N37AE

Destroyed
Fatal

BELL 206L-1S/N: 45230

Accident Details

Date
Sunday, August 31, 2008
NTSB Number
CHI08FA269
Location
Greensburg, IN
Event ID
20080909X01417
Coordinates
39.332221, -85.620277
Aircraft Damage
Destroyed
Highest Injury
Fatal
Fatalities
3
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
3

Probable Cause and Findings

The in-flight separation of a main rotor blade due to a fatigue failure of the blade spar, rendering the helicopter uncontrollable, and the manufacturer's production of main rotor blades with latent manufacturing defects, which precipitated the fatigue failure of the blade spar.

Aircraft Information

Registration
N37AE
Make
BELL
Serial Number
45230
Engine Type
Turbo-shaft
Model / ICAO
206L-1B06T
Aircraft Type
Rotorcraft
No. of Engines
2

Registered Owner (Historical)

Name
AIR EVAC EMS INC
Address
306 DAVIS DR
Status
Deregistered
City
WEST PLAINS
State / Zip Code
MO 65775-2279
Country
United States

Analysis

HISTORY OF FLIGHT

On August 31, 2008, about 1320 eastern daylight time, a Bell 206L-1 helicopter, N37AE, operated by Air Evac EMS Inc., was destroyed during an in-flight collision with terrain and post impact fire near Greensburg, Indiana. The flight was being conducted under 14 Code of Federal Regulations Part 91 without a flight plan. Visual meteorological conditions prevailed. The pilot, flight nurse, and paramedic sustained fatal injuries. The accident flight departed at 1317 from Burney, Indiana, with the intention of returning to the aircraft's base located in Rushville, Indiana.

The crew had attended a local fund raising event for the Burney fire station in a community support role. No patient transport activity was associated with the flight to the fire station, or with the accident flight. The crew had arrived at the event about 1150 that morning. The return flight lifted off at 1317.

Witnesses reported that the helicopter appeared to depart the fire station without difficulty. One witness recalled seeing the helicopter clear a set of high-tension power lines east of the fire station. Witnesses stated that they subsequently saw components separate from the helicopter before it descended and impacted the ground.

Local authorities from the fire station in Burney responded upon witnessing the accident. One firefighter estimated that they were on-scene within 2 minutes. The helicopter came to rest approximately 1.2 miles north-northeast of the departure point in a cornfield.

PERSONNEL INFORMATION

The accident pilot, age 43, held a Commercial Pilot certificate with rotorcraft helicopter and single-engine land airplane ratings. His certificate also included an instrument rating for both helicopters and airplanes. The airplane rating was limited to private pilot privileges. He was issued a Second-Class Airman medical certificate without limitations or waivers on April 22, 2008.

The accident pilot was hired by the operator on June 14, 2006. His most recent Part 135 checkride was completed on June 10, 2008. The pilot had acquired approximately 5,493 hours total flight time. Of that flight time, about 5,176 hours were in helicopters and 1,915 hours were in the same make and model as the accident aircraft. He had accumulated about 38 hours and 9 hours in the 90-day and 30-day periods prior to the accident, respectively. He had acquired about 419 hours during his tenure with the company.

According to the operator's duty logs, the accident pilot had been scheduled for 12-hour shifts from 0800 until 2000, for a 7-day period beginning on August 25th. The accident occurred on the 7th day of the rotation. He had flown 3.1 hours during that 6-day period, with 1.5 hours flown the previous day. He was off-duty for the 4 days prior to that 7-day assignment.

AIRCRAFT INFORMATION

The accident helicopter, N37AE, was a 1979 Bell Helicopter Textron 206L-1, serial number 45230. It was powered by a Rolls-Royce/Allison Model 250-C30P turbo-shaft engine, serial number CAE-895470. The helicopter was certificated under FAA type certificate H2SW. It was owned and operated by Air Evac EMS Inc in an air medical transport role.

According to the operator's maintenance records, the accident helicopter had accumulated 26,250 hours total flight time as of the day of the accident. The engine had accumulated 11,554 hours, which was comprised of 27,403 start cycles.

The helicopter was maintained under an FAA Approved Aircraft Inspection Program (AAIP). The most recent AAIP phase inspection was completed on August 21, 2008. The inspection consisted of an Event 1 and a 200-Hour procedure as outlined in the AAIP. The airframe time was recorded as 26,243.9 hours, at the time of that inspection. Prior to that, an Event 4 inspection procedure had been accomplished on August 12, 2008, at 26,232.5 hours airframe time.

The records contained a maintenance discrepancy that stated: "While on approach heard (and) felt low rumble (and) vibration from rear of aircraft." The entry was dated August 21, 2008, the same day as the Event 1 and 200-Hour progressive phase inspection. The aircraft time noted was 1.3 hours after the inspection. The resulting maintenance inspection did not reveal any anomalies. A ground run and flight check could not duplicate the write-up, nor did they identify any discrepancies. There was no mention of a similar discrepancy in the maintenance records subsequent to that event.

Maintenance records indicated that the main rotor blades (part number 206-015-001-115, serial numbers A-5165 and A-5168) were installed on the accident helicopter on March 21, 2005. Both blades were new at that time. The aircraft flight time was 23,442 hours at installation. At the time of the accident, the blades had accumulated about 2,808 hours time in service. The blade service life was 3,600 hours.

A review of aircraft discrepancy and maintenance records provided by the operator from January 1, 2008, through the date of the accident, did not reveal any write-ups related to the main rotor blades.

The accident helicopter was based at Rushville, Indiana, which was located about 18 miles north of the accident site.

METEOROLOGICAL INFORMATION

The closest weather reporting facility to the accident site was Columbus Municipal Airport (BAK), which was located approximately 16 miles west-southwest of the accident site. The airport was equipped with an Automated Weather Observing System (AWOS).

At 1250 the BAK AWOS recorded conditions as: Winds from 090 degrees at 9 knots; 10 miles visibility; clear skies; temperature 30 degrees Celsius; and altimeter 30.18 inches of mercury. The dew point was not available.

At 1350, the BAK AWOS recorded conditions as: Winds from 080 degrees at 10 knots; 10 miles visibility; few clouds at 4,000 feet above ground level; temperature 30 degrees Celsius; and altimeter 30.16 inches of mercury. The dew point was not available.

WRECKAGE AND IMPACT INFORMATION

The accident site was located in a cornfield approximately 1.2 miles north-northeast of the departure point. The main wreckage consisted of the fuselage, engine, tail boom, and landing skids. The fuselage was consumed by a post impact fire. The tail boom and landing skids separated from the fuselage. The tail boom was located about 10 feet south of the fuselage, and the skids were located about 10 feet southwest of the fuselage. The main rotor blade/hub assembly separated at the rotor mast and came to rest approximately 220 yards west-southwest of the main wreckage.

The fuselage came to rest nearly inverted. It was oriented on an approximate 317-degree magnetic heading. The cockpit and cabin areas were destroyed by impact forces and the post impact fire. The flight controls were damaged consistent with impact forces. The engine assembly remained secured to the airframe. The transmission separated from the airframe and was located about 194 yards northeast of the main wreckage. Post accident examinations of the engine and transmission did not reveal any anomalies consistent with a pre impact failure.

The main rotor blades remained attached to the hub. One blade was intact. The other blade was fractured into three sections, with the inboard blade section remaining attached to the hub. The two separated blade sections were recovered at the accident site. The outboard section, about 8 feet in length, was recovered approximately 147 yards west-northwest of the main wreckage. The mid-blade section, about 3 feet in length, was recovered approximately 40 yards west-southwest of the main wreckage. The main rotor hub and attached rotor blades had separated from the aircraft. The main rotor mast failed near the lower surface of the hub. The mast was bent in the direction of the failed blade immediately above the point of failure. The mast exhibited indentations matching the teetering stops on the hub. The fracture surface of the main rotor mast exhibited 45-degree shear planes and a course, dull appearance consistent with overload failure. The main rotor blade yokes were intact and the pitch change horns appeared undamaged. The mating pitch change link rod ends remained attached to the horns. The torsion-tension strap was intact.

The tail boom separated from the airframe approximately 12 inches aft of the tail boom to fuselage attachment. A linear indentation was observed on the left side of the tail boom forward of the horizontal stabilizer. The left horizontal stabilizer was separated from the tail boom near the root consistent with a main rotor blade strike. It was recovered about 212 yards south of the main wreckage. The right horizontal and vertical fin stabilizers remained attached to the tail boom.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy of the pilot was performed by the Marion County Coroner's Office, Indianapolis, Indiana, on September 2, 2008. The cause of death was attributed to multiple blunt force trauma sustained in the accident.

A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute. The results were negative for all substances tested.

COMPANY INFORMATION

Air Evac EMS, LLC, dba Air Evac Lifeteam, was a commercial on-demand air taxi operator, which was authorized to conduct Part 135 visual flight rules (VFR) day and night operations. The company provided medical air transportation services from a total of 82 bases over 13 states. The company employed approximately 350 pilots and 106 mechanics. The company operated approximately 100 aircraft, including Bell 206 series and Bell 407 helicopters

Air Evac utilized an FAA approved pilot training program that addressed new hire, initial aircraft, recurrent, re-qualification, transition, and upgrade training. Training activity was monitored by the Chief Pilot and Director of Operations in order to insure compliance with company requirements and FAA regulations. The accident pilot had previously completed all required training at the time of the accid...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CHI08FA269