SEA98GA159

NTSB accident investigation · Bell 212 · Juntura, OR · August 8, 1998

Accident · No injuriesFinal report
Date
August 8, 1998, 15:05 local (21:05 UTC)
Place
Juntura, OR
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N291BBell 212
Weather
Visual (VMC) · Day
Status
Completed · report January 11, 2000
Report
Approved by Office Director
FAA report
19980808030099A
Case key
46179

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-in-command's failure to maintain proper clearance between the long line cable and hell hole structure resulting in airframe contact and binding of the cable. This resulted in separation/disabling of the fuel control solenoid and a subsequent restriction/cessation of fuel flow to the #1 engine. Contributing factors were separation of the #1 engine push/pull rod and a tree.

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) - mech failure/malfHover
Throttle/power lever,push/pull rod - separationFactor
Fuel system,fuel control - disabledCause
Fluid,fuel - flow restrictedCause
External load cable/hook - binding(mechanical)Cause
Clearance - not maintainedPilot in commandCause
Forced landingDescent - emergency
On ground/water encounter with terrain/waterLanding - flare/touchdown
Object - tree(s)Factor

Analysis

The pilot-in-command (PIC) had just maneuvered the Bell 212 helicopter into a 100 foot hover above a small reservoir to fill a 'Bambi' bucket for fire-fighting operations. The rotorcraft began to settle. The PIC, perceiving that he had encountered rotor vortex conditions, slipped the helicopter to the right with the bucket still in the reservoir. This, in turn, increased the angle of the long line from the vertical or zero degree reference. Immediately thereafter, the PIC noted a loss of power in the #1 engine. He then executed a single-engine autorotation, during which a rotor blade impacted a dead tree. Post-crash examination revealed that the long line had pulled aft and left from its vertical reference into the airframe structure (the 7:30 position of the hell hole in the belly of the helicopter) resulting in 1) the separation of one of the #1 engine push/pull rods, and 2) the deformation of engine control rods associated with the #1 engine flight idle stop (solenoid) which then sheared. The shearing of the flight idle stop resulted in a restriction/cessation of fuel flow to the #1 engine fuel control unit, and subsequent engine shutdown.

Factual narrative

History of flight

On August 8, 1998, approximately 1505 mountain daylight time, a Bell 212, N291B, registered to Air One Helicopters, Inc., being operated by the Bureau of Land Management (Vale District), and being flown by an airline transport pilot, incurred substantial damage during a single engine auto-rotation landing following a total loss of power in the number one engine. The accident occurred approximately nine miles northwest of Juntura, Oregon, and the pilot was uninjured. Visual meteorological conditions prevailed and a company flight plan was in effect. The flight, which was engaged in fire fighting, was to have been operated as a Public Use mission.

The pilot reported in a written statement that he was "supporting fire fighters on the Beulah Butte fire in Oregon" and that "approximately 2PM in the afternoon I was dipping the last bucket on the third fuel cycle with a 100 foot line into a cattle tank. As the Bambi bucket settled onto the water I applied collective to maintain altitude while the bucket sank. The aircraft settled as I applied collective which initially I thought was settling in my own rotor vortex. Collective was reduced and the aircraft slipped to the right for the purpose of gaining clean air. As collective was reapplied to stop the descent the low rotor warning sounded. I looked at the triple tacometer [sic] in the door which indicated around 90% Nr then looked at the number one and two N1 guages [sic]. Number one was directly on '0' and number two was in the high '90's.' At this point an autorotative glide was established toward the shoreline and the hook release activated. Upon landing in the shallow end of the tank the main rotor blade struck a branch on a dead tree."

The pilot was also interviewed by a member of the Department of the Interior, Office of Aircraft Services (a participant in the investigation). The pilot reported during the interview that he "was all morning - probably on my third fuel load - slinging water to the fire on a 100-foot line with a Bambi bucket, 320-gallon one. I had just put the bucket onto the pond that I was dipping out of and noticed the aircraft starting to settle. I immediately assumed that I was possibly in my own vortex, lowered the collective, moved a little to the right to fly out of it as I reapplied the collective it continued to sink further and I got a low rotor rpm warning horn. I immediately realized something was wrong and was not going to continue hovering there. I went into the autorotative mode, turned the aircraft towards the level area on the pond there on the shoreline where I thought I could make a successful run-on landing. At the same time [I] attempted to punch off the bucket. Either I punched it or there was slack or I was not quick enough to punch off the line. There was a little bit of a jolt that I felt on the belly hook and after that I slid it successfully onto the shore of the dip site" (refer to ATTACHMENT INTV-I).

Personnel information

The pilot-in-command reported to the Federal Aviation Administration (FAA) at his last medical examination, a second class conducted November 3, 1997, that he had a total of 12,000 hours of flight experience. He reported on the attached Pilot/Operator Report (NSTB Form 6120.1/2) that he had a total of 500 hours in the Bell 212 rotorcraft (all pilot-in-command), with 80 and 50 hours in the previous 90 and 30 days respectively. Additionally, he reported that he had completed a bi-annual flight review (or equivalent) in the Bell 212 rotorcraft but did not report that date of this review. Records indicated that this review was conducted on May 11, 1998.

The operator reported that the pilot had flown a total of 4.9 hours within the 9 hour crew duty day on the day previous to the accident. On the day of the accident he had flown a total of 3.7 hours in a 7 hour crew duty day.

Aircraft information

The rotorcraft was equipped with two Pratt & Whitney PT6T-3 turboshaft engines. The "Bambi" bucket, according to the pilot, had a capacity of 320 gallons, which, at 8.345 pounds per gallon of water, would yield a load weight of 2,670 pounds exclusive of the empty bucket weight and associated hardware. The bucket was designed to easily tip over and sink when set in water to facilitate expeditious filling (refer to photograph 1).

The rotorcraft's maximum gross takeoff weight was reported by the operator as 11,200 pounds. The weight of the rotorcraft at the time of the accident was estimated based upon the following information:

6,320 pounds rotorcraft empty weight 246 pounds pilot weight (from 11/20/98 medical) 400 pounds fuel according to pilot 200 pounds Bambi bucket/line/shackle/cable 2,670 pounds 320 gallons of water @ 8.345#/gal

9,836 pounds rotorcraft weight at the site

No information was available from either the Office of Aircraft Services or Bell Helicopter Textron defining the maximum long line angle displacement allowable (from the vertical) during long line operations. Specifically, neither the operator nor the manufacturer were able to provide any documentation which the pilot could routinely use defining a maximum angle (from the vertical) for long line displacement before the line, hook, bumper or other hardware might come in contact with the surrounding hell hole structure. Nor was there any information available regarding the effectiveness of the long line hook release mechanism at angles other than purely vertical.

Additionally, no sensing system exists, nor is one required on the Bell 212 such that when any portion of the long line hardware contacts the hell hole structure the pilot is provided with a warning (e.g., horn, caution light, etc.). A member of the Office of Aircraft Services discussed the operating characteristics of the Bell 212 with the USDA Forest Service Region 4 Helicopter Program manager who reported that pilots "normally can feel the cargo hook hitting the stops when the load is oscillating."

The pilot's assessment of angular displacement of the long line is acquired exclusively through visual observation through the rotorcraft's side window.

Meteorological information

The density altitude at Burns, Oregon, situated 4,144 feet above mean sea level (MSL) was calculated. Based upon the 1453 (mountain time) surface observation reporting a temperature of 30 degrees Centigrade and a station pressure setting of 30.04 inches of mercury, the approximate density altitude was 6,749 feet. The density altitude at the accident site at 1500 on the afternoon of the accident was estimated as 7,000 feet.

Wreckage and impact information

The accident site was reported to be at 43 degrees 52.7 minutes north latitude and 118 degrees 6.3 minutes west longitude (refer to CHART I), approximately 4,700 feet MSL, and adjacent to a small reservoir (cattle tank).

On-site examination by FAA personnel revealed that the rotorcraft came to rest approximately 60 feet beyond the south edge of the reservoir. Skid marks were observed leading from the water's edge up to the rotorcraft's skids (refer to photograph 2). The underside of one rotor blade displayed a radial gouge which the pilot reported as being associated with the blade's impacting a dead tree at the site. Tearing deformation was noted on the underside of the rotorcraft in the hell hole area. This deformation was observed to extend along an axis oriented toward the seven o'clock position (when looking at the rotorcraft from above with its nose oriented in the twelve o'clock position - refer to photograph 3).

Examination of the interior of the hell hole area revealed a separation between the aft end of the number one engine fore/aft push-pull control tube where it connected to the bell crank for the number one engine jackshaft (refer to photograph 4, DIAGRAM I, and ATTACHMENT I). This separation would have effectively

Aircraft

Registration
N291B
Reported as
Bell 212
Category
Helicopter
Serial number
30842
Airframe hours
11,806
Engine
P&W PT6T-3, 1,600 horsepower, turbo shaft
Damage
Substantial damage
Flight
Public aircraft · Public use
Operator
Blm (Vale District)
Registered owner
Air One Helicopters, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · August 8, 1998 · 4 hours before
Departed
BNO · Burns, OR
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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
50
Certificates
Airline transport, Flight engineer, Commercial, Flight instructor
Airplane ratings
Single-engine sea, Multi-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
12,000 total · 500 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 6 knots
Visibility
10 statute miles
Temperature
86 °F, dew point 61 °F
Altimeter
30.00 inHg
Observed at
BNO, 40 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.