MIA94LA100

NTSB accident investigation · Bell 206L · Orlando, FL · March 25, 1994

Accident · Serious injuriesLimited investigationFinal report
Date
March 25, 1994, 12:42 local (17:42 UTC)
Place
Orlando, FL
Injuries
4 serious, 2 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N16705Bell 206L
Weather
Visual (VMC) · Day
Status
Completed · report June 1, 1995
Report
Approved by Office Director
FAA report
19940325006599A
Case key
37511

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 pilot's failure to cross-check a faulty engine speed indication with other engine performance indications to verify whether an engine malfunction had actually occurred, and his failure to maintain adequate rotor RPM during an emergency landing. The pilot's reaction to the perceived engine malfunction led to an unnecessary reduction of engine power and subsequent emergency landing.

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/malfunctionTakeoff - initial climb
Engine instruments,engine rpm gage - false indicationFactor
Remedial action - improperPilot in commandCause
Throttle/power control - reducedPilot in command
Precautionary landing - initiatedPilot in command
Adequate rotor rpm - not maintainedPilot in commandCause
Hard landingEmergency landing after takeoff

Analysis

Shortly after takeoff, using water/alcohol injection, the pilot noted the N2 turbine speed indication went to the top of the gauge. He rolled off throttle to reduce the N2 gauge reading; at the same time, he looked for a place to land. The pilot believed there was insufficient altitude for an autorotation. Subsequently, the helicopter touched down hard & came to rest with extensive damage. A postaccident exam revealed no preimpact failure of the airframe, flight controls, or fuel system. Testing of the water/alcohol solution revealed 66.5% methanol & 33.5% water. Specifications required 33.5% methanol & 66.5% water, but allison engine personnel said the high level of methanol would not have affected engine performance. During a postaccident test, the engine operated to full power with no evidence of failure or malfunction. Testing of the engine instruments revealed the N2 gauge was providing a faulty indication. The other engine instruments operated normally after the accident.

Factual narrative

On March 25, 1994, about 1242 eastern standard time, a Bell 206L, N16705, registered to Universal Air Service of Florida, Inc., crashed while making an off-heliport landing at Orlando, Florida, while on a 14 CFR Part 91 sightseeing flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The aircraft received substantial damage. The commercial-rated pilot and one passenger received minor injuries. Four passengers received serious injuries. One passenger was not injured. The flight was originating at the time of the accident.

The pilot stated that shortly after departure he activated the water-alcohol injection system and noticed an increase in engine performance and a reduction in turbine out temperature (TOT). A short time later he noticed that the N2 turbine speed was slightly above red line and rapidly swung to near the upper limit of the gauge. He reduced the throttle slowly to attempt to manually override the N2 overspeed, picked out a landing area, and began an approach to the landing area. He rolled the throttle to the idle detent, with no effect on the N2 overspeed and the engine quit shortly after this. He did not have enough altitude and airspeed to enter autorotation and the helicopter descended and touched down hard.

Witnesses observed the helicopter flying from east to west at about 300 feet. The helicopter was making a high pitched squeal and was descending. The helicopter appeared to lose power and then crash in a construction area.

Examination of the helicopter by FAA inspectors after the accident indicated that there was no evidence of precrash failure or malfunction of the aircraft structure, flight control systems, or airframe fuel system. A usable amount of uncontaminated fuel was found in the airframe and engine fuel systems. A water- alcohol solution was found in the water injection tank.

After the accident the engine was removed from the aircraft and mounted in a engine test cell. The engine was started and operated to full power with no evidence to indicate precrash failure or malfunction. After the test run, the engine fuel control, governor, fuel pump, and bleed valve were removed from the engine and tested on a test bench. Each of the units operated normally.

After the accident the N1, NR, N2, and TOT gauges and signal generators were removed from the aircraft for testing. The N1 gauge and generator, TOT gauge, and NR gauge operated within limits. The N2 gauge was found to read 10 to 15 percent low in the range above 90 percent. The N2 generator operated normally. See attached Bell Helicopter report.

Laboratory testing of fuel and water-alcohol samples obtained from the helicopter after the accident was performed by Panair Laboratory, Inc., Miami, Florida. The fuel sample met specifications for aviation turbine fuel and no contamination of the fuel sample was reported. The water-alcohol sample was found to be a mixture of 66.5 percent methanol and 33.5 percent water. See attached laboratory report.

Bell Helicopter and Allison Engine specifications require that water-alcohol fluid be mixed 33.5 percent methanol and 66.5 percent water. Allison engine personnel stated that the high level of methanol which was found in the accident helicopter would not have effected engine performance, for the engine controls would have countered any effect. See attached Allison Engine report.

Aircraft

Registration
N16705
Reported as
Bell 206L
Category
Helicopter
Serial number
4150
Airframe hours
11,590
Engine
Allison 250-C20B, 420 horsepower, turbo shaft
Damage
Substantial damage
Flight
Part 91
Operator
Falcon Helicopter Service, Inc
Registered owner
Universal Air Service
Airworthiness certificate
Standard, Utility
Last inspection
100 hour · February 23, 1994 · 32 hours before

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
42
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
3,366 total · 1,476 in this make and model · 3,366 as pilot in command · 62 in the last 90 days · 20 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
240° at 12 knots
Visibility
10 statute miles
Lowest ceiling
3,700 ft broken
Temperature
82 °F, dew point 66 °F
Altimeter
30.00 inHg
Observed at
MCO, 8 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.