SEA07LA135

NTSB accident investigation · Hughes 369D · Columbus, MT · May 28, 2007

Accident · FatalLimited investigationFinal report
Date
May 28, 2007, 13:40 local (19:40 UTC)
Place
Columbus, MT
Injuries
1 fatal, 2 serious
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N765HVHughes 369D
Weather
Visual (VMC) · Day
Status
Completed · report May 28, 2008
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20070528011329A
Case key
65882

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 fatigue failure of a turbine blade due to a localized over-temperature of the turbine section as result of a non-uniform fuel distribution by the fuel nozzle. Contributing to the accident was the close proximity of a power line support structure which restricted maneuverability for a successful autorotation.

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
Fuel system,nozzle - malfunctionCause
Turbine assembly - overtemperatureCause
Turbine assembly,turbine blade - fatigueCause
Turbine assembly,turbine blade - failureCause
In flight collision with terrain/waterEmergency landing
Autorotation - restrictedFactor
Object - electrical towerFactor
Terrain condition - ground

Analysis

During a stable hover about 120 feet above ground level for the purpose of visually inspecting a power line support structure, the helicopter had a complete loss of engine power. The pilot's maneuvering options were limited by the support structure, and he attempted an autorotation to a forced landing. During that sequence of events the helicopter collided with terrain. The investigation determined that the engine's fuel nozzle was supplying a nonuniform fuel spray, leading to a localized over-temperature in the turbine section, which lead to turbine blade rub, the eventual fatigue separation of a second stage turbine blade, and the loss of engine power.

Factual narrative

On May 28, 2007, approximately 1340 mountain daylight time, a Hughes 369D helicopter, N765HV, impacted the terrain during an attempted forced landing, after experiencing a complete loss of engine power near Columbus, Montana. The commercial pilot and one crewmember received serious injuries, and a second crewmember was killed. The helicopter, which was owned by Dylan Aviation, LLC., and operated by Haverfield Corporation, was destroyed by the impact and post-crash fire. The 14 CFR Part 91 aerial observation flight, which departed Billings Logan International Airport, Billings, Montana, about 50 minutes prior to the accident, was being operated in visual meteorological conditions. The flight, for which a company visual flight rules (VFR) flight plan had been filed and activated, was intended to terminate back at Billings. The ELT was activated by the accident sequence.

According to the pilot, the helicopter, which was being used for comprehensive visual inspection of power lines and power line support structures, was in a stationary hover about 120 above ground level (AGL), when it experienced a sudden and complete loss of engine power. The pilot, who's direction of maneuver was limited by the presence of the power line support structure that was being inspected, initiated an autorotation to an emergency forced landing. Although the helicopter contacted the relatively level grassy ground in a upright attitude, the impact forces where high enough that both front seat crewmembers sustained serious injuries, and the helicopter's airframe was distorted. The two front seat crewmembers were able to exit the helicopter through the broken out front windscreen. The back seat crewmember had sustained "significant blunt traumatic injuries," and according to the opinion of the medical doctor who performed the autopsy, he expired prior to the initiation of the fire that started a few minutes after the impact. The majority of the helicopter's airframe, except for about the last five feet of the tail boom, and most of the engine accessory systems were consumed by the fire.

Both the engine and airframe underwent initial inspections after being recovered to Arlin's Aircraft Service in Bozeman, Montana. After those inspections, the engine was shipped to Rolls-Royce Corporation, where under the oversight and guidance of the Federal Aviation Administration's Indianapolis Flight Standards District Office, it underwent a further teardown inspection, testing, and metallurgical examination. These further investigative actions determined that a second stage turbine blade had separated from its turbine wheel due to high cycle fatigue (HCF), which initiated at the suction (forward) side blade-to-rim fillet. There were no metallurgical anomalies found at the fatigue crack initiation site, and microstructure, hardness, and chemistry of the turbine wheel conformed to the requirements of the engineering drawings. Further inspection of the second stage turbine wheel found evidence of blade tip rub, including on the blades immediately preceding and following the failed blade. Fluorescent penetrant inspection (FPI) and binocular examination revealed cracking on the suction side blade-to-rim fillets of many of the remaining blades. Dimensional inspection of the seconds stage turbine nozzle assembly determined that both the first and second stage turbine blade tracks were circumferentially distorted (out of round), and inspection of the power turbine-3 and power turbine-4 (P/T-3 and P/T-4) determined that the wheel shroud knife seals were worn non-uniformly around the circumference of the turbine wheel shrouds.

Inspection of the first stage turbine nozzle assembly revealed that four adjacent airfoils near the 11:00 o'clock position (aft looking forward view) showed extensive thermal damage, to include incipient melting near the surface, and complete mid-span burn-through along the entire length of one of the airfoils. The second stage turbine nozzle showed thermal damage, although to a lesser degree, near the same position. The combustion liner showed a non-uniform discoloration indicative of a non-uniform burner profile.

Although the aforementioned thermal damage is consistent with a streaking fuel nozzle, the fuel nozzle itself suffered heat distress due to the post-crash fire, and was therefore tested on the flow bench, in accordance with the 250-C20B overhaul manual, in its as-found condition. During the test sequence, streaking was observed, and the fuel flow (in pounds per hour) was lower than the minimum specified in three out of the four defined nozzle pressure differential test points. After the as-found flow test, the nozzle was disassembled, and no evidence of foreign contamination was observed.

During the investigation, a review of the operator's engine maintenance records revealed that during only two of the last seven 100-hour inspections (a period of about 810 engine hours) was there documentation showing that the fuel nozzle had been removed, inspected, and cleaned, as called for in the June 1, 2004, revision of the Rolls-Royce 250-C20 Series Operation and Maintenance Manual 72-00-00. According to the records, at the time of the accident, it had been about 236 hours since the nozzle inspection/cleaning requirements had been met. During the other five 100-hour inspections, the checklist used did not contain the current June 1, 2004, revision page (page 609) where item 21A (Remove, inspect and clean the fuel nozzle) had been added. The investigation also revealed that item 21A in the June 1, 2004 revision contained a note that stated, "Operators may find it necessary to inspect and clean the fuel nozzle more often depending on past experience or operating conditions."

Aircraft

Registration
N765HV
Reported as
Hughes 369D
Category
Helicopter
Serial number
310904D
Airframe hours
10,774
Engine
Rolls-Royce 250-C20B, 450 horsepower, turbo shaft
Damage
Destroyed
Fire
On-Ground
Flight
Aerial observation · Part 91
Operator
Haverfield Corporation
Registered owner
Dylan Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 1, 2007 · 43 hours before
Departed
KBIL · Billings, MT
Destination
KBIL · Billings, MT
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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
42
Injuries
Serious
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
May 1, 2006
Seat
Left
Flight hours
11,487 total · 6,749 in this make and model · 10,862 as pilot in command · 235 in the last 90 days · 72 in the last 30 days · 3 in the last 24 hours
Role
Other flight crew
Age
38
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
May 1, 2006
Seat
Right

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F

Docket · 2

The files NTSB released with the investigation on April 30, 2008, on NTSB’s docket system: statements, records, photos and specialists’ reports. 787 KB in all.

FAA reports on this event · 1

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