WPR16LA104

NTSB accident investigation · Bell UH 1B · Maxwell, CA · May 7, 2016

Accident · No injuriesLimited investigationFinal report
Date
May 6, 2016, 17:00 local (May 7, 2016, 00:00 UTC)
Place
Maxwell, CA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N486SABell UH 1B
Defining event
Takeoff: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 2018
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Honeywell Aerospace, Federal Aviation Administration
Case key
93147

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

A reduction in available engine power during takeoff due to a stuck hot air valve, which resulted in low rotor rpm and a forced landing. Contributing to the accident was the lack of dry film lubricant and the presence of corrosion on the hot air valve assembly, which resulted in the sticking of the valve.

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.

Engine bleed air system: engine anti-icing systemAircraft › Aircraft power plant · MalfunctionBell UH-1B: 1 caseAll aircraft: 4 casesProbable cause
Engine bleed air systemAircraft › Aircraft power plant · Fatigue/wear/corrosionBell UH-1B: 1 caseAll aircraft: 7 casesProbable cause
AircraftAircraft › Aircraft power plant · Damaged/degradedBell UH-1B: 2 casesAll aircraft: 151 casesProbable cause
FluidsAircraft › Fluids/misc hardware · Not serviced/maintainedBell UH-1B: 1 caseAll aircraft: 11 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 commercial pilot reported that, after loading the helicopter with chemical for the agricultural application flight, he completed a pre-takeoff checklist, noted that all instrument indications were normal, and initiated a takeoff from the loading truck platform. As the helicopter climbed over the tree canopy, the rotor and engine rpm began to rapidly decay. The pilot initiated a right turn in an attempt to gain airspeed and recover rotor rpm; however, the attempt was unsuccessful, and he initiated a forced landing within an almond orchard. The helicopter landed hard and came to rest upright. The postaccident engine test run revealed a stuck, partially-open hot air valve used for engine inlet anti-icing. The open hot air valve allowed compressor bleed air to escape the power flow path, thereby reducing the maximum power that the engine could produce before reaching its maximum exhaust gas temperature limitations. The manufacturer of the engine reported that, with the partially-open hot air valve, the engine would only produce about 80% of its maximum power. Further examination of the hot air valve revealed a lack of dry film lubricant on the flow surfaces in addition to corrosion buildup throughout the valve assembly. The dry film lubricant reduces friction between the sliding elements, allowing for smooth, unimpeded motion of the valve. The lack of lubricant coating in these areas would increase the sliding friction such that the closing spring would be unable to overcome the friction forces, causing the valve to remain open even when commanded closed. It is likely that the valve became stuck before the accident flight, which would have resulted in reduced power available for takeoff. The engine overhaul manual indicated that an inspection of the hot air valve should occur with an overhaul of the engine. A review of the engine logbooks revealed that the engine was overhauled about 9 years before the accident and that the helicopter had accumulated about 598 hours since the overhaul. There were no logbook entries pertaining to the inspection of the hot air valve.

Factual narrative

On May 6, 2016, about 1700 Pacific daylight time, a Bell UH-1B helicopter, N486SA, was substantially damaged during a forced landing following a loss of main rotor RPM near Maxwell, California. The commercial pilot was not injured. The helicopter was privately owned and operated by Jones Flying Service, Biggs, California, as a Title 14 Code of Federal Regulations Part 137 agricultural flight. Visual meteorological conditions prevailed, and no flight plan was filed. The flight was originating at the time of the accident. The pilot reported that after loading 300 gallons of chemical, he conducted a pre-takeoff checklist, noting that all instruments displayed normal indications. A takeoff was initiated from the loading truck platform, and as it climbed over the tree canopy, the rotor and engine RPM began to rapidly decay. The pilot initiated a right turn to gain airspeed and recover the rotor RPM, however, the attempt was unsuccessful and he initiated a landing within an almond orchard. The helicopter landed hard and came to rest upright. The pilot further reported that at the time of the accident, the helicopter weighed 7,854 pounds, which was 1,646 pounds under its maximum gross weight of 9,500 pounds. Postaccident examination of the helicopter by a Federal Aviation Administration (FAA) inspector revealed that the fuselage and tailboom were substantially damaged. Following a visual examination of the engine, it was mounted on a test stand and run for approximately 30 minutes. During the engine run, the engine was advanced to 75% of normal rated power followed by an acceleration to the maximum exhaust gas temperature (EGT) limit of 1,140° F. The engine was unable to reach full rated power before the temperature limit was reached. Inspection of the engine revealed that hot air was being discharged from the engine air inlet anti-ice overboard/vent port. Energizing and de-energizing of the hot air valve solenoid, which supplies compressor discharge air to the engine inlet for de-icing, had no effect on the engine operation or monitored parameters. The engine was shut down and a pressure gauge was added to the engine air inlet anti-ice overboard/vent port to confirm that pressurized air was escaping from this port. The engine was restarted and accelerated to the same performance levels as before. The pressure gauge confirmed that pressurized air was escaping from the anti-ice overboard/vent even though the valve was being commanded closed. Further examination of the engine revealed that when cycling on and off the hot air valve solenoid, a clicking noise could be heard, and when felt by hand during the operation, a slight vibration was detected. The hot air valve and solenoid were removed and found in a partially open position. The engine's bleed air port, where the hot air valve was removed, was blocked using a blanking plate and the engine was run. During the run, it was noted that the engine obtained full rated power prior to reaching the EGTlimitations. A representative from the Honeywell manufacture stated that initially the engine was producing approximately 80% of its rated power prior to removal of the hot air valve. Disassembly of the hot air valve revealed that the main body of the valve appeared to be undamaged. The forward surface of the valve appeared to have deposits/corrosion present, and the solenoid body appeared to be discolored with most of the protective plating missing from the unit. Debris, similar to adhesive/sealant, was found within the valve after disassembly of two body halves. The top surface of the piston, as well as the retaining nut displayed evidence of a buildup of foreign material, consistent with corrosion. The edges of the piston also displayed evidence of corrosion. The valve's pistons shaft displayed evidence of corrosion and wear. The valve's spring and piston cavity displayed evidence of corrosion. The inside piston to cavity surface displayed evidence of corrosion and linear scoring. A buildup of debris and corrosion were displayed on the surface of the piston shaft guide bore. A microscopic examination of the hot air valve revealed that little to no molybdenum-disulfide coating was present on the flow surfaces of the valve in the areas where sliding contact is made. According to a Honeywell representative, during manufacture of the hot air valve, a dry film lubricant coating is applied to the flow surfaces of the valve. Once applied, the thickness of the coating is between 0.00015 to 0.0005 inch. Molybdenum-disulfide is a constituent of the dry film lubricant which reduces friction between the sliding elements allowing for smooth, unimpeded motion of the valve. The representative further stated that the lack of lubricant coating in these areas would increase the sliding friction such that the closing spring would be unable to overcome the friction forces thus causing the valve to remain open even when commanded closed. It could not be determined when the hot air valve had become stuck in the open position. Per the T5311 Overhaul Manual (75-10-1), an inspection of the hot air valve should occur with an overhaul of the engine. Review of the engine logbooks revealed that the engine was overhauled on December 29, 2006. No logbook entries pertaining to the inspection of the hot air valve were observed. At the time of the accident, the engine had accumulated a total of 598.2 hours since overhaul.

Aircraft

Registration
N486SA
Reported as
Bell UH 1B (NO SERIES)
Category
Helicopter
Serial number
62-4583
Built
1962
Airframe hours
9,132
Engine
Lycoming T-53-11B, 1,150 horsepower, turbo shaft
Damage
Substantial damage
Flight
Aerial application · Part 137
Operator
Jones Flying Service
Registered owner
Spyres Peter J
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · July 15, 2015 · 106 hours before
Departed
Maxwell, CA
Destination
Maxwell, CA

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
42
Injuries
None
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Seat
Right
Restraint
4-point
Flight hours
1,906 total · 213 in this make and model · 1,829.3 as pilot in command · 203 in the last 90 days · 44.2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 6 knots
Visibility
10 statute miles
Lowest ceiling
5,000 ft broken
Temperature
68 °F, dew point 54 °F
Altimeter
29.85 inHg
Observed at
KMYV, 34 nm away

Docket · 7

The files NTSB released with the investigation on June 21, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.3 MB in all.