# NTSB MIA04LA123: Bell 206B3, N107PH, Panama City, FL, August 24, 2004 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: August 24, 2004, 17:20 local (22:20 UTC) - Place: Panama City, FL - Coordinates: 30.211944, -85.682777 - Nearby events: https://openairdocs.org/map.md?lat=30.2119&lon=-85.6828&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report September 13, 2005 - Report: Approved by Office Director - Parties: Alabama, FSDO-09 - NTSB case key (mKey): 60015 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA04LA123 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60015/pdf - Page: https://openairdocs.org/ntsb/MIA04LA123 ## Probable cause Inadequate maintenance inspection resulting in the partial loss of engine power due to a loose pneumatic line on the governor and ditching of the helicopter. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - mech failure/malf, maneuvering - maintenance,inspection - inadequate, company maintenance personnel (cause) - fuel system,line fitting - loose - Ditching, emergency descent/landing - emergency floats - activated ## Analysis The pilot stated he flew out from Panama City-Bay County International Airport to survey a boat located on Deer Point Lake, approximately 8 miles northeast of the airport. With an altitude of about 50 feet and a forward airspeed around 35 to 40 mph he entered a circling maneuver. While flying upwind he reduced engine RPM, and as he turned downwind, he pulled up on the collective, but felt the helicopter sinking instead of climbing. He then looked at the engine instruments and saw the rotor RPM going below 85%. Immediately, he pushed the collective down, but was unable to regain RPM. He deployed emergency floats about 10 feet above the water. The helicopter hit the water "hard" in about 4 feet of water and then rolled onto its right side, due to the right flotation bag being torn off upon impacting the water. The FAA inspector who responded to the accident stated, upon inspection of the helicopter, after recovery, it was found that a pneumatic tubing line had backed off the governor and caused the engine to go to minimum RPM. The governor was last installed 500 hours before the accident and showed signs of a torque seal on the B-nut. The pneumatic line that backed off the fitting is located on the backside of the governor and is hard to see and check for proper torque during routine maintenance. ## Factual narrative On August 24, 2004, about 1720 central daylight time, a Bell 206B, N107PH, registered to and operated by Heliworks Inc., as a Title 14 CFR Part 135 on demand air taxi flight, crashed into Deer Point Lake, Panama City, Florida. Visual meteorological conditions prevailed, and no flight plan was filed. The commercial-rated pilot and two passengers received no injuries, and the helicopter incurred substantial damage. The flight originated from Panama City-Bay County International Airport, Panama City, Florida, earlier that day, about 1700. The pilot stated he flew out from Panama City-Bay County International Airport to survey a boat located on Deer Point Lake, approximately 8 miles northeast of the airport. With an altitude of about 50 feet and a forward airspeed around 35 to 40 mph he entered a circling maneuver. While flying upwind he reduced engine RPM, and as he turned downwind, he pulled up on the collective, but felt the helicopter sinking instead of climbing. He then looked at the engine instruments and saw the rotor RPM going below 85%. Immediately, he pushed the collective down, but was unable to regain RPM. He deployed emergency floats about 10 feet above the water. The helicopter hit the water "hard" in about 4 feet of water and then rolled onto its right side, due to the right flotation bag being torn off upon impacting the water. The FAA inspector who responded to the accident stated, upon inspection of the helicopter, after recovery, it was found that a pneumatic tubing line had backed off the governor and caused the engine to go to minimum RPM. The governor was last installed 500 hours before the accident and showed signs of a torque seal on the B-nut. He stated the pneumatic line that backed off the fitting is located on the backside of the governor and is hard to see and check for proper torque during routine maintenance. The following are excerpts taken from Rolls-Royce 250-C20 series Operation and Maintenance list of Warnings: Proper tightening of engine tubing is critical to flight safety. Correct torque values must be used at all times. Excessive torque on pneumatic sensing system connections results in cracking of the flare or adjacent tube area in contact with the ferrule. This produces an air leak, which can cause engine flame out, power loss, or overspeed. Tubing B-nuts used in installations exposed to a high degree of vibration and pressure surges are subject to torque relaxation when improperly tightened. Air leaks in the fuel system or the pneumatic sensing system can cause flameouts, power loss, or overspeed. ## Aircraft - Registration: [N107PH](https://openairdocs.org/aircraft/N107PH), registered now, S/N 2789, built 1979 (OpenAirDocs) - Reported make and model: BELL 206B3 - Registry model: [Bell 206B](https://openairdocs.org/model/bell-206b) (registry code 1181511) (OpenAirDocs) - Registry engine: [Allison 250-C20 series](https://openairdocs.org/engine/allison-250-c20-series) (registry code 03020, turbo-prop) (OpenAirDocs) - Category: Helicopter - Serial number: 2789 - Airframe hours: 154430 - Engines: Rolls-Royce C250-20B 420 horsepower turbo shaft - Damage: Substantial damage - Flight: Part 135 - Registered owner: Heliworks Inc. - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, August 20, 2004, 823 hours before - Departed: KPFN, Panama City, FL - Airport: KPFN, Panama City Bay County Interna ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: none; commercial; instrument ratings: helicopter; medical: class 2, valid medical--w/ waivers/lim; last flight review July 1, 2004; seat: front; flight hours: 12,000 total, 38,200 in this make and model, 11,500 as pilot in command, 84 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 280° at 10 knots - Visibility: 7 statute miles - Temperature: 81 °F, dew point 75 °F - Altimeter: 30.00 inHg - Observed at: KPFN, 7 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20040824019189A](https://openairdocs.org/incident/20040824019189A), Aug 24, 2004: Bell 206B, Panama City, FL, Substantial damage. (-23) Pilot stated that helicopter lost power about 50FT above water. He deployed the floats and landed hard in the water. Upon inspection of the helicopter it… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.