also in a previously repaired area. Maintenance records showed that all the starflex arms received a temporary repair 4 months before the accident. The repair in the red arm did not conform to the temporary repair procedure. Examination of the full repair was never accomplished, nor was it required until the rotor mast was to be removed for other scheduled maintenance. The maintenance manual does not specify the time when the temporary repair of the starflex arm should be fully repaired. The manufacturer's representatives state that the full repair should be made when the rotor head is removed for scheduled maintenance.

Factual narrative

History of Flight

On August 8, 1995, at 1545 hours Pacific daylight time, an Aerospatiale AS-355-F1, N813CE, entered ground resonance before lifting off a privately-owned helipad at Daggett, California, and sustained substantial damage. The pilot was beginning a visual flight rules business flight to John Wayne Airport, Santa Ana, California. The helicopter was registered to and operated by Southern California Edison (SCE), Ontario International Airport, Ontario, California. Neither the certificated airline transport pilot nor his passenger was injured. Visual meteorological conditions prevailed.

Preliminary examination revealed one of the arms (yellow) of the Starflex assembly was fractured between the elastomeric spherical bearing and its associated frequency adapter. The rotor mast assembly components were intact. The main rotor blades showed no evidence of any ground impact signatures. The transmission support tubes were intact and not buckled.

National Transportation Safety Board investigators interviewed the pilot on August 14, 1995, at the operator's flight operations/maintenance facility. The pilot said that he departed the operator's facility at 0640 hours and landed at John Wayne Airport about 0657 hours to pickup a passenger. The flight departed John Wayne Airport about 0700 hours and arrived at the operator's Coolwater Generating Station, Daggett, California, about 0750 hours and deplaned the passenger.

About 1540 hours, the passenger returned to the helipad and boarded. The pilot said that after starting the engines he let them idle for about 2 minutes until the gyroscopic flight instruments stabilized. He then applied power to begin the lift-off.

When the pilot felt the engines respond to the application of the power levers (the No. 2 engine was about 75 percent Ng and the No. 1 engine was slightly behind), the helicopter entered ground resonance. The helicopter began to turn, wobbling on each skid, about 45 degrees to the right and the pilot immediately shutdown both engines.

The pilot said that there was no advance warning of the resonance. Later he said that it appeared as if something in the rotor head broke. He also said that both previous landings and the entire flight were smooth.

The pilot described the winds as "light and variable (less that five knots)."

On January 31, 1996, the pilot said in a telephone interview that after starting the first engine he allowed the engine to remain in the idle position. He did not say that he advanced the fuel flow control lever to the "flight gate" position. He then started the second engine. The pilot said that the rotor speed during idle was about 290 rpm.

In a subsequent written statement (dated February 1, 1996), the pilot said that he started both engines while idling. He also said that this procedure was in accordance with the flight manual, whereas the engine(s) should be stabilized for 1 minute before advancing the fuel flow control lever to the flight gate position. He also said that the cyclic friction and the force trim mechanisms were engaged.

In a written statement, the passenger said that after boarding the helicopter, the pilot started both engines. The pilot then continued to ". . . perform additional operations on his control console. We were not yet ready to commence lift-off operations. . . ."

The passenger then stated:

Without any initiating event, we suddenly began to oscillate in a rhythmic fashion on the helipad. The oscillations started out quite small in amplitude, but began to build quite rapidly. As the oscillations built in intensity, we began to rotate slightly (clockwise) around the helipad.

Crew Information

The pilot holds an airline transport certificate with rotorcraft helicopter and AS-350 type ratings. The certificate is endorsed for commercial privileges with airplane ratings for single-engine land, multiengine land, instruments, and SK-61 type ratings. He also holds an unrestricted first-class medical certificate dated July 12, 1995.

The flight hours reflected on page 3 of this report were obtained from the pilot's company flight records. The records disclosed that the pilot accrued 12,242 total flight hours, of which 11,987 hours were flown in helicopters. The pilot also accrued 183 hours in the accident helicopter make and model.

The pilot satisfactorily completed a biennial flight review 17 months before the accident. A biennial flight review is required every 24-calendar months.

Aircraft Information

Safety Board investigators reviewed the helicopter's maintenance records at SCE maintenance facilities. The maintenance records' examination showed that SCE maintenance personnel accomplished the last annual inspection on February 16, 1995, and the last 100-hour inspection on June 1, 1995; the helicopter accrued 3,101 hours at the time of the 100-hour inspection. At the time of the accident, the helicopter accrued 3,170 hours (airframe and engines).

The maintenance records also revealed that the helicopter's previous owner installed the affected Starflex assembly on April 7, 1987; the assembly accrued 992.3 hours when it was installed.

On August 30, 1988, other maintenance personnel replaced all of the Starflex assembly sleeves.

At the time of the accident, the Starflex assembly accrued 2,177.6 hours. According to the manufacturer, the Starflex is a life-limited item and must be replaced when it accrues 2,200 operational hours.

On November 9, 1992, SCE maintenance personnel replaced the yellow Starflex sleeves; the helicopter accrued 2,500.6 hours.

On November 3, 1993, SCE maintenance personnel replaced the spherical thrust bearings and the red and blue sleeves.

On April 7, 1995, SCE maintenance personnel repaired the Starflex assembly according to the maintenance manual MRR repair card 62.20.00.601, Paragraph 3.1.3 (Temporary Repair). The maintenance manager told Safety Board investigators that the repairs were done in concert with the manufacturer's technical representative. The representative did not tell the mechanic that the full repair under MRR repair card 62.20.00.772 would have to be accomplished at a later time.

The mechanic told investigators that he contacted a manufacturer's technical representative before he started the repairs. He told the representative that the arms were splintered. The mechanic said he contacted the representative because he did not fully understand the explanation in the manual.

The representative then instructed the mechanic on how to repair the splintered arms. The representative said to blend the area on each side of the repaired area smoothly. He did not instruct the mechanic to remove the assembly and fully chamfer the entire affected arm.

The representative also told the mechanic that splintered arms were not uncommon and assured him that ". . . there has never been a Starflex failure. . . ."

During the helicopter examination the technical representative said that he instructed the mechanic on the repair procedure. The technical representative and an American Eurocopter engineer said the repairs were satisfactory.

Wreckage and Impact Information

The Safety Board did not conduct an on-scene investigation. The helicopter examination began on August 15, 1995.

Aircraft Examination:

The yellow arm of the Starflex assembly (serial No. M2060) fractured about 5 1/2 inches outboard of the elastomeric spherical bearing attach brackets; the red and blue arms were found intact. Visual examination of the fractured area showed adhesive separation.

The Starflex assembly yellow, red, and blue sleeves attach bolts were found tight. The lower side of the yellow arm upper sleeve displayed a single impact signature about 4.5 inches outboard of its vibration adapter assembly.

The Starflex assembly elastomeric bearings did not show any rubber mat

Aircraft

Registration
N813CE
Reported as
Aerospatiale AS-355-F1
Category
Helicopter
Serial number
5010
Airframe hours
3,170
Engine
Allison 250-C20F, 420 horsepower, turbo shaft
Damage
Substantial damage
Flight
Executive/Corporate · Part 91
Registered owner
Southern California Edison
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 1, 1995 · 69 hours before
Destination
SNA · Santa Ana, CA

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
47
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Toxicology
Performed
Flight hours
12,242 total · 183 in this make and model · 10,637 as pilot in command · 92 in the last 90 days · 44 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 5 knots
Visibility
50 statute miles
Lowest ceiling
None
Temperature
97 °F

FAA reports on this event · 1

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