WPR11LA352

NTSB accident investigation · Eurocopter AS 350 B3 · Troutdale, OR · July 27, 2011

Accident · No injuriesLimited investigationFinal report
Date
July 27, 2011, 15:40 local (22:40 UTC)
Place
Troutdale, OR
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N808LFEurocopter AS 350 B3
Defining event
Enroute: Part(s) separation from AC
Weather
Visual (VMC) · Day
Status
Completed · report April 20, 2012
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20110727014929A
Case key
81284

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 in-flight separation of the tail rotor drive shaft cover as a result of maintenance personnel not ensuring that it was secured after a maintenance inspection; also causal was the pilot’s inadequate preflight inspection of the helicopter.

Findings · 4

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.

Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelEurocopter AS 350 B3: 2 casesAll aircraft: 320 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotEurocopter AS 350 B3: 2 casesAll aircraft: 551 casesProbable cause
Fuselage: aerodynamic fairings structureAircraft › Aircraft structures · Incorrect service/maintenanceEurocopter AS 350 B3: 1 caseAll aircraft: 5 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · Maintenance personnelEurocopter AS 350 B3: 3 casesAll aircraft: 792 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 reported that, about 12 minutes into a repositioning flight following a maintenance task performed by a company mechanic, he felt something that he described as similar to a bird strike. The pilot subsequently elected to make a precautionary landing in order to assess the situation. During an examination of the helicopter after the uneventful landing, the pilot discovered that a portion of the tail rotor drive shaft cover was missing and that one main rotor blade and two tail rotor blades had been damaged. Postaccident discussions with the company’s director of maintenance determined that the maintenance staff (who had recently performed a maintenance inspection) and the pilot likely looked at the tail rotor drive shaft cover prior to the accident flight and presumed that it was secure or had been secured by someone else; however, it was not secure and came off during flight. Following the accident, the company implemented a primary mechanic position into its Field Mechanic Procedures in order to mitigate a similar occurrence.

Factual narrative

On July 27, 2011, about 1540 Pacific daylight time, a Eurocopter AS 350 B3 helicopter, N808LF, sustained substantial damage after being struck by an object in cruise flight near Troutdale, Oregon. The commercial pilot and his five passengers were not injured. The helicopter was being operated by Air Methods Corporation of Englewood, Colorado. Visual meteorological conditions prevailed for the repositioning flight, which was being operated in accordance with 14 Code of Federal Regulations Part 91, and a flight plan was not filed. The flight departed the Aurora State Airport (UAO), Aurora, Oregon, about 1528, with Dallesport Airport (DLS), Dallesport, Washington, as its destination. In a report submitted to the National Transportation Safety Board investigator-in-charge (NTSB IIC), the Air Methods’ Aviation Compliance Manager stated that the aircraft departed from its maintenance facility at UAO to its normal base of operations located at DLS. The manager further stated that about 12 minutes into the flight the pilot reported that he felt something, like a bird strike, and elected to make a precautionary landing at TTD to inspect the helicopter for possible damage. Subsequent to an uneventful landing the pilot performed a walk-around inspection of the helicopter, during which it was discovered that a portion of the tail rotor drive shaft covering was missing. Upon further inspection of the helicopter, it was revealed that a single main rotor blade and two tail rotor blades had been damaged. In a statement provided to the IIC, the Air Methods’ Director of Maintenance (DOM) reported that as a result of his review of the maintenance that was performed on the helicopter prior to the accident flight, that all of the procedures for the 100-hour maintenance task were complied with, which included proper documentation of the work performed, including the required “Confirm Your Aircraft” (CYA) procedure, which was documented in the aircraft maintenance logbook. As provided to the IIC by Air Methods, the CYA requirements are as follows: • Any maintenance performed must be entered in the Air Methods’ Record of Maintenance. For all routine maintenance performed in the field by a company mechanic, a “Confirm Your Aircraft (CYA)” check will be performed. Whenever possible, a mechanic who did not sign off the maintenance action will perform the CYA. If a second mechanic is not available, a pilot will perform the check. • The CYA will include a thorough face-to-face briefing between the person who performed the work and the person performing the CYA. The person performing the CYA is required to do a general overview of the area in which the maintenance was performed. The person should look for disconnected lines, proper safeties (including safety wire, cotter pins, and lock tabs), oil or fuel, any cowlings/panels that were opened/removed, and any components/lines that were repositioned or removed in order to facilitate maintenance. • The CYA check shall beperformed before the aircraft is returned to service and will include at a minimum, a general overview for the following: o Loose or missing hardware in the area of maintenance. o Obvious defects in the area of maintenance. o Loose hardware or foreign objects left on the aircraft. The DOM reported that during post-accident discussions with the maintenance staff and the pilot, both felt that the [tail rotor drive shaft] cowling was secured. The DOM further reported that a possible scenario was that the maintenance staff and the pilot looked at the cowling prior to the ground runs and the accident flight and presumed that it was secure and that the work had been reviewed by someone else. The DOM revealed that in order to improve their Air Methods’ operations, the company had implemented a new policy designating a Primary Mechanic when more than one mechanic is working on a maintenance task.

Aircraft

Registration
N808LF
Reported as
Eurocopter AS 350 B3
Category
Helicopter
Serial number
4983
Airframe hours
282
Engine
Turbomeca Arriel 2B1, 653 horsepower, turbo shaft
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
Air Methods
Registered owner
PNC Band NA Trustee
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · July 27, 2011 · 0 hours before
Departed
UAO · Aurora, OR
Destination
DLS · Dallesport, WA
Flight plan
Company VFR
Airport
TTD · Portland-Troutdale

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
38
Injuries
None
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
January 24, 2011
Seat
Right
Flight hours
2,650 total · 339 in this make and model · 2,600 as pilot in command · 47 in the last 90 days · 18 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 52 °F
Altimeter
30.09 inHg
Observed at
TTD

Docket · 3

The files NTSB released with the investigation on March 15, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.6 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.

Other investigations on N808LF · 2

Matched to the same aircraft by N-number and date.