# NTSB WPR14LA084: Eurocopter EC 130 B4, N133GC, Boulder City, NV, January 1, 2014 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: January 1, 2014, 15:07 local (23:07 UTC) - Place: Boulder City, NV - Coordinates: 35.946945, -114.86 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.9469&lon=-114.8600&mi=10 - Phase of flight: [Emergency descent](https://openairdocs.org/ntsb-phases/600) (OpenAirDocs' grouping) - Defining event: [Autorotation: Hard landing](https://openairdocs.org/ntsb-events/092) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report July 13, 2015 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA-FSDO, Papillon Airways - NTSB case key (mKey): 88613 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR14LA084 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88613/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88613 - Page: https://openairdocs.org/ntsb/WPR14LA084 ## Probable cause A loss of engine power due to fuel starvation as a result of the noncertificated maintenance technician’s failure to properly tighten and safety wire a B-nut fitting. Contributing to the accident was the maintenance technician’s failure to follow the manufacturer’s maintenance manual instructions. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Not specified (probable cause); cases with it: [Eurocopter EC 130 B4, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=8680989), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Eurocopter EC 130 B4, 2 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=8680989), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Misc hardware](https://openairdocs.org/ntsb-findings/01071400): Aircraft › Fluids/misc hardware · Incorrect service/maintenance (probable cause); cases with it: [Eurocopter EC 130 B4, 1 case](https://openairdocs.org/ntsb-findings/01071400/cases.md?model=8680989), [All aircraft, 41 cases](https://openairdocs.org/ntsb-findings/01071400/cases.md) - [Use of equip/info: use of manual](https://openairdocs.org/ntsb-findings/02063020): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Eurocopter EC 130 B4, 1 case](https://openairdocs.org/ntsb-findings/02063020/cases.md?model=8680989), [All aircraft, 15 cases](https://openairdocs.org/ntsb-findings/02063020/cases.md) - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Eurocopter EC 130 B4, 1 case](https://openairdocs.org/ntsb-findings/02062000/cases.md?model=8680989), [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) - [Experience/qualifications: qualification/certification](https://openairdocs.org/ntsb-findings/02031010): Personnel issues › Experience/knowledge · Maintenance personnel (probable cause); cases with it: [Eurocopter EC 130 B4, 1 case](https://openairdocs.org/ntsb-findings/02031010/cases.md?model=8680989), [All aircraft, 280 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Eurocopter EC 130 B4, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=8680989), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Autorotation: Hard landing](https://openairdocs.org/ntsb-events/092) (defining event); cases with it: [Eurocopter EC 130 B4, 5 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=8680989), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) - [Autorotation: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Eurocopter EC 130 B4, 9 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=8680989), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot stated that, during a postmaintenance operational check flight and while on final approach for landing, the fuel pressure indicator light illuminated, and the engine "flamed out." The pilot lowered the collective to initiate an autorotation; however, due to the low altitude and airspeed, the helicopter subsequently landed hard and rolled over. During a postaccident examination of the wreckage, a main fuel supply line B-nut fitting was found without the safety wire, and the nut was loose when turned by hand. Before the accident flight, the line had been disconnected during a task to replace the bidirectional suspension cross-bar assembly, and the accident flight was the first flight since the task was performed. According to the noncertificated maintenance technician who performed the task, the line was removed to defuel the fuel tank, which was contrary to manufacturer's maintenance manual instructions. Based on the evidence, it is likely that the B-nut fitting was not properly tightened and safety-wired during reassembly, which allowed it to back off due to normal engine vibration and resulted in the interruption of the fuel flow during flight. ## Factual narrative On January 1, 2014, about 1507 Pacific standard time, a Eurocopter EC-130 B4, N133GC, landed hard during an autorotation, while on short final at the Boulder City Municipal Airport (BVU), Boulder City, Nevada. The commercial pilot was the sole person on board and was not injured. The helicopter came to rest on its right side and sustained substantial damage to the fuselage and tail boom. The helicopter was registered to Zuni LLC, and operated by Papillon Airways, Inc. (PAI), under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the post-maintenance operational check flight. A company flight plan was filed for the local flight that departed about 1457. In a written statement, the pilot reported that she completed the post-maintenance operational check portion of the flight and was on short final to BVU, about 200 feet above the ground, with an airspeed of 40 to 50 knots. Shortly thereafter, the fuel pressure indicator light illuminated and the engine "flamed out". The pilot stated that she lowered the collective to initiate an autorotation, but did not have sufficient airspeed to successfully complete it. The helicopter's tailboom impacted the ground first during the accident sequence, followed by a hard landing. During the landing, the helicopter's skids separated and the fuselage sustained substantial damage. A postaccident examination of the wreckage by a Federal Aviation Administration (FAA) inspector, revealed that safety wire was removed from a B-nut fitting that connects the main fuel supply to the aft side of the engine firewall, which delivers fuel to the engine Hydro Mechanical Unit. The B-nut fitting was loose when rotated by hand. The safety wire that was removed from the B-nut fitting remained attached to hardware [intermediate fitting] near the engine firewall. Maintenance records revealed that the replacement of the bi-directional suspension cross-bar assembly was due and that the accident flight was the first flight since the task was performed. According to the FAA, several maintenance technicians at PAI, stated that the selected method to gain access for the replacement of the bi-directional suspension cross-bar assembly, is contrary to the manufacturer's maintenance manual, by choosing to defuel and remove the fuel tank. They further stated that they defuel the tank by disconnecting the main fuel supply line that delivers fuel to the engine Hydro Mechanical Unit. This line is then attached to a tank on the ground, and the fuel is then pumped out from the tank with the use of the helicopter's fuel boost pump. This task was performed by a non-certificated technician. Several maintenance technicians were aware of the tasks performed to gain access to the bi-directional suspension cross-bar assembly, yet none of them made a statement reflecting they had followed the helicopter manufacturer's maintenance manual. The maintenance records showed no entry regarding the removal ordisconnection of the main fuel supply line. The manufacturer's maintenance manual [Section 63-31-00, 4-1] recommends that the bi-directional suspension cross bar assembly will be accessed by removing the main gear box and not by removing the fuel tank. Following the accident, PAI implemented a 16-step independent control check to their Safety Control System which will be conducted by only experienced maintenance inspectors. This system is complemented by the addition of the inclusion of exclusively assigned Maintenance Ops Check Pilots who provide an additional level of oversight. An internal maintenance training system was created with heavy focus on FAA CFR 39, 43, 91, to include onsite manufacturer's training programs that encompass airframe and engine systems. ## Aircraft - Registration: [N133GC](https://openairdocs.org/deregistered/N133GC-2014-11-06), registration cancelled 2014-11-06, S/N 3883 (OpenAirDocs) - Reported make and model: EUROCOPTER EC 130 B4 (B) - Registry model: [Eurocopter EC 130 B4](https://openairdocs.org/model/eurocopter-ec-130-b4) (registry code 8680989) (OpenAirDocs) - Category: Helicopter - Serial number: 3883 - Airframe hours: 10321 - Engines: Turbomeca Aerial 2B1 832 horsepower turbo shaft - Damage: Substantial damage - Flight: Flight test, Part 91 - Operator: Papillon Airways Inc. - Registered owner: Zuni LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, January 1, 2014, 0 hours before - Departed: KBVU, Boulder City, NV - Destination: KBVU, Boulder City, NV - Airport: BVU, Boulder City Muni, runway 27R, 2,166 × 60 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 28; injuries: none; flight instructor, commercial; instrument ratings: helicopter; medical: class 2, without waivers/limitations; seat: left; restraint: 4-point; toxicology performed; flight hours: 2,157 total, 537 in this make and model, 2,126 as pilot in command, 63 in the last 90 days, 12 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 21 °F - Altimeter: 30.18 inHg - Observed at: KBVU ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20140101000299A](https://openairdocs.org/incident/20140101000299A), Jan 1, 2014: Eurocopter EC 130 B4, Boulder City, NV, Substantial damage. On January 1, 2014 at approximately 2255Z, an American Eurocopter EC-130-B4 helicopter, N133GC, operated by papillon airways inc. (PG9A), departed the Boulder… ## Docket (11 files) The files NTSB released with the investigation on June 12, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88613. 9.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 932 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427825&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot’s Written Statement (item 2, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427826&FileExtension=.PDF&FileName=Pilot%E2%80%99s%20Written%20Statement-Redacted.PDF - FAA Witness Statements (item 3, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427827&FileExtension=.PDF&FileName=FAA%20Witness%20Statements-Master.PDF - FAA Inspector’s Statement of Examination (item 4, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427828&FileExtension=.PDF&FileName=FAA%20Inspector%E2%80%99s%20Statement%20of%20Examination-Master.PDF - Aircraft Maintenance Manual, 28-11-00, Fuel Tank Removal (item 5, .PDF, 837 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427829&FileExtension=.PDF&FileName=Aircraft%20Maintenance%20Manual,%2028-11-00,%20Fuel%20Tank%20Removal-Master.PDF - Aircraft Maintenance Manual, 63-31-00, 4-1 Removal or Replacement-Bidirectional Suspension Cross-bar Assembly (item 6, .PDF, 463 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427830&FileExtension=.PDF&FileName=Aircraft%20Maintenance%20Manual,%2063-31-00,%204-1%20Removal%20or%20Replacement-Bidirectional%20Suspension%20Cross-bar%20Assembly-Master.PDF - Aircraft Maintenance Manual, 12-10-00 3-2, Refueling-Draining Fuel System (item 7, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427831&FileExtension=.PDF&FileName=Aircraft%20Maintenance%20Manual,%2012-10-00%203-2,%20Refueling-Draining%20Fuel%20System-Master.PDF - Papillon Letter-Safety Changes (item 8, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427832&FileExtension=.PDF&FileName=Papillon%20Letter-Safety%20Changes-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427833&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photo 1 - Main Wreckage (Photo Courtesy of FAA) (item 10, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427834&FileExtension=.PDF&FileName=Photo%201%20-%20Main%20Wreckage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 2 - Fuel Line Connection (item 11, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427835&FileExtension=.PDF&FileName=Photo%202%20-%20Fuel%20Line%20Connection-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.