WPR09IA070

NTSB incident investigation · MD Helicopter MD 900 · Kamuela, HI · December 28, 2008

Incident · No injuriesIncident investigationFinal report
Date
December 27, 2008, 15:50 local (Dec 28, 2008, 01:50 UTC)
Place
Kamuela, HI
Injuries
2 uninjured
Damage
Minor damage
Phase of flight
Landing
Aircraft
N902AFMD Helicopter MD 900
Defining event
Landing-flare/touchdown: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report December 29, 2009
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
FAA FSDO
FAA report
20081227853739I
Case key
73158

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

The separation of the endplate bolts for undetermined reasons, resulting in an in-flight separation of the right endplate. Contributing to the accident was the manufacturer's failure to provide sufficient guidance for endplate bolt installation.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

A witness informed the flight crew that the helicopter "lost a panel" during landing. Inspection of the helicopter revealed that the lower right stabilizer (endplate) separated and was located approximately 70 feet from where the helicopter landed. The endplate was later recovered; however, the two associated attachment bolts were not. Without the bolts, it could not be determined if the attachments were not properly torqued or if the bolts' locking mechanism was no longer serviceable. The operator reported that the endplate was removed approximately 42 flight hours prior to the incident to facilitate a maintenance action on the horizontal stabilizer. Following the maintenance action and inspection, the endplate was reinstalled using the original attachment bolts. The applicable maintenance manual instructions for endplate installation directed maintenance personnel to secure the endplate to the spar tube and torque bolts to a specified value; however, it did not direct maintenance personnel to apply sealing and locking compound to bolt threads prior to installation. Following the incident, the manufacturer issued a mandatory Service Bulletin requiring the inspection of endplate bolts for serviceability and application of thread locking compound.

Factual narrative

The factual narrative410 words

On December 27, 2008, at 1550 Hawaiian standard time, a McDonnell Douglas MD 900 helicopter, N902AF, sustained minor damage during an in-flight separation of the lower right endplate (vertical stabilizer) while landing near Kamuela, Hawaii. The helicopter is registered to, and operated by Vulcan Aircraft, Inc. The local flight was operated under the provisions of Title 14, Code of Federal Regulations (CFR) Part 91. The two pilots, the only occupants aboard the helicopter, were not injured. Visual meteorological conditions prevailed, and company visual flight rules (VFR) flight-following procedures were in effect. The flight originated offshore at 1512 with a planned destination of Kamuela. The pilots reported that a witness informed them that the helicopter had "lost a panel" during the approach. A postflight inspection revealed that the lower right endplate had separated from its mounting support bracket and was located approximately 70 feet from where the helicopter landed. The pilot seated in the left front seat, who was flying at the time of the incident, reported that he noted a slight momentary yaw approximately 15 minutes prior to landing. A representative from the operator reported that the endplate was later recovered; however, the two associated attachment bolts were not. Maintenance records showed that the endplate was removed on May 20, 2008, approximately 42 flight hours prior to the incident, to facilitate maintenance actions on the horizontal stabilizer. Following the maintenance action and inspection, the endplate was reinstalled using the original self-locking bolts (NAS6305LU12). The helicopter maintenance manual instructions for endplate installation (section 53-55-00) listed the following actions, in part, with respect to endplate installation: 1. Prepare endplate attach hole for electrical bond. 2. Position endplate on spar tube and align bolt holes. 3. Secure endplate to spar tube and torque bolts to 7-17 inch-pounds. 4. Test washer for electrical bond. 5. Environmentally seal washer to endplate with sealant. On April 11, 2009, following this incident, MD Helicopters issued Service Bulletin (Mandatory) SB900-111, titled Horizontal Endplate (Vertical Stabilizer) Installation. The service bulletin instructs operators, in part, to do the following: 1. Remove endplate attach bolts. 2. Clean threads of endplate attachment bolts. 3. Make certain thread lock device on bolts is serviceable. 4. Apply sealant primer to bolt threads. 5. Apply sealing and locking compound to bolt threads. 6. Install endplate attach bolts. 7. Make a record in the rotorcraft log book that indicating the service bulletin has been completed. 8. Complete Bulletin Completed Record form and forward to MD Helicopters.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N902AF
Reported as
MD Helicopter MD 900
Category
Helicopter
Serial number
900-00023
Airframe hours
1,304
Engines
PW206A, 621 horsepower, turbo shaftP&W Canada PW206A, 621 horsepower, turbo shaft
Damage
Minor damage
Flight
Positioning · Part 91
Operator
Vulcan Aircraft Inc
Registered owner
Vulcan Aircraft Inc
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · July 25, 2008 · 87 hours before
Departed
Kona, HI
Destination
Kamuela, HI
Flight plan
Company VFR
Airport
Hapuna Heliport

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
50
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea, Multi-engine sea
Instrument ratings
Helicopter, Airplane
Medical
Class 1, With waivers/limitations
Last flight review
November 23, 2008
Seat
Right
Flight hours
14,000 total · 200 in this make and model · 13,000 as pilot in command · 9 in the last 90 days · 2 in the last 30 days
Role
Co-pilot
Age
61
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, With waivers/limitations
Last flight review
November 7, 2007
Seat
Left
Flight hours
10,500 total · 1,700 in this make and model · 9,500 as pilot in command · 2 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
250° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 61 °F
Altimeter
29.95 inHg
Observed at
PHKO, 23 nm away

Docket · 4

The files NTSB released with the investigation on October 23, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.4 MB 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.