WPR22LA084

NTSB accident investigation · Bell UH-1E · Gustine, CA · January 23, 2022

Accident · No injuriesClass 3 · LimitedFinal report
Date
January 23, 2022, 10:30 local (18:30 UTC)
Place
Gustine, CA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N333XLBell UH-1E
Defining event
Maneuvering-low-alt flying: Sys/Comp malf/fail (non-power)
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
20220123001259A
Case key
104563

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

Failure of the 90° gearbox due to the lack of lubricating oil, which resulted in a loss of rotational drive to the tail rotor and a subsequent loss of control of the helicopter.

Findings · 1

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.

Tail rotor drive system: tail rotor gearboxAircraft › Aircraft propeller/rotor · MalfunctionBell UH-1E: 1 caseAll aircraft: 12 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 pilot was conducting aerial spray applications of a chemical to a field. He had checked the oil quantity of the 90° gearbox during the preflight check but did not recall the quantity of oil at the time. The pilot had operated the helicopter for about 45 minutes and, while making a turn, lost control of the helicopter. The helicopter descended and impacted terrain. Maintenance records revealed no anomalies. Postaccident examination of the 90° gearbox revealed severe damage to the internal components and no evidence of lubricating oil inside the housing. The pinion was severely deformed, which resulted in the loss of rotational drive to the tail rotor assembly and the subsequent loss of control. Examination of the oil level sight glass revealed that the inside was covered with a material that did not allow for sufficient viewing of the oil level. It is likely that, when the pilot looked at the oil level sight glass during his preflight check, he interpreted what he saw as an adequate amount of oil.

Factual narrative

On January 23, 2022, about 1030 Pacific standard time, a Bell UH-1E, N333XL, was substantially damaged when it was involved in an accident near Gustine, California. The pilot was not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot reported that he was applying herbicide to a wheat field and that the accident occurred on the third load of the day and after the pilot had been operating the helicopter for about 45 minutes. At the apex of a turn, the pilot lost control of the helicopter, and it descended and struck terrain, which substantially damaged the main rotor system, tailboom, and fuselage. The pilot turned off the fuel boost and the master electrical switch and exited the helicopter through the roof window. The pilot reported that he had checked the oil level of the 90° gearbox before the flight but did not recall the quantity of oil at the time. A review of postaccident photos provided by the pilot revealed the helicopter came to rest on its left side in an open, level field. All major components were located in the debris area around the airframe. The tailboom had partially separated from the fuselage. One main rotor blade separated from the hub about 24 inches outboard of the blade grip. The other main rotor blade remained attached and exhibited upward bending about 24 inches from the blade grip. The tail rotor assembly and the 90° gearbox remained attached to the top of the vertical stabilizer. The 90° gearbox had an internal gear that had breached the housing. The green paint around the breach was thermally damaged, and no evidence of oil was observed around the exposed area of the gearbox. The 90° gearbox was shipped to the National Transportation Safety Board (NTSB) Materials Laboratory. Examination of the 90° gearbox revealed that the housing and the parts within the housing were dry and covered with a black deposit of fine metallic particles and that they contained no evidence of lubricating oil/fluid (see figures 1and 2). The gear and bearings exhibited evidence of heat damage and deformation. The pinion exhibited severe heat and wear damage, which is also shown in figure 2. Figure 1. Overall view of the 90° gearbox assembly showing a portion of the exposed gear that breached the gearbox housing. Figure 2. View of the internal components of the 90° gearbox and the damage to the pinion. The interior of the housing was covered in soot. When a flashlight was aimed at the oil level sight glass, no light passed through it (figure 3). Figure 3. Oil level sight glass for the 90° gearbox. Review of the airplane’s maintenance records revealed that, on October 23, 2007, the 90° gearbox was installed on the accident helicopter at an airframe time of 8,412 hours. The gearbox had 260.9 hours since overhaul. The gearbox complied with Federal Aviation Administration Airworthiness Directive 90-10-05, dated June 5, 1990, which was issued to prevent the failure of the tailrotor gearbox duplex bearing. On February 15, 2022 (23 days after the accident), the 90° gearbox was removed for examination; at that time, the helicopter had an airframe time of 9,025.8 hours, and the gearbox had accumulated 3,124.5 historical hours and 298.9 hours since overhaul.

Aircraft

Registration
N333XL
Reported as
Bell UH-1E
Category
Helicopter
Serial number
154951
Built
1967
Airframe hours
9,004
Engine
Lycoming T53-L-11D, 1,200 horsepower, turbo shaft
Damage
Substantial damage
Flight
Aerial application · Part 137
Operator
Marquis Aviation
Registered owner
David Lee Aircraft Sales And Leasing LLC
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · February 12, 2021
Departed
LSN · Los Banos, CA
Destination
Same as departure
Airport
LSN · Los Banos
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
77
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Single-engine sea
Medical
Class 2, With waivers/limitations
Last flight review
August 10, 2021
Seat
Right
Restraint
4-point
Flight hours
27,000 total · 900 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
5 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 43 °F
Altimeter
30.29 inHg
Observed at
KMCE, 24 nm away
METAR
METAR KMCE 231853Z AUTO 00000KT 5SM HZ CLR 12/06 A3029 RMK AO2 SLP259 T01220061 $=

Docket · 7

The files NTSB released with the investigation on January 30, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.6 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.