WPR09LA253

NTSB accident investigation · Gauchat Safari · Rock Springs, AZ · May 22, 2009

Accident · FatalLimited investigationFinal report
Date
May 22, 2009, 13:30 local (20:30 UTC)
Place
Rock Springs, AZ
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N147MDGauchat Safari
Defining event
Enroute: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report June 27, 2011
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Adminstration
FAA report
20090522011129A
Case key
73884

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

The separation of the main rotor head during cruise flight as a result of cyclic fatigue of the main rotor head spindle. The fatigue crack was due to an inadequate manufacturing process.

Findings · 2

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

Analysis

During a personal flight the experimental helicopter experienced an in-flight separation of the main rotor head. Both main rotor blades were located in opposite directions from the main wreckage. The helicopter was substantially damaged by the impact forces and the postimpact fire. Postaccident examination of the main rotor head assembly and the main rotor spindle revealed that the main rotor spindle had failed due to cyclic fatigue. The origin area was located near distinct circumferential machining marks. The manufacturer subsequently issued a mandatory inspection bulletin requiring inspection of all main rotor spindles.

Factual narrative

The factual narrative704 words

HISTORY OF FLIGHT On May 22, 2009, about 1330 mountain standard time (MST), an experimental homebuilt helicopter, Gauchat Safari, N147MD, impacted terrain near Rock Springs, Arizona, following the separation of both of the main rotor blades. The builder/pilot was operating the helicopter under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot and one passenger were fatally injured; impact forces and the post crash fire substantially damaged the helicopter. The local personal flight departed Rock Springs about 1325, with a planned destination of Phoenix, Arizona. Visual meteorological conditions prevailed, and no flight plan had been filed. Witnesses reported that the helicopter had just departed from a parking lot .3 nautical miles north of the accident site. They observed the helicopter flying southbound parallel to highway 17, when one of the main rotor blades departed the helicopter. The helicopter then fell to the ground. PERSONNEL INFORMATION No personal flight records were located for the pilot. The National Transportation Safety Board investigator-in-charge (IIC) obtained the aeronautical experience listed in this report from a review of the Federal Aviation Administration (FAA) airmen medical records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. The pilot reported on his medical application dated May 5, 2008, that he had a total time of 270 hours, with 50 hours logged in the last 6 months. AIRCRAFT INFORMATION The experimental homebuilt helicopter, a Gauchat Safari, serial number 2129, was issued a special airworthiness certificate on May 30, 2006. A review of the helicopter’s logbooks revealed that the helicopter had a total airframe time of 237.3 hours at the last conditional inspection dated May 10, 2009. WRECKAGE AND IMPACT INFORMATION An inspector from the FAA responded to the scene. The accident site consisted of the helicopter's fuselage, tailboom, and tail rotor system. The debris field contained both main rotor blades; one blade was located 620 feet northwest of the main wreckage, and the second blade was located 300 feet east of the main wreckage. One of the push pull control tubes was found 170 feet northwest of the main wreckage, and an operating handheld Global Position Satellite unit was located 100 feet northwest on the main wreckage. MEDICAL AND PATHOLOGICAL INFORMATION The Maricopa County Coroner completed an autopsy on the pilot May 26, 2009. The cause of death was determined to be as a result of blunt force injuries. The FAA Civil Aerospace Medical Institute (CAMI), Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide, cyanide, and volatiles. The report contained the following findings for tested drugs: 0.101 (ug/ml, ug/g) Doxylamine detected in blood, Doxylamine detected in liver. TESTS AND RESEARCH Investigators examined the wreckage at AirTransport, Phoenix, on June 29, 2009, and on August 14, 2010. Portions of the main rotor head were shipped to the NTSB materials laboratory in Washington, D.C., for further examination. The materials specialist found that the main rotor head spindle had failed in fatigue that initiated in machining marks at a radius located at the intersection of the bearing diameter with the larger inboard diameter normally obscured by the grip nut. The full report is in the public docket. ADDITIONAL INFORMATION Because of this accident and the ensuing investigation, the manufacturer issued the mandatory inspection bulletin MI-002. The bulletin requires inspection of the Main Rotor Spindle for distinct machining marks of irregular depth. In addition, any spindle which has been subjected to shock loads resulting from any accident of sufficient force to cause damage to other areas of the helicopter, re-engagement of the clutch while the rotor blades are still in motion, hard starts of the engine, over-torque of the castle nut, or repeated over speed of the main rotor head should be inspected. A copy of the mandatory inspection bulletin is located in the public docket. According to FAA Advisory Circular AC 20-27F, Certification and Operation of Amateur-Built Aircraft, "Amateur builders are free to develop their own designs or build from existing designs. We do not approve these designs and it would be impractical to develop design standards for the wide variety of design configurations, created by designers, kit manufacturers, and amateur builders."

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
N147MD
Reported as
Gauchat Safari
Category
Helicopter, amateur-built
Serial number
2129
Engine
Superior XP-O-360-A3A2, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Departed
Rock Springs, AZ
Destination
Rock Springs, AZ

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
41
Injuries
Fatal
Certificate
Private
Medical
Class 2, Without waivers/limitations
Toxicology
Performed
Flight hours
270 total

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 3 knots
Visibility
10 statute miles
Lowest ceiling
7,000 ft overcast
Temperature
72 °F, dew point 59 °F
Altimeter
29.86 inHg
Observed at
DVT, 22 nm away

Docket · 7

The files NTSB released with the investigation on April 15, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.7 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.