MIA00FA030

NTSB accident investigation · Bell 212 · Philadelphia, MS · November 27, 1999

Accident · FatalField investigationFinal report
Date
November 27, 1999, 14:45 local (20:45 UTC)
Place
Philadelphia, MS
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N8144MBell 212
Weather
Visual (VMC) · Day
Status
Completed · report December 6, 2002
Report
Approved by Office Director
Parties
Pratt and Whitney, FAA FSDO, Houston Helicopters, Bell Helicopter, NTSB
FAA report
19991127033769A
Case key
47850

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 pilot and company maintenance personnel during preflight and periodic inspections to identify the signs of fretting and looseness in the "red" main rotor blade pitch change horn to main rotor blade grip attachment, resulting in the helicopter continuing in service with a loose pitch change horn, separation of the pitch change horn from the blade grip, and inflight breakup of the helicopter due to the main rotor striking the tailboom. Contributing to the accident was the pilot's failure to respond to increased vibration in the main rotor system and land immediately.

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/malfunctionCruise
Maintenance,inspection - inadequateCompany maintenance personnelCause
Rotorcraft flight control,pitch change horn - loose part/bolt/nut/clamp/etc
Aircraft preflight - inadequatePilot in commandCause
Operation with known deficiencies in equipment - continuedPilot in commandCause
Rotor system - vibration
Rotorcraft flight control,pitch change horn - separation
Misc rotorcraft,main rotor/tail boom contact
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

At the last refueling stop the pilot and passenger stated to the lineman that the greenhouse window above the pilot had cracked during the previous leg of the flight. The transcript of communications recorded on the cockpit voice recorder showed that about 29 minutes before the accident, the passenger stated to the pilot "I think if I hadn't-a broke that off we wouldn't had any greenhouse by the time we got home". About 18 minutes before the accident, the passenger stated to the pilot "boy those catfish are going crazy down there aren't they". The pilot respond "yep", "must have been the vibrations from the helicopter". About 2 minutes later the passenger and pilot discuss sighting deer in a field. About 1 minute 30 seconds before the accident, the pilot asked the passenger "has this vertical just gotten in here or has it been here for a while?" The passenger replied "we haven't had any verticals at all." The pilot replied, "we do now." The passenger replied, "yeah well it started right after we left back there. I think it maybe ah that's why I was thinking it was the air." About 20 seconds later, the passenger stated that another person had tracked the helicopter's blades before they left and that he was commenting on how smooth it was. About 40 seconds later the pilot stated "this stuff is getting worse." The recording then ended. Witnesses in the area of the accident site stated that they observed the helicopter flying from east to west, just above the treetops. The helicopter began rolling back and forth. They then observed the main rotor blades contact the tail area, and the aft tail boom and tail rotor separate. Shortly after this, the main rotor separated and the helicopter descended and crashed to the ground. A fire erupted during ground impact. Witnesses did not observe any smoke come from the helicopter prior to the accident. The entire main rotor system was accounted for in the wreckage, except for the pitch change horn for the "red" main rotor blade and the majority of the pitch change link that attaches to the "red" pitch change horn at the pitch change links lower rod end. The "red" grip remained in place in the main rotor system. The surface of the "red" grip exhibited two boreholes that mated with two bushing that were part of the departed and missing "red" pitch change horn. The mating grip surface exhibited a blackish residue near the pitch change horn boreholes, and the blackish area extended beyond the boreholes. The crashsite and an extended area back-up the wreckage path were searched extensively, including by Boy Scout parties; the "red" pitch change horn and most of the "red" pitch change link were not found. Examination of the red grip by an NTSB metallurgist showed the surfaces of both the upper and lower holes showed extensive areas of dark deposits and surface damage consistent with repeated small relative movements against mating objects (fretting). Visible fretting areas covered most of the surface of the bushing counter bores and portions of the fractured surfaces of the threads. Energy dispersive x-ray analysis of samples of the black deposits taken from the upper hole found them to mostly contain aluminum and iron and significant amounts of oxygen along with minor amounts for the other constituents of the grip and bushing. Samples from the lower hole were found to be mostly aluminum with large peaks for iron, cadmium, silicon and oxygen. Both bushing counter bores showed localized material removal and enlargement of the diameters. Up to .020 to 0.025 inches of material were removed in localized areas from the bushing bore. In addition, the bores were deformed and distorted adjacent to the grip surface. The surfaces of the holes, particularly the upper one, also contained circumferential marks in the bushing counter bore, the lock ring diameter and on the fractured threads indicating progressive and incremental movement of the mating objects. No other evidence of failure or malfunction of the helicopter structure, flight controls, engine, or rotor and rotor drive system was found. Aircraft records show the rotor head, including the"red" blade grip and pitch change horn, was last removed from the helicopter in March 1998, 162.2 flight hours before the accident, for blade retention strap replacement.

Factual narrative

History of the Flight

On November 27, 1999, about 1445 central standard time, a Bell 212, N8144M, registered to Houston Helicopters, Inc., crashed near Philadelphia, Mississippi, while on a Title 14 CFR Part 91 positioning flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The helicopter was destroyed and the airline transport-rated pilot and one passenger were fatally injured. The flight last departed Tuscaloosa, Alabama, the same day, about 1408.

The helicopter was being positioned from Virginia, to Pearland, Texas, the home base for the helicopter operator. Transcript of communications from the FAA Air Traffic Control Tower, Tuscaloosa, Alabama, show the flight arrived at Tuscaloosa at 1329. The lineman at Dixie Air, Inc., Tuscaloosa, Alabama, who fueled the helicopter, stated he talked with the pilot and passenger when they arrived. They stated they were flying to Texas, and had been flying since early that morning. They stated that sometime that morning, the greenhouse window above the pilot had broken. They then requested that the fuel tanks be completely topped off with Jet-A fuel. The lineman stated that when he went to the helicopter to fuel it, he observed that the greenhouse window was cracked lengthwise. Transcripts show that at 1408, the pilot requested and was given a west departure from Tuscaloosa. No further contact with air traffic control facilities were made after this. (See transcript of communications and witness statement).

The transcript of communications recorded on the cockpit voice recorder showed that about 29 minutes before the accident, the passenger stated to the pilot "I think if I hadn't-a broke that off we wouldn't had any greenhouse by the time we got home". About 18 minutes before the accident, the passenger stated to the pilot "boy those catfish are going crazy down there aren't they". The pilot respond "yep", "must have been the vibrations from the helicopter". About 2 minutes later the passenger and pilot discuss sighting deer in a field. About 1 minute 30 seconds before the accident, the pilot asked the passenger "has this vertical just gotten in here or has it been here for a while?" The passenger replied "we haven't had any verticals at all." The pilot replied, "we do now." The passenger replied, "yeah well it started right after we left back there. I think it maybe ah that's why I was thinking it was the air." About 20 seconds later, the passenger stated that another person had tracked the helicopter's blades before they left and that he was commenting on how smooth it was. About 40 seconds later the pilot stated "this stuff is getting worse." The recording then ended. (See NTSB Cockpit Voice Recorder Factual Report of Group Chairman).

Witnesses in the area of the accident site stated that they observed the helicopter flying from east to west, just above the treetops. The helicopter began rolling back and forth. They then observed the main rotor blades contact the tail area, and the aft tail boom and tail rotor separate. Shortly after this, the main rotor separated and the helicopter descended and crashed to the ground. A fire erupted during ground impact. Witnesses did not observe any smoke come from the helicopter prior to the accident. (See Witness Group Chairman Factual Report).

Personnel Information

The pilot held a FAA airline transport pilot certificate with a helicopter rotorcraft rating, last issued on March 5, 1984. The pilot held a FAA second-class medical certificate, issued on December 1, 1998, with the limitation that holder shall wear lenses to correct for distant vision and possess glasses that correct for near vision. The pilot was hired by Houston Helicopters, Inc., in March 1999, and after attending ground training, received flight checks to act as pilot in command in the Bell 212, Bell 206, and Sikorsky S-76 helicopters. The Bell 212 flight check was conducted on March 27, 1999. At the time the pilot was hired, he reported he had accumulated 11,019 total flight hours, all in helicopters. He reported he had 2,356 total flight hours in the Bell 212. (See pilot records).

The passenger was employed by the helicopter operator as a mechanic. He held a FAA airframe and powerplant mechanic certificate, last issued on February 26, 1980. The passenger also held a FAA private pilot certificate with a airplane single engine land rating, issued on May 5, 1978.

Aircraft Information

The accident helicopter was a Bell Helicopter Textron Model 212, serial no. 30706, which was manufactured in May 1975. The helicopter was equipped with a Pratt and Whitney Canada PT6-3 engine, rated at 1,800 shaft horsepower, consisting of two 900 shaft horsepower power sections and a reduction gear box.

The helicopter received a 100-hour and annual inspection on April 12, 1999, at aircraft total time 11,243.7. The helicopter received a 25 hour and 50 hour inspection on September 23, 1999, at aircraft total time 11,288.7. On November 5, 1999, the helicopter received a daily and preflight inspection, at aircraft total time 11,302.2. The following discrepancies and corrective actions were noted in the records for the daily and preflight inspection:

"Check M/R servo alignment" [action] "Realigned lateral servos"

"Track and Balance M/R [action] "Performed track & Bal. Check & adjust"

"adjust autorotation RPM" [action] "adjusted auto RPM per M&M"

The "Next Inspection Due, 100 Hr. A B [was entered as] 11,343.7" hours.

The helicopter operator stated that the records for the helicopter were retained on the helicopter after this inspection and were destroyed in the accident. They stated the helicopter would have received a daily inspection by a mechanic each morning. They estimated the helicopter flew about 19 flight hours from the time of this daily and preflight inspection on November 5, 1999, until the time of the accident.

Aircraft records show the "red" main rotor blade grip, part number 204-011-121-9, serial number GD-9312-6, was removed from main rotor hub serial number ADA-08684, in July 1985, after accumulating 4,334.1 total flight hours. The grip was sent to Bell Helicopter Textron by Houston Helicopters, Inc., at this time for overhaul. The grip was then placed in storage and was returned to Bell Helicopter Textron in April 1992 for installation of Rosan fittings in the pitch change horn mounting holes. The Rosan fittings had been left out during the 1985 overhaul at Bell Helicopter Textron. The "red" blade grip was installed on main rotor hub serial number FB-71829 in January 1993, at hub total time 2,500.0 hours and grip total time 4334.1. The hub assembly, including the "red" grip was installed on another helicopter. In February 1994, after 17.5 hours of operation, the hub was removed due to an overspeed occurrence and again overhauled. The "red" grip was inspected for overspeed at this time. In June 1995, the hub was removed for compliance with a service bulletin. On March 25, 1996, the main rotor hub and "red" blade grip was installed on the accident helicopter, N8144M, at helicopter total time 11,050.2. On March 25, 1998, the hub was removed for blade retention strap replacement and then reinstalled on N8144M, on April 3, 1998. At the time of the accident, the "red" grip had accumulated 162.2 flight hours since the March 1998 removal and reinstallation of the main rotor hub, 556.5 flight hours since overhaul in 1985, and 4,890.6 total flight hours since new.

The "red" main rotor blade pitch change horn, part number 204-011-120-005, serial number HT-834, was removed from service in 1985, after accumulating 1,634.9 total flight hours. On January 12, 1993, the horn was installed on main rotor hub serial number FB-71829. At the time of the accident the "red" pitch change horn had accumulated 2,191.4 total flight hours. The horn has a life limit of 3,000 total flight hours.

Meteorological Informat

Aircraft

Registration
N8144M
Reported as
Bell 212
Category
Helicopter
Serial number
30706
Airframe hours
11,302
Engine
Pratt & Whitney PT6T-3, 1,800 horsepower, turbo shaft
Damage
Destroyed
Fire
On-Ground
Flight
Positioning · Part 91
Registered owner
Houston Helicopters, Inc.
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · April 12, 1999 · 59 hours before
Departed
TCL · Tuscaloosa, AL
Destination
JAN · Jackson, MS

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
54
Injuries
Fatal
Certificate
Airline transport
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
March 27, 1999
Seat
Right
Toxicology
Performed
Flight hours
11,140 total · 2,469 in this make and model · 11,050 as pilot in command · 50 in the last 90 days · 20 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
240° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 30 °F
Altimeter
30.00 inHg
Observed at
MEI, 30 nm away

Docket · 73

The files NTSB released with the investigation on May 23, 2000, on NTSB’s docket system: statements, records, photos and specialists’ reports. 111 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2Item 1 · .PDF · 416 KBSupplement SItem 2 · .PDF · 47 KBWitness 4 - Factual Report of Group ChairmanItem 3 · .PDF · 2.7 MBMeteorology 5 - Factual Report of Group ChairmanItem 4 · .PDF · 2.3 MBSystems / Airworthiness 9 - Factual Report of Group ChairmanItem 5 · .PDF · 182 KBSystems/Airworthiness - Attachment 1 - Bell Helicopter Textron Engineering Laboratories Report , January 21, 2000Item 6 · .PDF · 476 KBSystems/Airworthiness - Addendum 2 - Bell Helicopter Textron Engineering Laboratories Report, September 26, 2001Item 7 · .PDF · 538 KBSystems/Airworthiness - Attachment 3 - Factual Observations of Aircraft MishapItem 8 · .PDF · 27.0 MBSystems/Airworthiness - Attachment 4 - Wreckage PhotographsItem 9 · .PDF · 14 KBSystems/Airworthiness - Attachment 4 - Photo 4a and 4b - Aft portion of the tail boom, and diagonal fracture.Item 10 · .PDF · 69 KBSystems/Airworthiness - Attachment 4 - Photo 4c and 4d - Main transmission and portion of main rotor mastItem 11 · .PDF · 79 KBSystems/Airworthiness - Attachment 4 - Photo 4e and 4f - Fractured main rotor mastItem 12 · .PDF · 72 KBSystems/Airworthiness - Attachment 4 - Photo 4g and 4h - "Red" pitch change link upper rod end, attached to mixing lever within stabilizer bar assembly.Item 13 · .PDF · 64 KBSystems/Airworthiness - Attachment 4 - Photos 4i 4j and 4k - Components from tail rotor flight controls and drive systemsItem 14 · .PDF · 132 KBSystem/Airworthiness - Attachment 4 - Photo 4l and 4m - "Red" and "White" Main Rotor Grips, in main rotor assembly.Item 15 · .PDF · 98 KBSystem/Airworthiness - Attachment 4 - Photo 4n - "White" Pitch Change Horn, including bushings, in main wreckage.Item 16 · .PDF · 37 KBSystem/Airworthiness - Attachment 4 - Photo 4o and 4p - Mating surface, Red Main Rotor GripItem 17 · .PDF · 65 KBSystems/Airworthiness - Attachment 4 - Photo 4q - Mating Surface Red Main Rotor GripItem 18 · .PDF · 116 KBSystem/Airworthiness - Attachment 4 - Photo 4r - Mating Surface, Red Main Roto GripItem 19 · .PDF · 122 KBSystem/Airworthiness - Attachment 4 - Photo 4s - Mating Surface, White Main Rotor GripItem 20 · .PDF · 39 KBSystems/Airworthiness - Attachment 5 - 40 Party-submitted pagesItem 21 · .PDF · 3.2 MBSystems/Airworthiness - Attachment 6 - NTSB Materials Laboratory Factual Report 00-141, October 19, 2000Item 22 · .PDF · 524 KBSystems/Airworthiness - Attachment 7 - FAA On-Site Investigator, Inspector's StatementItem 23 · .PDF · 90 KBSystems/Airworthiness - Attachment 8 - Pages 33 through 78 of Section 62-00-00Item 24 · .PDF · 4.9 MBSystems/Airworthiness - Attachment 9 - FAA Standard Airworthiness Certificate, Transport Category, Registry No. N90222, dated 5/7/75Item 25 · .PDF · 645 KBSystems/Airworthiness - Attachment 10 - Bill of Sale, Helicopter Registration N90222, dated 5/26/83Item 26 · .PDF · 4.1 MBSystems/Airworthiness - Attachment 11 - HHI Maintenance Documents, contains Work Orders, including "Work Order No. 03-99-044, page 1 of 3, dated 4/12/99Item 27 · .PDF · 2.7 MBSystems/Airworthiness - Attachment 12 - HHI Maintenance Form 10 - Pilot and Maintenance Reports, includes page 09957Item 28 · .PDF · 11.3 MBSystems/Airworthiness - Attachment 13 - N8144M flight times, November 5 through 27, 1999, recorded from crew call-ins to HHIItem 29 · .PDF · 75 KBSystems/Airworthiness - Attachment 14A - Letter From the President of MSI Helicopters, Inc., dated 9/17/01Item 30 · .PDF · 172 KBSystems/Airworthiness - Attachment 14B - FAXed historical documents from MSI HelicoptersItem 31 · .PDF · 184 KBSystems/Airworthiness - Attachment 14C - Historical documents from MSI HelicoptersItem 32 · .PDF · 196 KBSystems/Airworthiness - Attachment 14D - Change of Serviceability Log for Helicopter (212) S/N 30791 two pages.Item 33 · .PDF · 312 KBSystems/Airworthiness - Attachment 14E - Component Log card for Pitch Horn containing entries from installation - 21 May 1978Item 34 · .PDF · 152 KBSystems/Airworthiness - Attachment 15 - Letter From President of HHI - 12/16/99Item 35 · .PDF · 93 KBSystems/Airworthiness - Attachment 16 - Letter from MSI to HHI, December 13, 1999Item 36 · .PDF · 176 KBSystems/Airworthiness - Attachment 17 - Two December 14, 1999 letters from MSI to HHI.Item 37 · .PDF · 538 KBSystems/Airworthiness - Attachment 18A - Serial Number Check List from HHIItem 38 · .PDF · 141 KBSystems/Airworthiness - Attachment 18B - Serial Number Check List from HHIItem 39 · .PDF · 143 KBSystems/Airworthiness - Attachment 18C - Computer Run Sheet from HHIItem 40 · .PDF · 278 KBSystems/Airworthiness - Attachment 19A - Historical Service RecordItem 41 · .PDF · 1.0 MBSystems/Airworthiness - Attachment 19B - Historical Service Record (HSR), Pitch Horn, Serial No.HT-834Item 42 · .PDF · 973 KBSystems/Airworthiness - Attachment 19C - Historical Service Record (HSR), Pitch Horn Serial No. HT-624Item 43 · .PDF · 939 KBSystems/Airworthiness - Attachment 19D - Historical Service Record (HSR), M/R Grip, Serial No. GD312-6Item 44 · .PDF · 716 KBSystems/Airworthiness - Attachment 20 - HHI FAA Repair Station Work Order GURR498E Forms, including No. 2-941712, dated 2/11/94Item 45 · .PDF · 3.6 MBSystems/Airworthiness - Attachment 21 - Letter From President HHI to IIC, August 24, 2001Item 46 · .PDF · 135 KBSystems/Airworthiness - Attachment 22A - Entry for boring a hole on DP-0003562, submitted by BHTItem 47 · .PDF · 199 KBSystems/Airworthiness - Attachment 22B - Reference to MRB disposition of item #3 submitted by BHTItem 48 · .PDF · 120 KBSystems/Airworthiness - Attachment 22C - Material Disposition Report Supplement submitted by BHT.Item 49 · .PDF · 155 KBSystems/Airworthiness - Attachment 23 - Mandatory airworthiness limitations scheduleItem 50 · .PDF · 387 KBSystems/Airworthiness - Attachment 24 - Inspection Task DescriptionItem 51 · .PDF · 350 KBSystems/Airworthiness - Attachment 25 - BHT-212-CR&O, 62-00-00, Rev. 4.Item 52 · .PDF · 293 KBSystems/Airworthiness - Attachment 26 - BHT-ALL-SPM, 8-00-00Item 53 · .PDF · 263 KBSystems/Airworthiness - Attachment 27 - BHT-212-IPB, 62-99-00, Rev. 5.Item 54 · .PDF · 272 KBSystems/Airworthiness - Attachment 28 - BHT Technical Bulletin, No. 212-99-170, dated 02-10-99Item 55 · .PDF · 233 KBSystems/Airworthiness - Attachment 29A - BHT's Product Support Engineering letter to HHIItem 56 · .PDF · 73 KBSystems/Airworthiness - Attachment 29B - BHT Canada, letter to HHIItem 57 · .PDF · 74 KBSystems/Airworthiness - Attachment 29C - BHT Canada letter to HHI, October 19, 2001Item 58 · .PDF · 117 KBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 59 · .PDF · 596 KBMaterials Laboratory 15 - Factual Report of Group ChairmanItem 60 · .PDF · 2.1 MB
All 73 files on NTSB’s docket

FAA reports on this event · 1

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