WPR13LA290

NTSB accident investigation · Mcdonnell Douglas Helicopter 369E · Casa Grande, AZ · June 25, 2013

Accident · Minor injuriesLimited investigationFinal report
Date
June 25, 2013, 06:50 local (13:50 UTC)
Place
Casa Grande, AZ
Injuries
3 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N34CTMcdonnell Douglas Helicopter 369E
Defining event
Maneuvering: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report February 10, 2014
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Boeing, Pinal County Sheriff, MDHI, FAA FSDO, Rolls Royce
FAA report
20130625012029A
Case key
87292

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 total loss of engine power due to the ingestion of a foreign object and maintenance personnel's failure to remove shop rags before completing the installation of the air inlet barrier system.

Findings · 5

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): air inlet section (core eng)Aircraft › Aircraft power plant · Inadequate inspectionAll aircraft: 4 casesProbable cause
Maintenance: modification/alterationPersonnel issues › Task performance · Maintenance personnelAll aircraft: 69 casesProbable cause
Performance/control parameters: engine out controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedAll aircraft: 35 cases
Performance/control parameters: landing flareAircraft › Aircraft oper/perf/capability · Incorrect use/operationAll aircraft: 1,285 cases
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotAll aircraft: 9,295 cases

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

Before the accident flight, maintenance personnel exchanged the helicopter's air inlet barrier filter system, during which the engine was removed from the helicopter. A preflight inspection was completed before departure of the postmaintenance check flight, and no discrepancies were noted. The engine start and pretakeoff checks were normal, and, after departure, the flight appeared to progress normally. About 1 to 2 minutes after completing an in-flight power check, the pilot heard a "distinct loud pop." Subsequently, the engine lost total power, and the pilot entered an autorotation. The helicopter landed hard, its right skid collapsed, and it rolled on its right side. A postaccident examination of the helicopter's engine air inlet found that cloth material had been ingested into the engine air intake. During further examinations, more cloth material was found in the engine in a sufficient quantity and location to block the airflow through the engine and cause it to flame out. The cloth material found in the engine was consistent with maintenance rags found in a box at the operator's hangar facility. It is likely that, during the maintenance of the helicopter's engine, maintenance personnel covered vulnerable areas of the engine with shop rags to prevent contamination, and, during the reinstallation of the engine, they did not remove all of the shop rags. The engine then ingested the rags during the postmaintenance test flight. Due to the installation of the engine air inlet barrier system, the shop rags would not have been visible during the preflight inspection nor could they have made it into the engine from the outside of the helicopter with the system in place.

Factual narrative

On June 25, 2013, about 0650 mountain standard time, a McDonnell Douglas 369E helicopter, N34CT, sustained substantial damage during an off-airport hard landing, about 6 miles south-southeast of Casa Grande, Arizona. The helicopter was being operated by the Pinal County Sheriff's Office as a day, visual flight rules, post maintenance test flight, under the provisions of Title 14, CFR Part 91. The three occupants of the helicopter sustained minor injuries. Visual meteorological conditions prevailed, and company flight following procedures were in effect. During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), the pilot said they were flying about 700 feet above the ground performing a post-maintenance test flight, when he heard an audible bang. The helicopter engine lost all engine power, and he did an autorotation. The helicopter landed hard, the right skid collapsed, and the helicopter came to rest on its right side. The tailboom and fuselage sustained substantial damage. The helicopter was being test flown with maintenance personnel on-board, following the modification of the air intake. In a written statement to the NTSB dated July 1, the pilot reported that he arrived at the Sheriff's hangar facility, and met with their aircraft mechanic, and another deputy/tactical flight officer. Their mission was to do a post maintenance test flight on the accident helicopter. This was the first flight since the installation of a Donaldson Air Filtration System and a new horizontal stabilizer. A pre-flight inspection was completed, and the pre-engine start checks were performed via a checklist. The engine start was normal. Pre-takeoff checks were performed per the checklist. No discrepancies were observed during the run-up. In a hover, all the flight controls and the engine indications were normal. The pilot hover taxied the helicopter to a ramp area, and performed a few hover maneuvers to ensure control inputs were normal. Once the maneuvers were complete, they departed the airport to the south-southeast. During the departure flight, the engine and flight instruments operated normally. A power check was completed; the pilot reduced the torque, and climbed to 2,100 feet(600-700 feet above ground level) where he leveled off. He continued cruise flight at about 110 knots. About 1-2 minutes after the power check, the pilot heard a distinct loud pop, the nose yawed to the left, and the helicopter begin to descend. The pilot, noting the loss of engine power, entered an autorotation. Approaching the ground, the pilot flared hard, leveled the helicopter, and pulled in collective. The helicopter landed hard, the right skid collapsed, and the helicopter rolled on its side. The helicopter was examined at the accident site by an Federal Aviation Administration (FAA) aviation safety inspector (ASI). The helicopter was recovered to the Sheriff's hangar. At the direction of the NTSB IIC, the helicopter wasexamined under the supervision of the FAA ASI, by representatives/investigators from the airframe and engine manufacturers, in the presence of the operator's representatives. During the examination, the investigators removed the air intake assembly, and found cloth material had been ingested into the engine intake. The engine was removed and shipped to the engine manufacturer's authorized maintenance facility for further examination. No other anomalies were found during the examination of the airframe. An examination of the helicopter's maintenance logbooks revealed that the helicopter was being returned to service after an exchange of the air inlet barrier filter system. During the exchange the engine had been removed from the helicopter. According to a mechanic, the engine was re-installed and inspected, prior to the air inlet barrier filter system installation. At the engine manufacturer's authorized maintenance facility, the engine was disassembled and examined under the supervision of an FAA ASI, in the presence of the operator's representative. During the examination, more cloth material was found in the engine, in a sufficient quantity and location to cause engine flame out. The cloth material found in the engine was consistent with a box of maintenance rags found at the operator's hangar facility.

Aircraft

Registration
N34CT
Reported as
Mcdonnell Douglas Helicopter 369E
Category
Helicopter
Serial number
0392E
Airframe hours
4,785
Engine
Rolls Royce M250-C20R2, 450 horsepower, turbo shaft
Damage
Substantial damage
Flight
Flight test · Part 91
Operator
Pinal County Sheriff's Office
Registered owner
Pinal County Sheriff's Office
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 8, 2013
Departed
KCGZ · Casa Grande, AZ
Destination
KCGZ · Casa Grande, AZ
Flight plan
Company VFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
43
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
August 2, 2012
Seat
Left
Restraint
4-point
Flight hours
1,208 total · 498 in this make and model · 1,074 as pilot in command · 88 in the last 90 days · 29 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F
Altimeter
29.93 inHg
Observed at
KCGZ, 170 nm away

Docket · 9

The files NTSB released with the investigation on November 20, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.2 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.