# NTSB MIA08LA106: Eurocopter France AS350 B2, N417AE, Hiram, GA, May 21, 2008 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: May 21, 2008, 10:04 local (14:04 UTC) - Place: Hiram, GA - Coordinates: 33.874443, -84.743057 - Nearby events: https://openairdocs.org/map.md?lat=33.8744&lon=-84.7431&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) operating: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report September 26, 2008 - Report: Approved by Office Director - Parties: FAA/FSDO - NTSB case key (mKey): 68105 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA08LA106 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68105/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=68105 - Page: https://openairdocs.org/ntsb/MIA08LA106 ## Probable cause The failure of the starflex arm during engine run-up due to inadequate inspection by maintenance personnel. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Eurocopter AS 350 B2 ECUREUIL, 1 case](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=8680951), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) - [Main rotor system](https://openairdocs.org/ntsb-findings/01046200): Aircraft › Aircraft propeller/rotor · Failure (probable cause); cases with it: [Eurocopter AS 350 B2 ECUREUIL, 1 case](https://openairdocs.org/ntsb-findings/01046200/cases.md?model=8680951), [All aircraft, 25 cases](https://openairdocs.org/ntsb-findings/01046200/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Standing-engine(s) operating: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [Eurocopter AS 350 B2 ECUREUIL, 1 case](https://openairdocs.org/ntsb-events/330/sequence.md?model=8680951), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) ## Analysis The pilot stated that after engine start, the helicopter shook violently as the throttle was advanced to flight rpm. He conducted an emergency shutdown, inspected the helicopter, and discovered that the tail rotor boom was buckled. Further inspection revealed that the main rotor starflex arm was broken. According to the director of maintenance, the starflex arm was overlooked during a conformity inspection. As a result, it was overflown by 586 hours. A review of a manufacturer service bulletin revealed that the service life on the starflex arm was 2,200 hours. At the time of the accident, the total time on the starflex arm was 2,786 hours. Due to the operator's record keeping process, the complex component life limit historical records were overlooked. ## Factual narrative On May 21, 2008, at 1004 eastern daylight time, a Eurocopter AS350 B2, N417AE, was substantially damaged during engine run-up, prior to takeoff at Caffery Heliport, Hiram, Georgia. The certificated commercial pilot and two passengers were not injured. Visual meteorological conditions prevailed and a company flight plan was filed for the positioning flight to Austell, Georgia. The helicopter was registered to GE Business Financial Services Incorporated, and operated by Omniflight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. The pilot stated that after he conducted a preflight inspection, he started the helicopter. As he advanced the throttle from idle to flight rpm, the helicopter shook violently. He said that he immediately conducted an emergency shutdown and inspected the helicopter. During the inspection, he discovered that the tail rotor boom was buckled, and the main rotor starflex arm was broken. Based on information from the director of maintenance (DOM), the recent maintenance history and inspection status of the helicopter was reviewed. The review revealed that the starflex was not listed on the Aircraft Status Report for the accident aircraft. The DOM further stated that the record keeping process was prone to error, because interpretation of complex component life limit historical records were done by "lesser qualified personnel." An audit of the starflex's life limit status was conducted, and it was discovered that the life limit of 2,200 hours of the starflex had been exceeded by 586.4 operating hours. At the time of the accident, the total time on the starflex arm was 2,786 hours. When the accident aircraft was purchased, the starflex time in service was 2,588 hours. At that time, the operator's conformity inspection failed to discover the excess hours. After the accident the operator immediately audited the time in service of all the starflexes on the remainder of their fleet. No other starflexes were found to have exceeded their life limit. ## Aircraft - Registration: [N417AE](https://openairdocs.org/deregistered/N417AE-2010-06-22), registration cancelled 2010-06-22, S/N 9032, built 2000 (OpenAirDocs) - Reported make and model: Eurocopter France AS350 B2 - Registry model: [Eurocopter AS 350 B2 ECUREUIL](https://openairdocs.org/model/eurocopter-as-350-b2-ecureuil) (registry code 8680951) (OpenAirDocs) - Registry engine: [Turbomeca ARRIEL-1SER](https://openairdocs.org/engine/turbomeca-arriel-1ser) (registry code 60030, turbo-shaft) (OpenAirDocs) - Category: Helicopter - Serial number: 9032 - Airframe hours: 2786 - Engines: Turbomeca Arriel 1D1 732 horsepower turbo shaft - Damage: Substantial damage - Flight: Positioning, Part 91 - Operator: Omniflight Helicopters Inc - Registered owner: GE Business Financial Services - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, April 1, 2008, 51 hours before - Departed: 00GE, Hiram, GA - Destination: 34GA, AUSTELL, GA - Flight plan: Company VFR - Airport: 00GE, Caffery Heliport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: helicopter; medical: class 2, with waivers/limitations; last flight review May 1, 2008; seat: right; flight hours: 6,922 total, 11 in this make and model, 5,190 as pilot in command, 15 in the last 90 days, 15 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 15 knots, gusting 19 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 54 °F - Altimeter: 29.76 inHg - Observed at: KATL, 21 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 20080521834049A](https://openairdocs.org/incident/20080521834049A), May 21, 2008: Snias AS350B2, Hiram, GA, Substantial damage. (-23) During normal run-up, after full advance of the throttle to flight RPM, with the collective in the locked position, the aircraft began a violent lateral… ## Other investigations on N417AE (1) 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. - [NTSB ERA09FA537](https://openairdocs.org/ntsb/ERA09FA537), Sep 26, 2009: Eurocopter AS-350 (N417AE), Georgetown, SC, destroyed, 3 fatal. Probable cause: The pilot’s decision to continue the visual flight rules flight into an area of instrument meteorological conditions, which resulted in the pilot’s spatial disorientation and a loss of control of the… ## Docket (15 files) The files NTSB released with the investigation on September 15, 2008, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=68105. 6.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 509 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297219&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Statement (item 2, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399569&FileExtension=.PDF&FileName=Pilot%20Statement-Redacted.PDF - Passenger Statement 1 (item 3, .PDF, 376 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297221&FileExtension=.PDF&FileName=Passenger%20Statement%201-Redacted.PDF - Passenger Statement 2 (item 4, .PDF, 936 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297222&FileExtension=.PDF&FileName=Passenger%20Statement%202-Redacted.PDF - Other Pertinent Forms and Reports-Maintenance log pages (item 5, .PDF, 276 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297223&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-Maintenance%20log%20pages-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297226&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Other Pertinent Forms and Reports-Starflex Manufacturer's Life Limited (item 7, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297229&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-Starflex%20Manufacturer%27s%20Life%20Limited-Master.PDF - Other Pertinent Forms and Reports-Operator Statement (item 8, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399568&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-Operator%20Statement-Redacted.PDF - Other Pertinent Forms and Reports-Audit Master (item 9, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297234&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-Audit%20Master-Master.PDF - Other Pertinent Forms and Reports-\N417AE SN 9032 AC Records (item 10, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297235&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-%5CN417AE%20SN%209032%20AC%20Records-Redacted.PDF - Photo 1-Operator digital photo (item 11, .PDF, 387 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297236&FileExtension=.PDF&FileName=Photo%201-Operator%20digital%20photo-Master.PDF - Photo 1-Operator digital photo starflex component (item 12, .PDF, 387 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297237&FileExtension=.PDF&FileName=Photo%201-Operator%20digital%20photo%20starflex%20component-Master.PDF - Photo 2-Operator digital photo starflex component 2 (item 13, .PDF, 372 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297238&FileExtension=.PDF&FileName=Photo%202-Operator%20digital%20photo%20starflex%20component%202-Master.PDF - Photo 3-Operator digital photo tailboom (item 14, .PDF, 349 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297239&FileExtension=.PDF&FileName=Photo%203-Operator%20digital%20photo%20tailboom-Master.PDF - Photo 4-Operator digital photo tailboom 2 (item 15, .PDF, 363 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40297240&FileExtension=.PDF&FileName=Photo%204-Operator%20digital%20photo%20tailboom%202-Master.PDF 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.