WPR22LA340

NTSB accident investigation · Bell Helicopter Textron 206L-1 · Banning, CA · September 10, 2022

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
September 10, 2022, 15:50 local (22:50 UTC)
Place
Banning, CA · backyard of a residence
Injuries
3 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N242BHBell Helicopter Textron 206L-1
Defining event
Landing: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Cal-Fire
Case key
105896

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 improper attachment of the tail rotor drive shaft to the air conditioner drive pulley without a drive ring, which resulted in the failure of the hardware, a loss of tail rotor drive, and the loss of control of the helicopter followed by a hard landing and rollover.

Findings · 2

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 drive shaftAircraft › Aircraft propeller/rotor · Incorrect service/maintenanceBell Helicopter Textron 206L-1: 1 caseAll aircraft: 25 casesProbable cause
MaintenancePersonnel issues › Task performance · Maintenance personnelBell Helicopter Textron 206L-1: 1 caseAll aircraft: 143 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 and two passengers were returning to the base airport following an aerial firefighting mission. During the approach to the airport, the helicopter began an uncontrolled right rotation that could not be arrested despite full use of the left pedal. The pilot attempted to land in the back yard of a private residence; however, the helicopter landed hard and rolled onto its left side. The helicopter sustained substantial damage to the main rotor system, fuselage, and tailboom. An on-scene examination revealed the tail rotor drive shaft had separated at a flex coupling and components critical to the assembly were missing. Postaccident metallurgical examination of tail rotor drive shaft assembly, the pulley, and the recovered hardware revealed that tail rotor drive shaft flange was likely directly attached to the air conditioning pulley flange without a drive ring. The bolt length and recovered hardware would have been adequate to secure the drive shaft flange and the pulley flange together to a drive ring; however, the drive ring, two bolts, six washers and one nut were not found amongst the wreckage after a thorough search. The examination also revealed that the two bolts that were recovered failed from fatigue, likely from the cyclic stress due to the absence of a drive ring. According to the helicopter maintenance records, there had been no recent work on the tail rotor drive shaft or air conditioning unit that would have required disassembly and reassembly of the failed flex coupling.

Factual narrative

On September 10, 2022, about 1550, a Bell 206L-1 helicopter, N242BH, was substantially damaged when it was involved in an accident near Banning, California. The pilot and two passengers received minor injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 firefighting flight. According to the pilot, he was contracted by the California Department of Forestry and Fire Protection (Cal Fire) and was transporting two of their employees to the Banning Municipal Airport (BNG), Banning, California. The pilot had established the helicopter on a final approach path to land between the runway and a taxiway. While on approach, the helicopter made an uncommanded yaw to the right about the vertical axis. The right yaw slowly increased during the approach until he applied full left pedal. The pilot announced to the passengers that he thought he had lost his tail rotor. While about 100 to 150 ft above ground level (agl) he elected not to autorotate while over people and aircraft, and instead kept his power low and kept up his speed. After the helicopter had turned about 180°, the pilot saw a landing area in a back yard and maneuvered the helicopter toward it. As he neared the yard, about 50 ft agl, the helicopter began a continuous right rotation about its vertical axis despite the application of full left pedal. When the helicopter was close to the ground, he applied collective to cushion the landing. The helicopter landed hard, bounced, and rolled onto its left side. Multiple witnesses reported seeing the helicopter “spinning,” followed by a descent to the ground. The pilot turned off the fuel switch and exited the helicopter with assistance from first responders. One passenger exited unassisted and helped the other passenger exit. A review of photographs provided by the pilot showed substantial damage to the main rotor assembly, fuselage, and tailboom. A postaccident examination, which included photographs provided by the pilot, identified all major components near the main wreckage except for some fragments of the main rotor blades that were on a nearby street. The tail rotor drive shaft had separated from the air conditioner pulley flange at the flex coupling (figure 1). Two bolt shank fragments and the attached nuts were found trapped in the two holes of the pulley flange. A bolt head piece, a nut, and six washers were found in the enclosed area. Neither the drive ring, nor any of the hardware other than one nut for connecting the drive shaft flange to the drive ring, were recovered from the fuselage despite a thorough search. Figure 1. View of the separated drive shaft from the pulley at the flex coupling. According to the diagram, 4 nuts, 4 bolts, and a total of 14 washers are required for the drive shaft to pulley flex coupling assembly, as shown in figures 2 and 3. Figure 2. Illustration of a flex coupling for a drive shaft to pulley assembly. Illustration courtesy of Bell. Figure 3. Photograph of an exemplar flexcoupling for a tail rotor drive shaft. Photo courtesy of Bell. The drive shaft section, the pulley, and the recovered hardware were shipped to the National Transportation Safety Board’s Materials Laboratory for further examination. Examination of the drive shaft revealed a complete and intact flex coupling on one end and a separated flex coupling on the other end. The fracture surfaces of the bolt pieces trapped in the pulley flanges had relatively flat features with curving crack arrest lines across most of the fracture surfaces, which are features consistent with a fatigue fracture. A matching fracture surface was observed on the recovered bolt head piece and one of the bolt shanks trapped in the pulley flange. The trapped nut end of one bolt was removed from the pulley flange and mated to the recovered head piece. The total bolt shank length was measured at 0.494 inch between the clamping faces of the head and the nut. The thickness of the pulley flange was 0.164 inch, and the thickness of the flange on the drive shaft assembly was 0.161 inch. For reference, the total thickness of the drive ring adjacent to 1 of the bolts on the intact coupling was 0.119 inch. The 6 recovered washers consisted of 4 washers that were 0.058 inch thick, and 2 washers that were 0.029 inch thick. The specified washers for the pulley flange to drive ring have 2 thicknesses; the thinner washer has a specified nominal thickness of 0.032 inch, and the 3 thicker washers have a specified nominal thickness of 0.063 inch. A maintenance records review revealed no recent work to the tail rotor drive shaft or air conditioning unit. No anomalies were noted in the examination of the maintenance records.

Aircraft

Registration
N242BH
Reported as
Bell Helicopter Textron 206L-1
Category
Helicopter
Serial number
45506
Built
1980
Airframe hours
36,275.3
Engine
Rolls-Royc M250-C30P, 650 horsepower, turbo shaft
Damage
Substantial damage
Flight
Firefighting · Part 91
Operator
Blue Sky Aviation, doing business as CalFire
Registered owner
B3 Consultants LLC
Airworthiness certificate
Special, Restricted (Special)
Last inspection
100 hour · June 28, 2022
Destination
Same as departure
Airport
BNG · Banning Municipal Airport, runway 08, 4,955 × 100 ft, asphalt
Equipment
Satellite tracking device, Electronic flight bag or handheld device, ADS-B

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
34
Injuries
Minor
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 1, Without waivers/limitations
Last flight review
May 22, 2022
Seat
Right
Restraint
4-point
Flight hours
5,594 total · 93 in this make and model · 5,505 as pilot in command · 136 in the last 90 days · 66 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 6 knots
Visibility
10 statute miles
Lowest ceiling
12,000 ft broken
Temperature
84 °F, dew point 64 °F
Altimeter
29.89 inHg
Observed at
KHMT, 14 nm away
METAR
KHMT 102215Z AUTO 03006KT 10SM SCT050 BKN120 29/18 A2989 RMK AO2 T02920175

Docket · 5

The files NTSB released with the investigation on April 25, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 28.3 MB in all.