# NTSB SEA00TA013: Hiller UH-12E, N5388V, Stites, ID, November 2, 1999 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Final report - Date: November 2, 1999, 11:18 local (19:18 UTC) - Place: Stites, ID - Coordinates: 46.080829, -115.97068 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.0808&lon=-115.9707&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious, 1 uninjured - Status: Completed, report May 16, 2001 - Report: Approved by Office Director - ADs cited in the narratives: [AD 97-10-16](https://openairdocs.org/ad/97-10-16) (OpenAirDocs) - NTSB case key (mKey): 47779 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA00TA013 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/47779/pdf - Page: https://openairdocs.org/ntsb/SEA00TA013 ## Probable cause Inadequate inspection of the control rotor cuff by a company mechanic and subsequent fatigue fracture of the cuff, resulting in an inflight separation of the control rotor blade. Factors contributing to the accident were: inadequate quality control during manufacture; insufficiently defined manufacturer's inspection and repair procedures; inadequate FAA approval of the manufacturer's inspection and repair procedures; power lines in the helicopter's emergency descent flight path; and reduced aircraft controllability following the control rotor separation. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, climb - to cruise - rotor system,main rotor blade cuff - fatigue (cause) - maintenance,inspection - inadequate, company maintenance personnel (cause) - inadequate quality control, manufacturer (contributing factor) - condition(s)/step(s) insufficiently defined, manufacturer (contributing factor) - inadequate certification/approval,aircraft, faa(organization) (contributing factor) - rotor system,main rotor blade - separation - In flight collision with object, descent - emergency - object - wire,transmission (contributing factor) - aircraft control - reduced (contributing factor) - clearance - not maintained, pilot in command - In flight collision with terrain/water, descent - uncontrolled ## Analysis During a low-altitude fish survey, the helicopter experienced a separation of a control rotor while leveling off from a climb to about 400 feet above ground level (AGL). The pilot initiated an emergency descent but, due to severely reduced cyclic controllability resulting from the separation, was unable to avoid power lines in the aircraft's emergency descent flight path. The helicopter struck the power lines about 50 feet AGL and fell to the ground, landing hard but upright. Post-accident examination disclosed a fatigue failure in the cuff which retains the control rotor blade. The fatigue originated on two opposite sides of a retaining bolt hole that appeared to have been unevenly hand chamfered or deburred during original manufacture of the cuff, with gouging and sharp-bottomed dents visible at the origins. However, while a company mechanic had signed off an Airworthiness Directive (AD) requiring recurring inspection of the cuff about two months/56 flight hours before the accident, post-accident examination disclosed evidence indicative of inadequate inspection and maintenance of the assembly, including: old dried grease between the cuff and control rotor blade spar, large areas of the spar missing required paint with associated corrosion areas, and zinc chromate primer in corrosion pits. The FAA-approved Hiller service bulletin referenced by the AD contains procedures for inspection of spar tube retention bolt holes for 'elongation, corrosion, burrs, pitting or fretting' and associated repair procedures, but does not contain any instructions to inspect or repair bolt holes in the control rotor cuff for those same conditions. ## Factual narrative On November 2, 1999, approximately 1118 Pacific standard time, a Hiller UH-12E helicopter, N5388V, registered to Valley Helicopter Service of Clarkston, Washington, on a public-use fish survey in the Nez Perce Indian Reservation being conducted by the Nez Perce Tribe, experienced an inflight separation of a control rotor near Stites, Idaho. Following the control rotor separation, the helicopter struck power lines while in an emergency descent and subsequently impacted the ground. The helicopter was substantially damaged in the accident. The commercial pilot-in-command of the helicopter and one of the helicopter's two other occupants (both biologists conducting the survey) received serious injuries. The third occupant of the helicopter was not injured. The pilot reported that visual meteorological conditions prevailed and a company visual flight rules (VFR) flight plan had been filed for the flight from Clarkston, Washington, to Grangeville, Idaho. The pilot reported: We were performing a Chinook redd fish survey for the Nez Perce Indian Tribe along the Clearwater River....The fish count is made about 100' above the river, so as we approached the town of Stites, I climbed up to about 400' and started to cross over a rural area. As we leveled out at 400' AGL straight and level, we got a severe out of track condition on the main rotor blades. I increased the RPM slightly to see if it would smooth out, but this was not effective and at that time we got a severe lateral gyration that felt like a broken tt [sic] pin or drag strut, but was much more severe. I dropped the pitch and setup a decent [sic] that gave me the least feed- back and gyration. The out of balance condition was so severe that I felt the engine mounts were about to fail. The engine was running normal and the [tail rotor] controls were effective. Any change out of neutral position on the cyclic control gave the indication of a roll over effect, so I held the cyclic in the neutral position and used the [tail rotor] control to line the aircraft toward an open pasture. As we descended to about 100' AGL, I noticed a powerline crossing directly across my landing area and rather than make a control change to avoid it, as the helicopter was very unstable, I decided to hit it square with my skids. The engine was running at this point, and as we hit the lines the helicopter broke through but the lines wrapped around the mast slowing the the RPM and the rate of decent [sic] and we dropped vertically at that point with full collective pitch. When I pulled pitch we turned 90 degrees but hit level on both skids.... The blades stopped immediately and we evacuated the helicopter.... The control rotor paddle and part of the aluminum cuff was later found where it separated from the aircraft, about...1/4 mile from the landing/ impact site. An FAA inspector from the Spokane, Washington, FAA Flight Standards District Office (FSDO), who took possession of the separated control rotor following the accident, reported that the control rotor separated at the cuff and trunnion area. The separated control rotor was one of two control rotors on the UH-12E that provide cyclic control to the main rotor disc (mechanical linkage from the cyclic control operates to cyclically vary the angle of incidence of the control rotors, which in turn tilts the main rotor disc in the commanded direction via aerodynamic and gyroscopic forces.) Component service and maintenance history data furnished to the NTSB indicates that the fractured cuff was installed new in the cuff and trunnion assembly during a 1980 overhaul of the assembly. From 1980 to 1996, the cuff and trunnion assembly was installed on two other helicopters for a total of five different periods of service. A check of the NTSB accident database revealed no accidents involving aircraft registration numbers on which this cuff and trunnion assembly was installed for the corresponding service periods between 1983 and 1996 (records were not available from the Internet for accidents prior to 1983.) The cuff and trunnion assembly was removed from another helicopter and returned to stock on November 24, 1996, according to the component historical service record. Most recently, the cuff and trunnion assembly was indicated as being "rebuilt" by a Valley Helicopter Service mechanic on April 15, 1999, to include a dye check of cuff serial number 10653. The cuff and trunnion assembly was then installed on the accident helicopter in conjunction with its most recent annual inspection, on April 20, 1999. FAA Airworthiness Directive (AD) 97-10-16, which requires inspection of UH-12E control rotor cuffs and spar tubes at 100-hour intervals as well as at annual inspections "to prevent separation of the control rotor blade assembly and subsequent loss of control of the helicopter", was last signed off as complied with on the accident helicopter by the Valley Helicopter Service mechanic on September 6, 1999, at the time of the helicopter's most recent 100-hour inspection, approximately 56 flight hours prior to the accident. According to the records furnished by the operator, at the time of the accident, the fractured cuff had 2,844.6 hours in service since new and 237.8 hours since the April 15, 1999, overhaul or "rebuild." No indication was noted in the maintenance records or on the components that the control rotor blade assembly had been reworked according to Hiller Aviation Service Bulletin 36-1, Revision 3. The life limit of the control rotor cuff, when installed with a control rotor blade assembly that has not been reworked, is 6,860 hours. The separated control rotor cuff (part number 36124-3, serial number 10653) was sent to the NTSB Materials Laboratory, Washington, D.C., for metallurgical examination. The Materials Laboratory factual report of this examination (Report No. 00-028, February 2, 2000, attached) reported as follows: ...As received, the outboard portion of the aluminum cuff was still attached to the inboard end of the steel control rotor blade spar by two through bolts (0.25 inch nominal diameter). The cuff was fractured through both holes for the inboard through bolt.... ...Initial optical examinations of the separated cuff uncovered fracture features indicative of fatigue emanating from the cuff hole at the head side of the inboard bolt....From the Illustrated Parts Breakdown (IPB) orientation, this would be the upper trailing quadrant of the cuff. The fracture surfaces were partially obscured by heavy black deposits adjacent to the initiation hole. The deposits appeared typical of aluminum fretting products. It was also noted that as-received the cuff was loose on the spar and would move longitudinally an estimated 0.02 to 0.05 inches. To aid in further examinations, the connecting bolts were removed and the outboard portion of the cuff was disassembled from the shaft....As- received, some pliable sealant material was visible around the nut and washers of the outboard bolt, but none was visible at the head side or at either end of the inboard bolt. Small remnants of sealant were found between the washers of the inboard bolt during disassembly. Each of the through bolts had two rings of fretting and wear on the shanks at locations corresponding to the installed position of the spar. The IPB...shows two...washers used for each bolt (one under each [sic] the head and nut). As assembled, each of the existing through bolts had two washers under both the head and the nut.... Gummy black deposits partially covered the mating surfaces of both the spar and the cuff and a small amount of what appeared to be dried black grease was found at the outboard edge of the cuff. Translucent yellow brown grease was apparent on the inner diameter surface of the spar. The exterior spar surfaces under the deposits were partially covered by gr ## Aircraft - Registration: [N5388V](https://openairdocs.org/deregistered/N5388V-2021-05-08), registration cancelled 2021-05-08, S/N 2099, built 1963 (OpenAirDocs) - Reported make and model: Hiller UH-12E - Registry model: [Hiller UH-12E](https://openairdocs.org/model/hiller-uh-12e) (registry code 4360122) (OpenAirDocs) - Registry engine: [Lycoming VO-540 series](https://openairdocs.org/engine/lycoming-vo-540-series) (registry code 41534, reciprocating) (OpenAirDocs) - Category: Helicopter - Serial number: 2099 - Airframe hours: 22137 - Engines: Lycoming VO-540-C2A 305 horsepower reciprocating - Damage: Substantial damage - Flight: Public aircraft, Public use - Registered owner: James R. Pope - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, October 29, 1999, 57 hours before - Departed: CLARKSTON, WA - Destination: GRANGEVILLE, ID - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; commercial; airplane ratings: single-engine land; instrument ratings: helicopter, airplane; medical: class 2, valid medical--no waivers/lim.; seat: center; flight hours: 32,275 total, 22,000 in this make and model, 228 in the last 90 days, 87 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Day - Wind: calm - Visibility: 50 statute miles - Lowest ceiling: none - Temperature: 64 °F ## 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 19991102043059A](https://openairdocs.org/incident/19991102043059A), Nov 2, 1999: Hiller UH12E, Stites, ID, No damage. (-23) Pilot reported loss of control of helicopter when control rotor tube assembly separated from helicopter. Helicopter fell through electrical power lines… ## Other investigations on N5388V (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 SEA67A0060](https://openairdocs.org/ntsb/SEA67A0060), Apr 21, 1967: Hiller UH-12E (N5388V), Orofino, ID, substantial damage 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.