WPR11LA386

NTSB accident investigation · Air Tractor AT-401 · Hardin, MT · August 16, 2011

Accident · No injuriesLimited investigationFinal report
Date
August 16, 2011, 09:00 local (15:00 UTC)
Place
Hardin, MT
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N1012TAir Tractor AT-401
Defining event
Takeoff: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report January 12, 2015
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
FAA FSDO
FAA report
20110816018769A
Case key
81510

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 loss of engine power during takeoff due to the fatigue failure of the turbine wheel blades, which resulted from inadequate maintenance and inspections.

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.

Engine (turbine/turboprop): turbine sectionAircraft › Aircraft power plant · Fatigue/wear/corrosionAir Tractor AT-401: 1 caseAll aircraft: 74 casesProbable cause
Engine (turbine/turboprop)Aircraft › Aircraft power plant · Not serviced/maintainedAir Tractor AT-401: 2 casesAll aircraft: 67 casesProbable cause
Engine (turbine/turboprop)Aircraft › Aircraft power plant · Inadequate inspectionAir Tractor AT-401: 2 casesAll aircraft: 67 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, shortly after takeoff for the aerial application flight, the engine quit. He did not have sufficient altitude to restart the engine, so he made a forced landing to an open field; the airplane came to rest upright, and the airframe sustained structural damage. A visual examination of the engine at the accident site revealed that the compressor section had sustained fire damage and that the turbine section had broken and missing vanes. Postaccident metallurgical examination revealed that one of the turbine wheel blades had fractured and that the fracture surfaces revealed signatures consistent with fatigue propagation and subsequent failure. About 1 year 5 months before the accident, an examination of the engine revealed excessive wear to the combustor outer liner lugs, and the engine was determined to be unserviceable. About 1 year 1 month later (about 4 months before the accident), the airplane underwent a 100-hour inspection and was returned to service in an airworthy condition. No evidence was found indicating that the engine was overhauled or replaced during the 1-year period between when it was determined to be unserviceable and when it was returned to service. The pilot reported that the airplane had undergone a 100-hour inspection 1 week before the accident, but no entries were found pertaining to the inspection in the airplane's maintenance logbooks. The engine had accrued 2,819.6 hours since major overhaul. No evidence was found indicating that the engine was inspected in accordance with the manufacturer's recommended time between overhaul inspection interval of 2,000 hours. It is likely that proper maintenance inspections would have detected the crack and wear in the engine.

Factual narrative

HISTORY OF FLIGHT On August 16, 2011, about 0900 mountain daylight time, an Air Tractor AT-401 airplane, N1012T, was substantially damaged during a forced landing near Hardin, Montana. The owner/pilot operated the airplane under the provisions of 14 Code of Federal Regulations Part 137 as an aerial application flight. The commercial pilot, the sole occupant, was not injured. Visual meteorological conditions prevailed, and no flight plan was filed. According to the pilot, he had just taken off and was maneuvering the airplane to start an application pass when the engine quit. During the forced landing to the field, the airplane came to rest upright and sustained structural damage to the entire airplane. A Federal Aviation Administration (FAA) inspector responded to the accident site and reported that the debris field consisted of fire damaged hay fields about 1 mile behind the main wreckage. A visual inspection of the engine revealed that the compressor section had sustained fire damage, and the turbine section had broken and missing vanes. AIRCRAFT INFORMATION According to the engine logbook, on April 4, 2002, the accident engine was installed on the accident airplane, with zero time since overhaul. The engine was started and test flown with no discrepancies. In March 2010, a GE aviation field support manager, and a technician from Premier Turbine in Neosho, Missouri, performed a borescope inspection of the engine in accordance with combustor outer liner lugs Service Bulletin. At that time they noted that the combustor outer liner lugs were 85-90 percent worn, which rendered the engine unserviceable. They passed on the information to the operator and recommended an engine overhaul due to the condition of the engine hot section and high time since overhaul. On April 19, 2011, the airplane had undergone a 100-hour inspection and was returned to service in an airworthy condition; no evidence was found indicating that the engine had been worked on or replaced during the 1-year period between when it was deemed unserviceable and when it was returned to service. According to the pilot, the airplane had undergone a 100-hour inspection a week prior to the accident; however, there was no corresponding airframe or engine logbook entry. Recorded time since major overhaul was 2,819.6 hours. According to the engine manufacturer, the engine had three inspection times that were required to be adhered to: 1. Time between Overhaul (TBO) – 2,000 engine flight hours 2. Cycles between Overhaul – 2,250 engine flight cycles 3. Calendar time – Five years TEST AND RESEARCH The turbine section assembly and exhaust housing, turbine wheel and blades, and compressor assembly with shaft were shipped to the National Transportation Safety Board's (NTSB) Materials Laboratory in Washington, D.C., for further examination. The materials lab specialist reported that the majority of the first stage turbine wheel blades were missing the bulk of the airfoil material above theplatforms. One blade, at the 12 o-clock position had fractured below the airfoil platform, with a blade fragment retained in the wheel slot. This area exhibited features consistent with a fatigue crack that initiated at the forward left side of the blade fir tree. The specialist reported a flat faceted feature that was consistent with stage 1 fatigue crack growth typical after fatigue crack initiation in nickel-based superalloys, was located at the crack initiation site. Ratchet marks observed in this area were also consistent with fatigue crack propagation from the crack initiation site. A detailed examination report is attached to the docket for this accident.

Aircraft

Registration
N1012T
Reported as
Air Tractor AT-401
Category
Airplane
Serial number
401-0719
Airframe hours
7,300
Engine
GE Aviation Czech M601E-11, 751 horsepower, turbo prop
Damage
Substantial damage
Flight
Aerial application · Part 137
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · April 19, 2011 · 295.4 hours before
Departed
Hardin, MT
Destination
Hardin, MT

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
54
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 2, Without waivers/limitations
Seat
Single
Flight hours
15,600 total · 5,000 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 52 °F
Altimeter
30.17 inHg
Observed at
BIL, 39 nm away

Docket · 6

The files NTSB released with the investigation on November 19, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.7 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.