SEA06FA067

NTSB accident investigation · Kaman K-1200 · Dayville, OR · March 17, 2006

Accident · FatalField investigationFinal report
Date
March 17, 2006, 09:35 local (17:35 UTC)
Place
Dayville, OR
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N263KAKaman K-1200
Weather
Visual (VMC) · Day
Status
Completed · report May 29, 2007
Report
Approved by Office Director
Parties
FAA FSDO, Honeywell, Kaman Aerospace Corporation, Grizzly Mountain Aviation
FAA report
20060317008649A
Case key
63396

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 improper overhaul of the reduction gear box assembly and improper installation of the N1 seal and nut assembly lockcup by maintenance personnel, which resulted in failure of the reduction gear box and a total loss of engine power. A contributing factor was the pilot's failure to maintain adequate rotor rpm following the power loss, which resulted in an uncontrolled descent to ground impact.

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 powerHover - out of ground effect
Turboshaft engine,reduction gear box - failure,totalCause
Maintenance,overhaul - improperOther maintenance personnelCause
Maintenance,installation - improperOther maintenance personnelCause
Turboshaft engine,gas generator turbine shaft - loose part/bolt/nut/clamp/etcCause
Loss of control - in flightDescent - emergency
Rotor rpm - not maintainedPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The helicopter experienced a total loss of engine power while hovering out of ground effect during a long-line logging operation. Witnesses observed the helicopter descend vertically with the rotors visibly slowing down, nose over to an inverted position, impact the ground inverted, and roll onto its left side. Initial examination of the engine revealed that when the power turbine was rotated, the engine output adapter attached to the reduction gearbox did not rotate, indicating a mechanical disconnect within the engine. Disassembly of the engine revealed severe damage to the sun gear shaft, which coupled the power turbine to the reduction gear box. Further disassembly and materials analysis disclosed an assembly error of one of the three aft planetary gear shaft roller bearings in the reduction gear box and improper crimping of the lockcup on the N1 seal and nut assembly. These two errors resulted in misalignment in the planetary gear train leading to high tooth loading in the sun gear shaft, which resulted in stripping and separation of gear teeth and loss of transmitted torque through the reduction gear box. Examination of maintenance records indicated that the bearing assembly error occurred during an overhaul of the reduction gear box by a certified repair station 822.8 operating hours before the accident. The improper crimping of the lockcup occurred during a repair by the same certified repair station performed 350.2 operating hours before the accident.

Factual narrative

History of flight

On March 17, 2006, about 0935 Pacific standard time, a Kaman K-1200 helicopter, N263KA, collided with terrain in an uncontrolled descent following a loss of engine power while hovering out of ground effect about 16 nautical miles north of Dayville, Oregon. The commercial pilot, the sole occupant, received fatal injuries, and the helicopter sustained substantial damage. The helicopter was registered to and operated by Grizzly Mountain Aviation Inc. of Prineville, Oregon. Visual meteorological conditions prevailed and no flight plan was filed for the 14 CFR Part 133 flight. The helicopter was being used for long-line logging and operations for the day had commenced about 0700.

Witnesses reported to local authorities that the pilot set down a load of logs and stated on the radio that he was going to reposition the helicopter to land at the service area. At this point, the helicopter was about 300 feet above ground level (agl), hovering, with the 200-foot long line still attached. The witnesses then heard the engine "shutdown." They observed the helicopter descend vertically with the rotors visibly slowing down, nose over to an inverted position, impact the ground inverted, and roll onto its left side. There was no fire.

Personnel information

The pilot held a commercial pilot certificate with a helicopter rating. Additionally, he was rated as a private pilot in single engine land airplanes. His most recent medical certificate was a second class medical issued on April 5, 2005, with the limitation, must wear corrective lenses.

According to information provided by Grizzly Mountain Aviation, the pilot had accumulated a total flight time of 4,019 hours of which 3,858 hours were in helicopters and 1,646 hours were in the Kaman K-1200. In the previous 90 days, he had accumulated 267 hours, all in the Kaman K-1200.

Records provided by Kaman Aerospace Corporation indicated that in September 2004, the pilot satisfactorily completed the K-1200 Pilot Familiarization Training Course at the Kaman facility in Bloomfield, Connecticut. The training included 54 hours of ground school and 15 hours of flight instruction.

Aircraft information

The 2002 model Kaman K-1200 helicopter, S/N A940033, was powered by one 1,500-horsepower Honeywell T5317A-1 turboshaft engine, S/N LE-81003. At the time of the accident, the helicopter had accumulated 3,193.1 hours of flight time, and the engine had accumulated 6,636.1 operating hours since new and 3,257.4 hours since overhaul.

Review of the engine logbook revealed that an overhauled reduction gear box, P/N 1-030-350-16, S/N 5E003, was installed on January 10, 2005, at engine time since new of 5,813.3 hours. At the time of the accident, the reduction gear box had accumulated 822.8 hours since this overhaul, which was performed by a certified repair station. Review of the work order for the reduction gear box overhaul indicated that overhauled planetary gear shafts with serial numbers (S/Ns) 16336, 16363, and 16449 were installed.

The last major maintenance action performed on the engine was conducted on August 29, 2005, at engine time since new of 6,285.9 hours. The logbook entry for this maintenance indicated the engine was sent to the same repair station that performed the reduction gear box overhaul for "repair of reported low power and high EGT." The entry stated, in part: "Inspected hot section and compressor section, replaced air diffuser, replaced combustion liner, reassembled and functionally tested I/A/W [in accordance with] Honeywell 330.2 and 330.3 manuals." At the time of the accident, the engine had accumulated 350.2 hours since this repair.

Review of the daily maintenance report sheets for the helicopter from February 15, 2006, to the date of the accident revealed no listings of any uncorrected maintenance discrepancies.

Wreckage and impact information

An on scene examination of the wreckage was conducted on March 17, 2006, by representatives from the FAA and Kaman Aerospace Corporation. According to information provided by the representatives, the helicopter came to rest inverted with the left side of the nose compartment, top and left sides of the cockpit, top of the transmission rotor shafts, left side of the landing gear boom, and left stabilizer contacting the ground. A circular debris field surrounded the helicopter with the farthest piece of wreckage located about 90 feet from the helicopter. The cargo hook on the helicopter's belly was open with the corresponding end of the long line several feet away. The long line was laid out on the ground aft of the helicopter. The line was intact, and there was no evidence of the line becoming entangled during the accident sequence.

The fuselage remained intact, but was crushed, distorted and broken aft of the landing gear boom. The tail boom remained attached and was distorted. The top 18 inches of the vertical fin were broken off, and the rudder was separated from the vertical fin. The separated section of the vertical fin and the rudder were found within the debris field. All four main rotor blades were broken into sections; all of the sections were accounted for in the debris field. According to the Kaman representative, "the rotor blade sections were in relatively large pieces denoting a slow rotor speed at impact." During examination of the helicopter at the accident site, 80 gallons of fuel were drained from the helicopter's fuel system, and the fuel filter and fuel samples appeared to be clean.

The wreckage was recovered from the accident site and transported to Specialty Aircraft in Redmond, Oregon, where it was further examined by the FAA and Kaman representatives on March 20, 2006. The transmission, rotor shafts and hubs remained together as a single unit, but the unit sustained heavy impact damage. The engine-to-transmission drive shaft was separated into 3 sections. The fracture surfaces on the drive shaft showed no signs of fatigue. Inspection of the engine revealed that the power turbine could be rotated by manually turning the second stage power turbine wheel. When the power turbine was rotated, the engine output adapter attached to the reduction gearbox did not rotate, indicating a mechanical disconnect within the engine. The engine was removed from the helicopter and sent to the facilities of Honeywell in Phoenix, Arizona for further examination.

Medical and pathological information

An autopsy of the pilot was conducted by the Medical Examiner Division of the Oregon State Police in Clackamas, Oregon. Toxicology tests conducted by the FAA's Toxicology and Accident Research Laboratory were negative for carbon monoxide, cyanide, ethanol and drugs.

Tests and research

The engine was examined at the Honeywell facilities in Phoenix, Arizona on May 1 and 2, 2006, under the supervision of the NTSB investigator-in-charge (IIC). Disassembly of the engine revealed severe damage to the sun gear shaft (P/N 1-130-192-04, S/N 71037), which coupled the power turbine to the reduction gear box. Specifically, the center section of the sun gear on the forward end of the shaft was completely milled away, well into the gear shaft rim. The three planetary gear shafts (P/N 1-030-193-01, S/Ns 16336, 16363, and 16449) displayed damaged and missing teeth on their aft gears, which mated with the sun gear. There was metal debris adhering to all of the gear shafts. A large amount of metal debris, including pieces that appeared to be fragments of gear teeth, was found in the inlet housing, which covers the reduction gear box.

Each planetary gear shaft was supported at its aft end by a roller bearing, the outer race of which was pressed into a bore in the aft plate of the planetary gear carrier assembly. The aft roller bearing that supported planetary gear shaft S/N 16336 was found missing its cage, and the individual rollers were clustered together, such tha

Aircraft

Registration
N263KA
Reported as
Kaman K-1200
Category
Helicopter
Serial number
A940033
Airframe hours
3,193
Engine
Honeywell T5317A-1, 1,500 horsepower, turbo shaft
Damage
Substantial damage
Flight
Other work use · Part 133
Registered owner
Grizzly Mountain Aviation Inc
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · March 1, 2006 · 3 hours before
Departed
Dayville, OR

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
39
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 2, With waivers/limitations
Last flight review
September 1, 2004
Seat
Single
Toxicology
Performed
Flight hours
4,019 total · 1,646 in this make and model · 267 in the last 90 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
50 statute miles
Lowest ceiling
None
Temperature
37 °F

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.