WPR21LA107

NTSB accident investigation · Hughes OH-6A · Horseshoe Bend, ID · February 5, 2021

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
February 5, 2021, 14:00 local (21:00 UTC)
Place
Horseshoe Bend, ID
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N6639RHughes OH-6A
Defining event
Maneuvering-low-alt flying: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Rolls Royce, Rolls-Royce Corporation, MD Helicopters, USDA APHIS Wildlife Services, FAA
FAA report
20210205001189A
Case key
102608

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A partial loss of engine power due to a leak in the fuel cell outlet valve.

Findings · 3

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.

Fuel systemAircraft › Aircraft systems · FailureHughes OH-6A: 1 caseAll aircraft: 181 casesProbable cause
Terrain: mountainous/hilly terrainEnvironmental issues › Physical environment · Effect on equipmentHughes OH-6A: 1 caseAll aircraft: 329 cases
Misc hardwareAircraft › Fluids/misc hardware · Not inspectedHughes OH-6A: 1 caseAll aircraft: 41 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

While conducting wildlife damage management operations at low altitude over hilly terrain, the pilot of the helicopter noted a loss of main rotor rpm. To regain main rotor rpm, he reduced the engine power demand by descending into a draw; however, the helicopter impacted terrain, rolled over, and came to rest on its left side. Two days before the accident flight, the pilot experienced a similar loss of main rotor rpm; however, he was able to safely land the helicopter. The pilot was unable to replicate the loss of main rotor rpm and continued the flight. The pilot believed that the event was an isolated anomaly and did not notify maintenance personnel. Postaccident examination of the helicopter revealed an air leak located in the fuel cell outlet valve near the firewall. Subsequent examination of the fuel cell outlet valve revealed circumferential scratch marks around the barrel of the pipe. Damage due to cross-threading was observed on the first two threads. When the O-ring was removed, metal chips were located embedded throughout the O-ring. A review of the maintenance records indicated that the fuel system components were inspected during the 100-hour inspection, along with correspondence from the maintenance facility that a vacuum check of the fuel system was conducted during that inspection, with no anomalies noted. No entries were found in the maintenance records of any work done to the fuel outlet valve. The approved maintenance manual for the helicopter contained multiple warnings that air in the fuel system will cause a power reduction or flame out. It could not be determined when, or how, the fuel cell outlet valve developed a leak.

Factual narrative

On February 5, 2021, about 1400 mountain standard time, a Hughes OH-6A helicopter, N6639R, was substantially damaged when it was involved in an accident near Horseshoe Bend, Idaho. The pilot sustained serious injuries and a passenger sustained minor injuries. The helicopter was operated as a public use flight. The purpose of the accident flight was to conduct wildlife damage management operations. While maneuvering at low altitude over hilly terrain, the pilot noted a loss of main rotor rpm. The pilot maneuvered the helicopter into a draw to reduce the engine power demand and regain rotor rpm. The helicopter impacted sloped terrain, rolled over, and came to rest on its left side. The pilot reported that, two days before the accident flight, he experienced a similar loss of rotor rpm while over flat terrain and was able to safely land the helicopter. While on the ground, he utilized the “BEEP” switch (N2 governor control switch) on the collective to increase rotor rpm, but it had no effect. He then changed the position of the throttle from fly to idle and observed the engine instruments for any abnormalities. With no abnormalities identified, he again changed the position of the throttle from idle to fly and regained main rotor rpm. He then utilized the “BEEP” switch and all engine controls returned to normal operations. While remaining on the ground, he repeated the process several times attempting to duplicate the loss of main rotor rpm with no success. As there had not been a prior malfunction and unable to duplicate the loss of rotor rpm, the pilot believed the event as an isolated anomaly and did not notify maintenance personnel. Postaccident examinations of the helicopter revealed substantial damage to the fuselage and tail boom, as well as an air leak at the fuel cell outlet valve that connected the fuel supply line from the fuel shutoff valve and the frangible in-line fuel valve on the self-sealing engine fuel inlet hose located at the firewall. (see Figure 1.) The fuel cell outlet valve along with the engine fuel inlet hose were shipped to the NTSB (NTSB) Materials Laboratory for further examination. Figure 1: view of fuel line leak (photo provided by MD Helicopters) Flight control continuity was confirmed from the cyclic pitch control and collective pitch control systems to the main rotor swashplate. Anti-torque pedal control continuity was established from the pedals up to tail rotor pitch control tube. The engine was removed and shipped to the manufacturer for additional examination and testing. The engine was installed in a test-run cell, where it was started and ran for about an hour with no mechanical anomalies identified that would have caused the reported sudden loss of engine power. Of note were two decelerations and a singular brief engine stall; both events were within the manufacturers experience of a mid-life engine and would not have contributed to the reported power loss. According to the engine manufacturer, the accidenthelicopter had a non-pressure-boosted fuel system that was utilized for normal operation. The engine fuel pump generated a vacuum at its inlet to draw the fuel from the tank to the engine fuel delivery system. A leak in the fuel delivery system prior to the engine can produce air entrainment in the fuel being supplied which could result in the interruption of homogenous fuel flow. Maintenance records provided by the operator indicated that a 100-hour inspection was completed on May 19, 2020. Correspondence with the maintenance facility revealed that a 100-hour inspection was conducted in accordance with the Rolls Royce maintenance and operation manual, 250-C20 Section 72-00-00. No other fuel system troubleshooting or repairs were completed. A vacuum check of the fuel system was conducted during the 100-hour inspection, with no anomalies noted. The Rolls Royce maintenance and operation manual, 250-C20 Section 72-00-00, titled “Engine Fuel and Control System -- Maintenance Practices,” contained multiple warnings that, “Air leaks in the fuel system or the pneumatic sensing system can cause flameouts, power loss or overspeed.” The fuel cell outlet valve was examined by the NTSB Materials Laboratory. A pressure test utilized soapy water as part of its testing protocols; soap bubbles formed at the barrel of the pipe and fuel outlet valve, which indicated the presence of an air leak. Visual examination of the fitting had circumferential scratch marks on the barrel of the pipe, as seen in Figure 2. A visual examination of the fitting threads revealed that the first two threads were damaged due to cross-threading. The O-ring was removed with both outer and inner diameter surfaces flattened/compressed. Metal chips were found embedded in the O-ring; when the O-ring was removed, a metal chip dislodged and revealed an impression in the rubber. Figure 2: View of optical microscope images showing circumferential scratch marks and pile-up material on the outer diameter surface of the pipe barrel (photo provided by NTSB) A review of the helicopter’s maintenance records could not determine the age of the fuel cell outlet valve, or if any maintenance had been performed on the valve.

Aircraft

Registration
N6639R
Reported as
Hughes OH-6A
Category
Helicopter
Serial number
66-078784
Airframe hours
14,627.5
Engine
Alison 250-C20B, 420 hp, turbo shaft
Damage
Substantial damage
Flight
Public aircraft - federal · Public use
Operator
Usda Aphis Ws Atoc
Registered owner
Usda Aphis Ws Atoc
Airworthiness certificate
None
Last inspection
Annual · May 16, 2020 · 130 hours before
Departed
KMAN · Nampa, ID
Destination
KEUL · Caldwell, ID
Flight plan
Company VFR
Equipment
ADS-B, Handheld GPS

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
52
Injuries
Serious
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, Without waivers/limitations
Last flight review
August 12, 2020
Seat
Right
Restraint
4-point
Flight hours
17,000 total · 1,500 in this make and model · 17,000 as pilot in command · 75 in the last 90 days · 40 in the last 30 days
Role
Other flight crew
Age
61
Injuries
Minor
Seat
Left
Restraint
4-point

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 19 knots, gusting 30
Visibility
10 statute miles
Lowest ceiling
6,000 ft overcast
Temperature
46 °F, dew point 30 °F
Altimeter
30.06 inHg
Observed at
KBOI, 26 nm away
METAR
KBOI 052053Z 32019G30KT 10SM SCT042 OVC050 08/M01 A3006 RMK AO2 PK WND 32030/2045 SLP185 T00831006 51009

Docket · 10

The files NTSB released with the investigation on September 13, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.7 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.

Other investigations on N6639R · 1

Matched to the same aircraft by N-number and date.