WPR24LA093

NTSB accident investigation · Bell 47G-3B-1 · Garey, CA · February 23, 2024

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
February 23, 2024, 07:40 local (15:40 UTC)
Place
Garey, CA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N2618WBell 47G-3B-1
Defining event
Maneuvering-low-alt flying: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Rolls-Royce
FAA report
20240223000789A
Case key
193831

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

Maintenance personnel’s failure to properly check the torque paint on a fuel control unit B-nut, which resulted in the loosening of the B-nut, a loss of engine power at a low altitude, and a subsequent impact with terrain.

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.

Engine fuel and control: fuel control/carburetorAircraft › Aircraft power plant · Incorrect service/maintenanceBell 47G-3B-1: 1 caseAll aircraft: 195 casesProbable cause
Aircraft capability: climb capabilityAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleBell 47G-3B-1: 1 caseAll aircraft: 183 cases
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelBell 47G-3B-1: 1 caseAll aircraft: 320 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 of the helicopter was applying a chemical to a field when the engine sustained a loss of power. The pilot entered an autorotation and the helicopter descended to the terrain, where it rolled onto its right side substantially damaging the main rotor system and severing the tailboom. Postaccident examination of the pneumatic air lines revealed that there was a slight air leak at the accumulator and a large air leak at a pneumatic air line (Pc) between the power turbine governor (PTG) and the fuel control unit (FCU); the Pc line was not connected to the FCU. The B-nut connecting the Pc line to the FCU had backed off, allowing the Pc line to become disconnected. . This Pc line is one of several lines that use air pressure to communicate fuel scheduling commands between the PTG and the FCU. The security of this line is necessary for proper engine operation. Engine operation without the Pc line properly connected would result in the FCU reducing fuel to a sub-idle condition, preventing the engine from producing sufficient power for continued flight. No other preaccident mechanical malfunctions or failures were found that would have precluded normal operation. Maintenance was performed on the helicopter 15 days and 29.2 flight hours before the accident that included checking all B-nuts for torque paint to ensure adequate torque remained on the B-nuts. Maintenance personnel likely did not properly inspect the condition of the torque paint on the affected B-nut, which resulted in a disconnection of the B-nut from the FCU and a total loss of engine power.

Factual narrative

On February 23, 2024, about 0740 Pacific standard time, a Bell 47G-3B-1, N2618W, was substantially damaged when it was involved in an accident near Garey, California. The pilot received minor injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. According to the pilot, he was about 5 ft above ground level (agl) at an airspeed of 40 knots conducting an aerial application of fungicide on a field when he then initiated a climb to clear a set of power lines. As he increased power for the climb, he noticed the engine out/low rotor audible warning and the engine simultaneously exhibited a loss of power. He performed an autorotation to an off-airport site. During the autorotation the helicopter entered an uncommanded roll to the left. Despite his control inputs, the pilot was unable to arrest the roll and the helicopter impacted terrain in a nose-down, left-side-low attitude. The helicopter came to rest on its right side with substantial damage to the tailboom and main rotor system. Postaccident examination of the airframe revealed the fuselage exhibited impact damage to the right side. The right skid fractured at the struts and separated from the fuselage. The bubble canopy fractured and separated from the fuselage. The tailboom exhibited a fracture and separation consistent with impact from the main rotor blades. Postaccident examination revealed the engine remained secured to the airframe by the mounts. Manual rotation of the main engine driveshaft resulted in the rotation of the stage four turbine wheel, confirming continuity of the N2 drivetrain. Motoring the engine by the starter generator resulted in smooth rotation of the compressor rotor, confirming continuity of the N1 drivetrain. Engine control continuity was confirmed from the throttle to the fuel control unit. All engine oil and fuel lines were found secured with all B-nuts being at least hand tight and with no evidence of leakage. A check of the pneumatic system by application of about 25 psi of air pressure at the Pc filter resulted in the detection of minor air leakage at both B-nuts on both ends of the accumulator and a large leak at the PTG to FCU Pc input line. Closer examination revealed the B-nut had no thread engagement and had slid aft down the Pc line, as shown in figure 1. The input union on the FCU exhibited evidence of green colored torque paint that was similar in color to the other B-nuts and inputs on the FCU. Figure 1. Image of the accident fuel control, showing the B-nut, the flared end of the Pc line, and the threads of the attachment fitting of the fuel control. According to Rolls-Royce, the engine manufacturer, the Pc line connecting the PTG to the FCU is the third of three Pc lines in the system. Pc air is the power supply or motive force that allows the fuel control to modulate fuel delivered to the engine fuel nozzle. With this line disconnected, the engine would reduce power to an unpowered static-stateor sub-idle condition. Further examination of the fuel control, fuel governor, and fuel nozzle revealed normal operation. No other preaccident mechanical malfunctions or failures with the engine or airframe were found that would have precluded normal operation. According to maintenance records, on June 23, 2023, the fuel control was installed on the accident engine along with several other engine components, including the fuel pump, governor, fuel nozzle, bleed control assembly, and a tachometer generator. On February 8, 2024, about 15 days before the accident, at a Hobbs time of 902.5, a maintenance facility completed the 150-hour/300-hour engine inspections, along with several airframe inspections. According to the Rolls-Royce Alternate Inspection Schedule, the 150/300-hour inspection states, in part, “Inspect all B-nuts for application and alignment of torque paint. If missing, loosen the B-nut, retighten, and apply torque paint.” The Hobbs meter at the time of the accident read 931.7. The maintenance technician who signed off the work did not recall the specifics of the annual inspection conducted on February 8, 2024, as he did several inspections during the shift, but did report the use of the checklists for each inspection. Rolls-Royce released commercial service letter (CSL) 2373 that addressed a special tool to access the subject B-nut. The CSL provides details on how to manufacture the tool locally and the tool is also available for purchase.

Aircraft

Registration
N2618W
Reported as
Bell 47G-3B-1
Category
Helicopter
Serial number
6580
Built
1966
Airframe hours
12,450.7
Engine
Rolls-Royce 250 SERIES, 420 horsepower, turbo shaft
Damage
Substantial damage
Flight
Aerial application · Part 137
Operator
English Air Service LLC
Registered owner
English Air Service LLC
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · February 8, 2024
Departed
SMX · Santa Maria, CA
Flight plan
Company VFR
Airport
SMX · Santa Maria
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
63
Injuries
Minor
Certificate
Commercial
Instrument ratings
Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
April 2, 2022
Seat
Left
Restraint
4-point
Flight hours
15,000 total · 15,000 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
9 statute miles
Lowest ceiling
20,000 ft broken
Temperature
46 °F, dew point 45 °F
Altimeter
30.08 inHg
Observed at
KSMX, 6 nm away
METAR
KSMX 231551Z 00000KT 9SM BKN200 08/07 A3008 RMK AO2 SLP191 T00780072

Docket · 8

The files NTSB released with the investigation on July 23, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 15.2 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.