WPR21LA268

NTSB accident investigation · Bell 212HP · Weed, CA · July 7, 2021

Accident · No injuriesClass 3 · LimitedFinal report
Date
July 7, 2021, 16:45 local (23:45 UTC)
Place
Weed, CA · Lake
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N911KWBell 212HP
Defining event
Maneuvering-low-alt flying: External load event (Rotorcraft)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
USFS, FAA, TSB, Bell Helicopters Inc, Pratt & Whitney
FAA report
20210707016999A
Case key
103465

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

The pilot’s failure to maintain altitude during an approach to a lake. Contributing to the accident was the pilot’s failure to release the full water bucket as the helicopter was settling, which reduced the helicopter’s out-of-ground-effect performance.

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.

Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedBell 212: 1 caseAll aircraft: 1,310 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · PilotBell 212: 1 caseAll aircraft: 792 cases

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 flight was on an approach to a lake to retrieve water for a water bucket drop operation. During the approach, the instruments scanned normal, and the radar altimeter was set to 200 ft above ground level to provide a buffer between the bucket and terrain. When the helicopter crossed the shoreline, the pilot visually confirmed that the 100-ft long line and bucket were slightly trailing the helicopter and had not dipped in the water. Shortly afterward, he felt a “sudden onset of a significant vibration.” The pilot aborted the water retrieval and noticed that helicopter lost altitude. He applied forward cyclic and raised the collective, but the helicopter continued to descend. The pilot realized that he would not be able to fly out of the descent, so he decided to make a forced water landing. The pilot did not jettison the long line and bucket. After he leveled the helicopter and the skids touched down on the water, he made another attempt to take off, but the helicopter settled into the lake. The pilot reduced both throttle settings to idle in preparation to ditch the helicopter and applied right cyclic as the main rotors slowed. The helicopter rolled right, and the main rotor blades struck the water, which resulted in substantial damage to the fuselage, rotor, and drive systems. Postaccident examination of the engine revealed no preimpact mechanical anomalies. The airframe examination revealed an out-of-tolerance condition of both pylon damper rod end bearings that likely caused the vibration reported by the pilot. It is likely that, after the lateral vibration, the pilot allowed the helicopter to descend while he tried to determine the source of the vibration. As the helicopter settled into the lake, the bucket filled with water. The resulting increased weight, combined with the pilot’s failure to release the water bucket, decreased the helicopter’s out-of-ground-effect performance.

Factual narrative

On July 7, 2021, about 1450 Pacific daylight time, a Bell 212 helicopter, N911KW, was substantially damaged when it was involved in an accident near Weed, California. The pilot was not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 133 external load flight. The pilot reported that he was supporting a US Forest Service contract involving water drop operations and that the accident flight was on approach to a lake to retrieve water using a 100-ft long line and bucket. When the helicopter was about 400 ft above ground level (agl), the pilot performed an instrument scan and noted no anomalies. The pilot added that the radar altimeter was set to 200 ft agl at the time. When the helicopter crossed the shoreline, the pilot observed that the long line and bucket were “not yet in view and still out behind [him].” Shortly afterward, he felt a “sudden onset of a significant vibration,” which he also described as once-per-minute rotation. (An inspector with the US Forest Service explained that the term “indicates an imbalance in main rotor head or main rotor blades.) The pilot scanned the instrument panel and saw no annunciator lights or indications that the engines had stopped producing power. He then glanced outside and realized that the helicopter had descended. The pilot aborted the water retrieval, made a forward cyclic input, and raised the collective, but the helicopter continued to descend. The pilot determined that he would be unable to stop the descent, and he did not want the engines or transmission to overspeed, so he performed a forced landing on water. After he leveled the helicopter and the skids touched down on the water, the pilot made a last attempt to take off, which was unsuccessful. The pilot reduced both throttle settings to idle in preparation to ditch the helicopter and applied right cyclic as the main rotors slowed. The pilot stated that the helicopter controls responded normally and that the helicopter did not yaw significantly. The helicopter rolled right, causing the main rotor blades to strike the water, and the helicopter subsequently sank into the lake. Automatic dependent surveillance-broadcast data showed that the bucket was about 35 ft above the water when the last data point was recorded. At that time, the helicopter's descent rate was about 768 ft per minute. The pilot did not jettison the long line and bucket because he thought that he would be able to fly away. The helicopter sustained substantial damage to the fuselage, main and tail rotor blades, and drive systems. Training records showed that the pilot completed six recurrent long-line training flights from May 3 to 29, 2021. On May 31, 2021, the pilot completed a helicopter pilot evaluation checkride with a US Forest Service pilot inspector and was cleared for solo external-load water bucket operations. The 240-gallon water bucket was configured to gather 90% of its total capacity, which would add an additional weight of about1,966 pounds to the helicopter and increase its 8,150-pound gross weight to about 10,116 pounds. The bucket was recovered attached to the helicopter by a cargo hook and the long line. Postaccident examination of the bucket and engine powerpack revealed no preimpact mechanical malfunctions or failures that would have precluded normal operations. The pylon corner mounts and pylon dampers were hydraulically tested with dynamic loads and exhibited normal operational performance. The rod end bearings for the pylon dampers had tolerances that were more than the Bell 212 Maintenance Repair and Overhaul Manual tolerance of 0.004-inch radial play: the right aft damper bearing play was 0.006 inch, and the left aft damper bearing play was 0.016 inch. According to Bell Textron, the excessive radial clearance of rod end bearings reduces the amount of damper stroking to counteract vibratory motion of the pylon. Also, a flight crew in a separate event experienced a vibration that was traced back to excessive radial wear of the pylon damper rod end bearings. The helicopter’s hover out of ground effect (OGE) performance was computed using the helicopter operator’s Rotorcraft External Load Manual, which included a performance chart from Bell Helicopter’s BHT-212-MD-1 manual. According to the performance chart, at an air temperature of 35°C, heater OFF, engine rpm at 100%, skid height of 50 ft, a 15-knot headwind, and generator values of 150 amperes, the helicopter had an OGE takeoff power gross weight limitation of about 10,250 pounds. According to the Bell 212 Rotorcraft Flight Manual: Supplement Cargo Hook, at a helicopter gross weight of 8,150 pounds, an air temperature of 35°C, heater OFF, engine rpm at 100%, skid height of 60 ft, and generator values of 150 amperes, the helicopter had an OGE takeoff power limitation at a pressure altitude of about 8,000 ft and a maximum continuous power setting limitation at a pressure altitude of about 6,600 ft. The Bell Helicopters manual also showed that, at a gross weight of about 10, 116 pounds, the helicopter had an OGE takeoff power limitation at a pressure altitude of about 3,700 ft and a maximum continuous power setting limitation of 9,300 pounds.

Aircraft

Registration
N911KW
Reported as
Bell 212HP
Category
Helicopter
Serial number
30592
Built
1973
Airframe hours
14,543.5
Engines
Pratt & Whitney PT6T-3B, turbo shaftPratt & Whitney PT6T-3B, turbo shaft
Damage
Substantial damage
Flight
Firefighting · Part 133
Operator
Rogers Helicopters Inc
Registered owner
Rogers Helicopters Inc
Airworthiness certificate
Standard, Utility
Last inspection
Continuous airworthiness · June 29, 2021
Departed
1O6 · Dunsmuir, CA
Equipment
None

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
35
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Helicopter
Medical
Class 1
Last flight review
May 5, 2021
Seat
Left
Restraint
Lap only
Flight hours
4,636 total · 239 in this make and model · 4,407 as pilot in command · 19 in the last 90 days · 8 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 15 knots, gusting 20
Visibility
10 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 25 °F
Altimeter
29.96 inHg
Observed at
KSIY, 16 nm away
METAR
KSIY 072153Z AUTO 33007G17KT 10SM CLR 34/M04 A2996 RMK AO2 SLP128 T03441044=

Docket · 26

The files NTSB released with the investigation on June 28, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports.

Pilot/operator aircraft accident report, NTSB form 6120.1Item 1 · PDF · 11 pages · 2.1 MBMemorandum for record - pilot interview with usfsItem 2 · PDF · 3 pages · 113 KBAccident photosItem 3 · PDF · 3 pages · 1.8 MBPilot training records external loadItem 4 · PDF · 5 pages · 16.6 MBEngine and airframe examination notesItem 5 · PDF · 9 pages · 1.5 MBMemorandum for record - bucket examinationItem 6 · PDF · 1 page · 95 KBPylon mounts examination notesItem 7 · PDF · 10 pages · 1.1 MBPylon support examination notes commentsItem 8 · PDF · 2 pages · 1.1 MBMemorandum for record - power pack engine exam summationItem 9 · PDF · 3 pages · 200 KBIpad examination narrativeItem 10 · PDF · 2 pages · 103 KBRecorded air traffic control radar data (plot)Item 11 · KMZ · 28 KBAdsb data csvItem 12 · CSV · 365 KBPylon support illustrated parts catalog excerptItem 13 · PDF · 1 page · 263 KBPilot training recordsItem 14 · PDF · 13 pages · 11.9 MBMaintenance due reportItem 15 · PDF · 13 pages · 417 KBOperator fire training manual excerptItem 16 · PDF · 3 pages · 196 KBHover gross weight performance chart excerptItem 17 · PDF · 1 page · 470 KBOge performance chart BHT-12-FMS-3 excerpt - takeoff powerItem 18 · PDF · 2 pages · 608 KBParty form - manufactureItem 19 · PDF · 1 page · 265 KBWreckage release formItem 20 · PDF · 1 page · 67 KBParty representative form - usfsItem 21 · PDF · 1 pageEvidence control form bambi bucket - 001Item 22 · PDF · 2 pages · 191 KBEvidence control form - 002Item 23 · PDF · 2 pages · 329 KBEvidence control form - 003Item 24 · PDF · 2 pages · 274 KBEvidence control form - 004Item 25 · PDF · 2 pages · 337 KBEvidence control form 005Item 26 · PDF · 2 pages · 139 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.