NYC95LA147

NTSB accident investigation · Bell 47G-3B-1 · Hammonton, NJ · July 10, 1995

Accident · FatalLimited investigationFinal report
Date
July 10, 1995, 08:00 local (12:00 UTC)
Place
Hammonton, NJ
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N48316Bell 47G-3B-1
Weather
Visual (VMC) · Day
Status
Completed · report September 3, 1996
Report
Approved by Office Director
FAA report
19950710017499A
Case key
38991

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

failure of the collective yoke bearing, which resulted in an uncontrolled descent and collision with trees. A factor relating to the accident was: the manufacturer's inadequate inspection interval of the yoke bearing.

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
Rotorcraft flight control,collective control - failureCause
Maintenance,inspection - inadequateFactor
Procedure inadequateManufacturerFactor
Loss of control - in flightCruise
Aircraft control - not possible
In flight collision with objectDescent - uncontrolled
Object - tree(s)

Analysis

At the end of an aerial application mission, the helicopter was refueled, and the pilot departed for home base. A few minutes after takeoff, the helicopter collided with trees. Examination of the engine and drive train revealed no preimpact failure; however, the collective pitch control yoke bearing had failed. The ball bearings and race in the yoke bearing were observed to be pitted, and the ball bearings were worn undersized. The last inspection of the yoke bearing occurred about 9 years and 839 flight hours before the accident, during the 1,200 hour inspection. The yoke bearing was not required to be inspected during the recent 600 hour inspection. The bearing was an on-condition item, and did not have a scheduled time change. The bearing could not be inspected, while installed on the helicopter.

Factual narrative

On July 10, 1995, at 0800 eastern daylight time, a Bell 47G- 3B-1, helicopter, N48316, was destroyed during a forced landing and collision with trees near Hammonton, New Jersey. The commercial pilot was fatally injured. Visual meteorological conditions prevailed, for the positioning flight that departed Hammonton, New Jersey, about 0750. No flight plan had been filed for the flight conducted under 14 CFR Part 137.

According to a company employee, after the pilot completed an application mission, he landed at the field site, rinsed out the chemical tank, and refueled the helicopter. The pilot then departed in N48316, for Mays Landing, New Jersey.

According to a Federal Aviation Administration (FAA) Inspector, a witness reported hearing the helicopter engine, and then heard the helicopter impact the trees.

Examination of the wreckage by the FAA Inspector confirmed that the engine could be rotated, and valve train continuity and compression were present on all cylinders. The carburetor bowl was full of fuel, and the fuel screen was absent of debris. No pre-impact failure of the engine was observed. Drive train continuity was confirmed from the engine, through the transmission, to the main and tail rotor systems. According to the FAA Inspector's statement, "Excessive travel was noted in the collective control system."

A certified airframe and power plant (A&P) mechanic, employed by the State of New Jersey, examined the collective control system at the accident site. His report stated:

Collective pitch levers could not be moved more than 1 inch travel, up and down. Movement was restricted and did not feel normal. Collective pitch change link was removed. Excessive vertical play was found in collective levers. Collective levers were removed. Collective pitch control yoke was then checked and it was found to have excessive play in all directions... Collective support was then moved upward on mast to expose pitch control bearing. Bearing lock nut appeared to be tight and intact. Movement of support dislodged three roller bearings from the bearing, and numerous thin slivers of metal. The grease was very black.

The main rotor mast and swashplate assembly were removed for further examination, and shipped to the Bell Helicopter Textron facility, Forth Worth, Texas. The Bell Helicopter Engineering Laboratories Report stated that the collective yoke ball bearings had rolled onto the bearing shield, and the collective pitch sleeve yoke spacer. The report further stated:

Spherical impressions and deformation were evident around the inner diameter of the yoke spacer which indicated bearing rotation at the time the bearing came apart...The bearing outer ring had an uneven raceway pattern as well as deformation over the edge of the raceway...The heaviest wear and deformation was in line with the loading arms on the collective pitch control yoke and may have been the exit point of the ball bearings. The raceway and other inside diameter surfaces on the outer ring were corrosion pitted and worn...The bearing inner ring was also corrosion pitted and worn...Eight of the balls that were recovered were examined...all the balls were corrosion pitted...Grease samples...were analyzed and found to be similar to Mobil 28 (Mil-G-81322)...

The helicopter was manufactured for the U.S. Army in 1966, as a TH-13T. On October 21, 1982, the helicopter was converted from a TH-13T, to a Bell 47G-3B-1. On January 24, 1986, the helicopter was completely rebuilt by Tulsa Helicopters Inc. (THI). During the rebuild, a 1,200 hour inspection was also completed, which included the installation of a new collective sleeve.

In July, 1990, a dampener arm failed and resulted in a hard landing. The helicopter was then returned to THI for repair, and a sudden stoppage inspection. The inspection did not require the removal of the collective sleeve assembly, or inspection of the collective yoke bearing. The helicopter was returned to service on April 24, 1991, with a completed annual inspection.

Since the 1986, annual and 1,200 hour inspection, the helicopter had 9 annuals conducted by 6 different mechanics. The 1,200 hour inspection was the only inspection that required the disassembly and examination of the collective sleeve and yoke bearing.

The annual completed on March 23, 1993, by Rotorcraft Inc., Black Rock, Arkansas, included a 600 hour inspection. Disassembly and inspection of the collective yoke bearing was not accomplished, or required, during the inspection.

The Bell Helicopter Maintenance and Overhaul Manual, required that either Mil-G-25537, or Mil-G-81322, grease be used inside the collective sleeve and the swashplate support. It also stated that intermixing of greases was prohibited. The grease removed from the inside of the collective sleeve was black; however, grease samples were analyzed and found to be similar to Mobil 28 (Mil-G-81322).

The investigation revealed that THI used Mobil 28 grease when the collective sleeve was installed, in 1986. The pilot also used Mobil 28 during his greasing of the helicopter, between the 100 hour and annual inspections. During the 600 hour inspection, the pilot supplied Mobile 28 grease to Rotorcraft Inc., to complete the inspection.

A review of the helicopter's log books revealed that during the past 9 years, the pilot maintained the helicopter's daily logs. He performed oil changes and helicopter greasing, between the annuals and 100 hour inspections. He also performed the cleaning and washing of the helicopter.

The log books also revealed that the helicopter experienced periods of low usage during the winter months. Between October 1993, and April 1994, 2 hours were logged on the helicopter. Also, between September 1994, and April 1995, only 9/10 of an hour was logged on the helicopter. The last entry in the helicopter's log book was dated April 3, 1995. According to a separate log, and the helicopter's Hobbs meter, 57 hours were flown on the helicopter after the April entry.

The Bell procedures for inspecting the pitch control sleeve and yoke assemblies were examined. According to the Bell 47D-1 Maintenance and Overhaul Manual, the removal and magnaflux inspection of these components occurred at the 600 hour inspection. The 600 hour inspection criteria, for the Bell 47G-3, stated that complete disassembly and magnaflux is accomplished at the 1,200 hour inspection.

The 600 hour inspection of the Bell 47G-3 addressed disconnecting links and bolts to examine components. The components included; the main rotor blade grips and gimbal ring bearings; the stabilizer bar; the swashplate for freedom of operation, and for indications of roughness or wear in the carrier bearings, gimbal pins and bearings; the scissor levers bushing and bearings for wear; and raising the transmission cap to inspect the main rotor mast bearing. It also included the removal and partial disassembly of the main transmission. There was no description of a procedure to inspect the collective yoke bearing.

The 47G-3 manual listed components that had a maximum hour life. The collective sleeve assembly was listed with a 5,000 hour retirement life. A retirement life was not listed for the collective yoke bearing. The yoke bearing was a condition item that would be changed when it was determined to be unserviceable, by disassembly and visual inspection. The criteria used to inspect the collective yoke bearing would be interpreted from the Bell 47G-3B-1 Maintenance and Overhaul Manual.

The 1,200 hour inspection criteria, stated that the inspection of all bearings for smooth and free operation should be accomplished before and after assembly. It also stated to check

Aircraft

Registration
N48316
Reported as
Bell 47G-3B-1
Category
Helicopter
Serial number
3628
Airframe hours
6,520
Engine
Lycoming VO-435-A1F, 265 horsepower, reciprocating
Damage
Destroyed
Flight
Aerial application · Part 137
Operator
Atlantic Blueberry Company
Registered owner
Cuzco Leasing Co. Inc.
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · April 3, 1995 · 57 hours before
Departed
NONE · Hammanton, NJ
Destination
NONE · Mays Landing, NJ

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
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
4,170 total · 3,000 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 6 knots
Visibility
3 statute miles
Lowest ceiling
10,000 ft broken
Temperature
64 °F, dew point 63 °F
Altimeter
30.00 inHg
Observed at
MIV, 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.

Other investigations on N48316 · 2

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