SEA04LA036

NTSB accident investigation · Bell 206B · Turner, OR · January 26, 2004

Accident · No injuriesLimited investigationFinal report
Date
January 26, 2004, 15:45 local (23:45 UTC)
Place
Turner, OR
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N92CABell 206B
Weather
Visual (VMC) · Day
Status
Completed · report September 29, 2004
Report
Approved by Office Director
Parties
FAA-FSDO, Rolls-Royce
FAA report
20040126000489A
Case key
58669

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 pilot's inadequate preflight inspection which failed to detect contaminated fuel. A collapsed fuel screen was a contributing factor.

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.

Loss of engine power(partial) - nonmechanicalHover - out of ground effect
Aircraft preflight - inadequatePilot in commandCause
Fluid,fuel - contamination,waterCause
Fluid,fuel - contamination,other than waterCause
Fuel system,screen - collapsedFactor
Forced landingEmergency descent/landing
Hard landingEmergency descent/landing
Terrain condition - open field

Analysis

The pilot reported that he was practicing maneuvers with a 100-foot long line attached in preparation for a check ride the following day. The pilot reported that he was in a hover with the hook at the end of the line just touching the ground. The pilot then increased altitude and raised the hook off the ground about 10 feet, when the engine suddenly decreased power to idle. The pilot immediately initiated an autorotation to an open field. The helicopter subsequently touched down tail low, followed by the main rotor blades contacting and severing the tailboom. Post-accident inspection of the engine found the fuel nozzle screen collapsed with traces of contaminant in the screen. Water and bacterial contaminants were found in the airframe filter bowl and fuel pump filter bowl. It was also noted that Kerosene (K-1), which is not approved for this engine was being used instead of Jet A. The engine was test run in a test cell and although the engine was found to run below normal rated shaft horsepower, no evidence of a mechanical failure or malfunction was found.

Factual narrative

On January 26, 2004, at 1545 Pacific standard time, a Bell 206B, N92CA, registered to and operated by Reforestation Services Inc., as a 14 CFR Part 91 personal proficiency flight, experienced a partial loss of engine power followed by an autorotation to a field near Turner, Oregon. After touchdown, the main rotor blades contacted and severed the tailboom. Visual meteorological conditions prevailed at the time and a company visual flight rules flight plan was in effect. The helicopter was substantially damaged and the commercial pilot, the sole occupant, was not injured. The flight departed from Salem, Oregon, about 30 minutes prior to the accident.

During a telephone interview, the pilot reported that he was practicing maneuvers with a 100-foot long line attached in preparation for a check ride the following day. The pilot reported that he was in a hover with the hook at the end of the line just touching the ground. The pilot then increased altitude and raised the hook off the ground about 10 feet, when the engine suddenly decreased power to idle. The pilot immediately initiated an autorotation to an open field. The helicopter subsequently touched down tail low, followed by the main rotor blades contacting and severing the tailboom.

The wreckage was recovered from the field and transported to the operator's base of operations in Salem, Oregon. A Federal Aviation Administration (FAA) Inspector from the Hillsboro, Oregon, Flight Standards District Office (FSDO), inspected the engine and found that the fuel nozzle screen was collapsed. Fuel samples were taken from the airframe filter bowl, and the fuel tank. It was visually noted that contaminants were present in the airframe filter bowl. These samples, along with the wetted fuel nozzle screen, and airframe filter were sent to the National Transportation Safety Board Investigator-in-Charge.

The pilot reported to the FAA Inspector the he did drain the fuel from the airframe fuel filter during the preflight, but did not note any water or contaminants.

Arrangements were made to remove the engine for transport to Rolls-Royce, Indianapolis, Indiana, for engine inspection and test cell run. The fuel samples and fuel nozzle screen and filter were sent to a Federal Aviation Administration Inspector from the Indianapolis FSDO. This inspector oversaw the testing of the engine and components.

The engine was visually inspected for preparation of an "as received" engine run. During the inspection, fuel samples were taken from the fuel pump filter bowl and the fuel nozzle supply line. The fuel pump filter bowl contained 20 ml of liquid. 3 ml of brownish/tan liquid separated to the bottom of the sample container. 5 ml of liquid was drained from the nozzle supply line. This fluid was clear. The samples from both sources had an aroma consistent with the smell of paint thinner.

The samples were tested and found that the fuel, later determined to be Kerosene (K-1), contained both water and bacteria. There was also Diethylene Glycol Methyl Ether (DIEGME), a fuel additive used as an icing inhibitor was present. The Rolls-Royce representative reported that K-1 is not approved fuel for this engine.

The collapsed fuel nozzle screen was inspected for the presence of contaminants. The contaminants noted on the collapsed fuel nozzle screen were found to be brass, oxidized aluminum, pure nickel and aluminum alloys.

The engine was placed in a test cell. The collapsed fuel nozzle screen was replaced with a new screen for the test run. The engine was started and warmed up before acceleration to full RPM. Two-aborted wave off's were made and smooth movements of the governor actuator were made. In both tests, the engine controls (fuel control and governor) showed no discrepancies. The engine was accelerated and power calibration readings were taken. The results indicated that the engine was -18.3 at take off horsepower and -20.5 at normal cruise power setting and 402 and 400 shaft horsepower. Normal rated shaft horsepower is 420. The engine was then shutdown and removed from the test cell.

Further bench testing to measure the fuel flow and fuel pressure indicated that there were no significant differences during testing of the collapsed fuel nozzle and screen versus a new fuel nozzle and new screen.

At the request of the owner's representative, the engine was returned to Standard Aero Limited, Richmond, B.C. on April 2, 2004.

Aircraft

Registration
N92CA
Reported as
Bell 206B
Category
Helicopter
Serial number
2016
Airframe hours
13,231
Engine
Rolls-Royce 250 C20B, 420 horsepower, turbo shaft
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Reforestation Services Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · October 27, 2003 · 61 hours before
Departed
SLE · Salem, OR
Flight plan
Company VFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
40
Injuries
None
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
May 13, 2003
Seat
Right
Flight hours
11,500 total · 6,000 in this make and model · 11,350 as pilot in command · 65 in the last 90 days · 0 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 10 knots
Visibility
10 statute miles
Lowest ceiling
4,000 ft overcast
Temperature
46 °F, dew point 36 °F
Altimeter
29.97 inHg
Observed at
SLE, 5 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.