WPR18LA147

NTSB accident investigation · Bell UH 1H · Olympia, WA · May 25, 2018

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
May 25, 2018, 09:47 local (16:47 UTC)
Place
Olympia, WA
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N111DRBell UH 1H
Defining event
Initial climb: Part(s) separation from AC
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20180525005909A
Case key
97325

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 loss of tail rotor thrust due to the improper installation of the tail rotor assembly by maintenance personnel resulted in the pilot’s inability to maintain control of the helicopter as he began transition into forward flight from a hover, which resulted in a hard landing. Contributing to the accident was the failure of company quality control personnel to identify the improper installation of the tail rotor assembly before certifying the helicopter for flight, and the pilot’s inadequate preflight inspection.

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.

Maintenance: installationPersonnel issues › Task performance · Maintenance personnelBell UH-1H: 1 caseAll aircraft: 371 casesProbable cause
Inspection: post maintenance inspectionPersonnel issues › Task performance · Maintenance personnelBell UH-1H: 1 caseAll aircraft: 57 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotBell UH-1H: 2 casesAll aircraft: 551 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleBell UH-1H: 2 casesAll aircraft: 1,269 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 purpose of the maintenance test flight was for a track and balance of the tail rotor and main rotor blades. The pilot reported that during his preflight check and walkaround, everything looked fine with no anomalies noted. After becoming airborne and performing a hover check, the pilot proceeded to transition to forward flight, when he experienced a loss of tail rotor thrust. This led to a near-vertical rotating descent and hard landing, which resulted in substantial damage to the tailboom and lower fuselage. On on-site examination found that both pitch change link bolts and the tail rotor pitch change horn were only finger tight and found no evidence of cotter pin installation. One of the two crosshead bolts found in the debris field showed thread wear damage but was observed to be relatively complete. The accident could have been prevented if, during the rigging process of the tail rotor assembly, the crosshead bolts and the tail rotor pitch change bolts had been properly torqued and cotter pins had been installed. Additionally, had company quality control personnel identified the improper installation of the tail rotor assembly before certifying the helicopter for flight, or had the pilot detected the missing cotter pins during his preflight inspection, the anomalies could have been corrected.

Factual narrative

The accident helicopter was operated by Northwest Helicopters. During the investigation, the company safety officer stated that, based on condition of parts in the wreckage, “it was reasonable to believe that the Crosshead Bolts and Pitch Change Link Bolts were installed but not torqued, nor were cotter pins installed to aid in the rigging process.” The safety officer stated that Northwest Helicopters was unable to determine who installed the tail rotor hub assembly on the aircraft or why the four bolts in question weren’t torqued. On May 25, 2018 about 0947 Pacific daylight time, a Bell UH-1H, N111DR, was substantially damaged when it was involved in an accident near Olympia, Washington. The pilot and the sole passenger sustained serious injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 maintenance test flight. The pilot stated that he arrived at Olympia Heliport (0WN4) about 0930. He performed a preflight walk-around of the aircraft, then he received a briefing from the passenger/mechanic about the forward flight track and balance checks that needed to be performed during the flight. The pilot stated that, during his preflight walk-around, everything looked good on the aircraft, so he and the passenger/mechanic boarded the helicopter and started the engine. The pilot stated that all indications were normal at idle and at 100% rpm. The pilot stated, “I picked up and hover taxied with a left pedal turn to the helipad. Hovering at the helipad, I got the ATIS [automatic terminal information service] information and aligned the helicopter into the wind.” In the hover, about 10 ft skid height, the passenger/mechanic took the hover measurements for the track and balance, which were within limits to allow for forward flight. The pilot reported that, about 0945, he contacted the tower for permission to take off and then departed to the south. Having received permission from the tower to take off, the pilot bang and felt a “violent right yaw.” The helicopter then increased power and nosed forward. The pilot stated that about 3 to 5 seconds later, while about 70 ft above ground level over a grass field and at an airspeed of about 20 knots, he heard “a loud squeal” with a violent right yaw. That was the last memory he had of the event until they were on the ground at rest upright in a grass field within the airport boundary. The helicopter sustained substantial damage to the tailboom and lower fuselage. The pilot recalled that, when the helicopter was on the ground, he shut the engine down, checked on the condition of the passenger/mechanic, and egressed the helicopter. There was no postcrash fire. The owner of the company observed the helicopter take off, climb to about 200 ft above ground level, start to spin, descend, and crash. He stated that the tail rotor did not appear to be turning. The main wreckage was located on flat terrain about 657 ft west of the 0WN4 heliport. 0WN4 is a privately-owned heliport situatedin the southeast corner of Olympia Regional Airport (OLM), Olympia, Washington. A survey of the accident site revealed that the helicopter’s tail boom had partially separated about 4 ft aft of the engine. Drive train continuity was established from the transmission to the 90° gearbox input quill. The 90° gearbox housing/output quill assembly, tail rotor hub, and tail rotor blade assembly separated from the tail boom mounted input quill of the 90° gearbox. The bolts, washers, castellated nuts, and cotter pins that connect the tail rotor crosshead to the slider were not found on the tail rotor assembly. Cotter pins that go through the attach bolt castellated nuts that connect the pitch link rod end bearing to the tail rotor grips were not located in the wreckage; both nuts were finger tight. The shims between the retainer plate and the pitch change links had separated and were found about 100 ft east of the wreckage. Both bolt holes on five of the shims appeared to be intact. No deformation or elongation of the holes was noted. During the on-site investigation, a Federal Aviation Administration airworthiness inspector observed that both pitch change link bolts and the tail rotor pitch change horn were finger tight and found no evidence of cotter pin installation. Three days after the accident, the company chief inspector found one of the two crosshead bolts in the debris field (see figure). The bolt showed thread wear damage but was described by the inspector as relatively complete. Figure - Tail rotor hub, blade assembly, and pitch control mechanism diagram and photographs of a crosshead bolt from the accident helicopter Continuity of the tail rotor control system was confirmed from the left seat pedals to the tail rotor gearbox through the bell crank clevis. However, the crosshead bolts and pitch change link bolts were installed but not properly torqued, as they were only finger tight. Additionally, cotter pins had not been installed.

Aircraft

Registration
N111DR
Reported as
Bell UH 1H (NO SERIES)
Category
Helicopter
Serial number
64-13699
Built
1996
Airframe hours
21,244
Engine
Lycoming T53-L-13, turbo shaft
Damage
Substantial damage
Flight
Flight test · Part 91
Operator
Northwest Helicopters I Inc
Registered owner
Northwest Helicopters I Inc
Airworthiness certificate
Special, Restricted (Special)
Last inspection
100 hour · May 24, 2018 · 1 hours before
Departed
0WN4 · Olympia, WA
Destination
0WN4 · Olympia, WA
Airport
KOLM · Olympia Regional
Equipment
Satellite tracking device

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
30
Injuries
Minor
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
May 16, 2017
Seat
Left
Restraint
4-point
Flight hours
2,124 total · 89 in this make and model · 2,015 as pilot in command · 68 in the last 90 days · 21 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
10° at 3 knots
Visibility
10 statute miles
Lowest ceiling
1,600 ft broken
Temperature
55 °F, dew point 46 °F
Altimeter
30.04 inHg
Observed at
KOLM, 1 nm away

Docket · 5

The files NTSB released with the investigation on June 17, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.1 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.