# NTSB WPR16LA134: Bell OH 58A, N6251G, Brawley, CA, July 2, 2016

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: July 2, 2016, 02:30 local (09:30 UTC)
- Place: Brawley, CA
- Coordinates: 32.99472, -115.518333 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=32.9947&lon=-115.5183&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Defining event: [Maneuvering-low-alt flying: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342)
- Highest injury: No injuries
- Injuries: 1 uninjured
- Status: Completed, report April 13, 2020
- Report: Approved by Office Director
- NTSB office: Western Pacific Region
- Parties: FAA FSDO, Rolls-Royce Corp.
- NTSB case key (mKey): 93515
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR16LA134
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93515/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93515
- Page: https://openairdocs.org/ntsb/WPR16LA134

## Probable cause

The engine's degraded performance due to excessive wear of the engine bleed valve, which prevented it from closing during the accident flight. Contributing to the accident was the operator's failure to overhaul the bleed valve within the manufacturer-recommended interval.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Engine bleed air system: compressor bleed valve](https://openairdocs.org/ntsb-findings/01057532): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Bell OH-58A, 1 case](https://openairdocs.org/ntsb-findings/01057532/cases.md?model=1181579), [All aircraft, 4 cases](https://openairdocs.org/ntsb-findings/01057532/cases.md)
- [Maintenance/inspections: scheduled maint checks](https://openairdocs.org/ntsb-findings/01010520): Aircraft › Aircraft handling/service · Not serviced/maintained (probable cause); cases with it: [Bell OH-58A, 1 case](https://openairdocs.org/ntsb-findings/01010520/cases.md?model=1181579), [All aircraft, 76 cases](https://openairdocs.org/ntsb-findings/01010520/cases.md)
- [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Other (probable cause); cases with it: [Bell OH-58A, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=1181579), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Maneuvering-low-alt flying: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Bell OH-58A, 4 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=1181579), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md)
- [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Bell OH-58A, 8 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1181579), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)
- [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Bell OH-58A, 10 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=1181579), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md)

## Analysis

The commercial pilot reported that, after departing for the agricultural flight, he maneuvered the helicopter to line up with the field to be sprayed. Shortly after lining up with the field, the engine started to surge, and he saw the torque meter needle "bouncing rapidly." The pilot initiated a precautionary landing to an open field. The helicopter landed hard, which resulted in substantial damage to the tailboom and tail rotor drive shaft. A test run of the engine revealed that the bleed valve did not close at any speed and that the engine produced less than 250 horsepower (hp). The bleed valve was disassembled, and the diaphragm was found to have several holes and cracks, and the poppet valve located in the bleed valve assembly had radial play, consistent with worn bushings. The damaged bleed valve was replaced with an overhauled bleed valve, and during a subsequent test run, the engine produced about 380 hp, which is about 7% below minimum allowable power for a serviceable engine. Given these results, the excessive wear of the bleed valve likely prevented it from closing during the accident flight, which resulted in the engine's degraded performance. According to the operator, the compressor, turbine, and bleed valve assemblies were overhauled about 2 years before the accident and then reassembled on the engine. The engine had operated about 766 hours since overhaul at the time of the accident. The engine manufacturer reported that the bleed valve assembly should be overhauled every 1,500 hours. No component log cards or historical information for the bleed valve was located during the investigation. According to the engine manufacturer, the bleed valve exhibited wear that was not consistent with a bleed valve with comparable service time. Therefore, it is likely that the bleed valve was likely not overhauled 2 years before the accident as reported by the operator and that it was beyond the overhaul period of 1,500 hours, which resulted in the observed wear that ultimately prevented the engine from producing sufficient power during takeoff.

## Factual narrative

On July 2, 2016, about 0230 Pacific daylight time, a Bell OH-58A, single-engine, agricultural helicopter, N6251G, experienced a partial loss of engine power while in the vicinity of Brawley Municipal Airport (BWC), Brawley, California. The commercial pilot was not injured. The helicopter was substantially damaged during the precautionary landing to a cropped field. The helicopter was registered to the Bank of Utah, and operated by Farm Aviation, Inc., Brawley, California, as a Title 14 Code of Federal Regulations Part 137 aerial application flight. Night visual meteorological conditions were reported about the time of the accident. A flight plan was not filed for the local flight which departed shortly before the accident. The pilot reported that after he departed BWC with a full chemical load, he maneuvered about 1/4 mile from the airport and made a 90° turn to line up on the field to be sprayed. Shortly after lining up, the engine started to surge, and the torque meter needle was "bouncing rapidly." The pilot then initiated a precautionary landing. The helicopter landed hard in an open field and came to rest in an upright position. Examination of the helicopter, which was conducted by a representative from the Federal Aviation Administration (FAA), revealed that the tailboom and tail rotor driveshaft had sustained impact damage consistent with a main rotor strike as a result of the hard landing. The onsite examination of the airframe and engine revealed no anomalies. Helicopter maintenance documentation was not available during the investigation. According to the pilot, the airframe had a total operating time of 13,688 hours at the time of the accident. The engine had a total operating time of 5,618 hours. The last 100-hour inspection was performed on June 15, 2016, about 74 hours prior to the accident flight. The helicopter was moved to a secure location and the engine was shipped to a facility for further examination. Examination of the engine was conducted at Aero Maritime in Phoenix, Arizona on July 28, 2016. An FAA inspector and a Rolls-Royce investigator were present for the examination. The engine was set up in a test cell and during the test run the engine's bleed valve did not close at any speed; the engine produced less than 250 horsepower. When the chip detectors were removed it was revealed that the lower detector had metal debris present and the upper detector had light amounts of metal debris present. When the bleed valve was replaced with an overhauled bleed valve, an additional test run resulted in increased performance rating of about 380 hp being produced (about 7% below minimum allowable power for a serviceable engine) before reaching the maximum specified operating temperature. After the engine test run, the engine was revealed to be unserviceable due to its low power production. No component log card or historical information for the bleed valve was found. According to the operator, the compressor, turbine and bleed valveassemblies were overhauled in July 2014, and assembled as an engine. According to Rolls-Royce, the overhaul period for the bleed valve assembly is 1,500 hours. No log cards were available for the bleed valve installed. The engine had 766 hours since overhaul at the time of the accident. When the accident engine's bleed valve was disassembled it was found that the diaphragm had several holes and cracks. The poppet valve located in the bleed valve assembly, had radial play consistent with worn bushings. According to Rolls-Royce, the non-functioning bleed valve exhibited wear that was not consistent with a bleed valve with comparable service time.

## Aircraft

- Registration: [N6251G](https://openairdocs.org/aircraft/N6251G), registered now, S/N 70-15444, built 1970 (OpenAirDocs)
- Reported make and model: BELL OH 58A (NO SERIES)
- Registry model: [Bell OH-58A](https://openairdocs.org/model/bell-oh-58a) (registry code 1181579) (OpenAirDocs)
- Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs)
- Category: Helicopter
- Serial number: 70-15444
- Year built: 1970
- Airframe hours: 13688
- Engines: AMA/EXPR UNKNOWN ENG turbo shaft
- Damage: Substantial damage
- Flight: Aerial application, Part 137
- Operator: Farm Aviation Inc
- Registered owner: Farm Aviation Inc
- Airworthiness certificate: Special, Restricted (Special)
- Last inspection: 100 hour, June 15, 2016, 74 hours before
- Departed: Brawley, CA
- Destination: Brawley, CA

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 42; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review May 30, 2015; seat: right; restraint: 4-point; flight hours: 7,000 total, 1,500 in this make and model, 7,000 as pilot in command, 150 in the last 90 days, 50 in the last 30 days, 3 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Night
- Wind: 80° at 9 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 84 °F, dew point 64 °F
- Altimeter: 29.77 inHg
- Observed at: KIPL, 10 nm away

## Docket (10 files)

The files NTSB released with the investigation on January 16, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93515. 8.0 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479988&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- FAA Engine Examinatiion and Test Run (item 2, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479989&FileExtension=.PDF&FileName=FAA%20Engine%20Examinatiion%20and%20Test%20Run-Master.PDF
- Commercial Service Letter-1209 Rev 2 (item 3, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479990&FileExtension=.PDF&FileName=Commercial%20Service%20Letter-1209%20Rev%202-Master.PDF
- Rolls Royce-Engine Investigation Report (item 4, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479991&FileExtension=.PDF&FileName=Rolls%20Royce-Engine%20Investigation%20Report-Master.PDF
- Email-Rolls Royce, Engine Examination and Test Run (item 5, .PDF, 225 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479992&FileExtension=.PDF&FileName=Email-Rolls%20Royce,%20Engine%20Examination%20and%20Test%20Run-Master.PDF
- Email-Rolls Royce, Engine Examination Test Run Cont (item 6, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479993&FileExtension=.PDF&FileName=Email-Rolls%20Royce,%20Engine%20Examination%20Test%20Run%20Cont-Master.PDF
- Allison-Commercial Service Letter (item 7, .PDF, 840 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479994&FileExtension=.PDF&FileName=Allison-Commercial%20Service%20Letter-Master.PDF
- Rolls-Royce Commercial Service Letter (item 8, .PDF, 915 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479995&FileExtension=.PDF&FileName=Rolls-Royce%20Commercial%20Service%20Letter-Master.PDF
- Statement of Party Representatives to NTSB Investigation-Rolls Royce (item 9, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479996&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Rolls%20Royce-Master.PDF
- FAA Photo Array (item 10, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479997&FileExtension=.PDF&FileName=FAA%20Photo%20Array-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.

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