MIA97TA139

NTSB accident investigation · Bell 204-B · Calderwood, TN · April 16, 1997

Accident · No injuriesFinal report
Date
April 16, 1997, 15:50 local (19:50 UTC)
Place
Calderwood, TN
Injuries
1 uninjured
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N4580YBell 204-B
Weather
Visual (VMC) · Day
Status
Completed · report January 7, 1998
Report
Approved by Office Director
FAA report
19970416006029A
Case key
38349

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The inadequate maintenance inspection of the helicopter resulting in loss of lubrication from the main drive shaft going undetected until failure of the drive shaft.

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/malfunctionHover - out of ground effect
Lubricant,grease - loss,total
Maintenance,inspection - inadequateCompany maintenance personnelCause
Rotor drive system,engine to transmission drive - overtemperature
Rotor drive system,engine to transmission drive - failure,total
Forced landingDescent - emergency
In flight collision with objectDescent - emergency
Object - tree(s)
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - drop-off/descending embankment

Analysis

The main drive failed at the transmission end resulting in loss of transmission drive. The pilot performed a autorotation landing in trees and the helicopter rolled inverted and descended through the trees coming to rest on a river bank. Metallurgical examination showed the main drive shaft teeth had separated at the transmission end due to wear from frictional overheating which is a result of loss of lubrication. The helicopter manufacturer instructions require that the main drive shaft be inspected by a mechanic for loss of lubrication and signs of overheating during a daily inspection before the first flight of each day. The operator did not have records to show that the daily inspection had been performed prior to the accident flight.

Factual narrative

On April 16, 1997, about 1550 eastern daylight time, a Bell 204-B, N4580Y, registered to South Coastal Helicopters, Inc. and operated by the U.S. Forest Service and the State of Tennessee, as a Title 14 CFR Part 91 public-use flight, crashed following loss of transmission drive near Calderwood, Tennessee. Visual meteorological conditions prevailed at the time and a company visual flight rules flight plan was filed. The helicopter was destroyed and the commercial-rated pilot was not injured. The flight originated from Copperhill, Tennessee, the same day, about 1500.

The pilot stated his company had a long term contract with the U.S. Forest Service. He had been in stationed in Tennessee with the helicopter for about 45 days. He was dispatched by the U.S. Forest Service dispatcher at Cleveland, Tennessee, to assist the State of Tennessee, Division of Forestry, with putting out a forest fire near Calderwood. After arrival on scene he dropped several buckets of water. While making another run, after filling his bucket, which was on a 100-foot line, he climbed to about 120 feet above the water. He suddenly heard a loud bang and the engine appeared to lose power. He entered autorotation and landed in trees on a hill near the river bank. After entering trees the helicopter rolled inverted and descended to the ground. He exited the helicopter and a postcrash fire erupted and consumed the helicopter.

Postcrash examination of the helicopter by an FAA inspector and a representative of Bell Helicopter showed the main engine to transmission drive shaft was separated at the coupling on the transmission end. No other evidence of failure or malfunction was found with the helicopter structure, flight controls, or systems. Examination of the engine assembly, after recovery from the crash site, showed no evidence of failure or malfunction of the engine assembly. The engine accessories were destroyed by the post crash fire and could not be tested.

Metallurgical examination of the separated main drive shaft was performed under FAA supervision at Bell Helicopter Engineering Laboratories, Fort Worth, Texas. The examination showed the male coupling teeth were separated from the remainder of the coupling on the transmission end of the shaft. Examination of the recovered teeth showed each tooth "peeled back from the drive-side to the coast-side." The teeth had had been worn due to frictional overheating, resulting in failure. Metallurgists reported that the normal cause of overheating are loss of lubrication, the improper lubricant, or severe mis-alignment. (See attached Bell Helicopter Report).

The Bell Helicopter Maintenance and Overhaul Instructions for the Bell Model 204B helicopter requires that a "Daily Inspection" be performed by a mechanic before the first flight of each day. Item 26 of the Daily Inspection requires that the mechanic inspect the "main driveshaft boots or seals and surrounding area for evidence of grease leakage. Inspect temperature indicators TEMP-PLATES, installed on driveshaft couplings for evidence of overheating indication, deterioration, debonding or excessive discoloration of the epoxy overcoating." The helicopter operator did not supply records to NTSB after the accident showing that the Daily Inspection had been complied with on April 16, 1997. (See attached pages from the Bell Helicopter Instructions).

The Bell Helicopter pilot preflight checklist does not require that the pilot inspect the main drive shaft prior to flight. The pilot is only required to inspect the engine and transmission cowling for security. (See attached pages from the pilot checklist).

Aircraft logbook records showed the main drive shaft was installed after overhaul on N4580Y on May 1, 1990, at aircraft total time 3,937 hours. On December 1, 1994, at aircraft total time 5,800 hours the main drive shaft was overhauled and reinstalled on the helicopter. On January 13, 1997, at aircraft total time 6,565 hours, the main drive shaft was inspected and the lubrication repacked. At the time of the accident the aircraft total time was about 6,645 total hours. (See attached pages from logbook records).

A representative of the U.S. Forest Service stated shortly after the accident that the flight was a public-use flight by the U.S. Forest Service. Another representative of the U.S. Forest Service reported to NTSB about 25 hours after the accident that the U.S. Forest Service was not the operator of the helicopter, but that the State of Tennessee was the operator. Representatives from the State of Tennessee stated they were called and offered the services of the helicopter by the U.S. Forest Service dispatcher at Cleveland. They accepted the offer under a cooperative agreement with the U.S. Forest Service. They did not expect to pay for the helicopter, which is part of the cooperative agreement. The pilot stated his company would be paid for the flight by the U.S Forest Service.

A postaccident drug screen performed on samples submitted by the pilot was negative.

Aircraft

Registration
N4580Y
Reported as
Bell 204-B
Category
Helicopter
Serial number
2066
Airframe hours
6,645
Engine
Lycoming T-53, 1,150 horsepower, turbo shaft
Damage
Destroyed
Fire
On-Ground
Flight
Public aircraft · Part 91
Operator
U.S. Forest Svc./State Of Tn.
Registered owner
South Coast Helicopters, Inc.
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · January 13, 1997 · 80 hours before
Departed
1A3 · Copperhill, TN
Flight plan
Company VFR

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
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
11,700 total · 1,900 in this make and model · 11,300 as pilot in command · 50 in the last 90 days · 20 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 37 °F
Altimeter
30.00 inHg
Observed at
TYS, 25 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.

Other investigations on N4580Y · 1

Matched to the same aircraft by N-number and date.