WPR09LA184

NTSB accident investigation · Sikorsky CH-54B · Corvallis, OR · April 7, 2009

Accident · No injuriesLimited investigationFinal report
Date
April 7, 2009, 15:30 local (22:30 UTC)
Place
Corvallis, OR
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Standing
Aircraft
N719HTSikorsky CH-54B
Defining event
Standing-engine(s) operating: Miscellaneous/other
Weather
Visual (VMC) · Day
Status
Completed · report April 22, 2010
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20090407004529A
Case key
73618

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 improper assembly of main rotor blade control components by the operator's maintenance personnel, which resulted in the main rotor blade's divergent path and their contact with the tail rotor drive shaft during ground operation following landing.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: incorrect action performancePersonnel issues › Action/decision · Maintenance personnelSikorsky CH-54B: 1 caseAll aircraft: 1,386 casesProbable cause
Maintenance/inspectionsAircraft › Aircraft handling/service · Incorrect service/maintenanceSikorsky CH-54B: 1 caseAll aircraft: 103 casesProbable cause
Main rotor systemAircraft › Aircraft propeller/rotor · Incorrect service/maintenanceSikorsky CH-54B: 1 caseAll aircraft: 25 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot and certified flight instructor departed for a local area instructional flight during which the pilot practiced a series of takeoffs and landings. During ground operations, the crew stated that they felt an unusual vibration, which was partially mitigated by keeping the collective pitch raised about 2 inches from the full down position. The pilot reported that he decided to adjust his seat position so he landed and handed off the controls to the certified flight instructor (CFI). The CFI lowered the collective to the full down position in preparation for the seat adjustment operation. At this time he noticed a vibration, which was followed by a loud "bang." The subsequent helicopter examination revealed that two of the six main rotor blades had diverged from their normal plane of rotation and impacted the tail rotor drive system, resulting in the number 5 and 6 tail rotor drive shaft sections separating from the helicopter. The investigation and examination of the helicopter found that during maintenance performed at an undetermined date by the operator's mechanics, the bell cranks that connect to the main rotor blades' control rods had been incorrectly installed in a reversed manner. This allowed the swash plate to travel outside of its designed range.

Factual narrative

On April 7, 2009, about 1530 Pacific daylight time, a Sikorsky CH-54B (Skycrane), N719HT, was substantially damaged following touchdown at the Corvallis Municipal Airport, Corvallis, Oregon, when the main rotor blades diverted from their normal rotation plane and severed the tail rotor drive shaft. The helicopter was operated by Helicopter Transport Services, Corvallis. Visual meteorological conditions prevailed at the time, and no flight plan had been filed. Neither the airline transport certificated pilot, who held a certified flight instructor (CFI) certificate, nor the second crewmember-pilot was injured during the instructional/proficiency flight. The flight was performed under the provisions of 14 Code of Federal Regulations Part 91 and originated from Corvallis about 1500. The CFI reported to the National Transportation Safety Board investigator that the helicopter had operated normally prior to the mishap, although a vibration was felt during ground operation. Therefore, the collective position was kept up about 2 inches, which seemed to reduce the ground vibrations. After practicing four or five landings from a hover, the pilot, who was receiving instruction, landed to adjust his seat position. He handed off the controls to the CFI. The CFI lowered the collective to the full down position, in preparation for the seat adjustment. The terrain on which he landed was sloped. The CFI reported that as he "lowered the collective to the full down position, a vibration was noticed, followed by a loud 'bang', followed by severe vibrations. An emergency shut down followed, with immediate application of the rotor brake." After exiting the helicopter, it was determined that the number 5 & 6 tail rotor drive shaft sections had departed the helicopter, with damage to 2 of the 6 main rotor blades. During the subsequent examination of the helicopter, the CFI verbally reported to the Safety Board investigator that the accident occurred when the main rotor blades diverged from their normal plane of rotation and contacted the tail rotor drive shaft. The operator's director of maintenance verbally reported to the Safety Board investigator that maintenance of the helicopter was by the company's mechanics. During maintenance, the bellcranks that connect to the control rods had been incorrectly installed (in a reversed manner) thereby allowing the swashplate to travel outside of its designed range. Federal Aviation Administration (FAA) personnel, who examined the wreckage and interviewed the operator's mechanics, stated they were unable to ascertain the date on which the subject bellcranks had been installed, but it appeared to have been several years prior to the accident date. To reduce the likelihood for recurrence of this type of accident, the operator modified its maintenance procedure regarding bellcrank installation.

Aircraft

Registration
N719HT
Reported as
Sikorsky CH-54B
Category
Helicopter
Serial number
69-18469
Airframe hours
5,365
Engines
P & W JFTD12A-5A, 4,800 horsepower, turbo shaftP & W JFTD12A-5A, 4,800 horsepower, turbo shaft
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Helicopter Transport Services, Inc.
Registered owner
U S Leaseco Inc
Airworthiness certificate
Special, Restricted (Special); Special, Experimental (Special)
Last inspection
AAIP · March 1, 2009 · 12 hours before
Departed
Corvallis, OR
Destination
Corvallis, OR
Airport
CVO · Corvallis Municipal

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
Flight instructor
Age
58
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
September 17, 2008
Seat
Right
Flight hours
19,000 total · 1,100 in this make and model · 18,700 as pilot in command · 50 in the last 90 days · 15 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
37
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Medical
Class 1
Last flight review
October 17, 2008
Seat
Left
Flight hours
2,982 total · 1,100 in this make and model · 2,356 as pilot in command · 180 in the last 90 days · 60 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 48 °F
Altimeter
29.76 inHg
Observed at
CVO

Docket · 1

The files NTSB released with the investigation on January 27, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 323 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.