N395AE

Substantial
None

Bell 206S/N: 45551

Accident Details

Date
Monday, April 15, 2019
NTSB Number
ERA19LA152
Location
Dublin, GA
Event ID
20190415X92143
Coordinates
32.000000, -82.000000
Aircraft Damage
Substantial
Highest Injury
None
Fatalities
0
Serious Injuries
0
Minor Injuries
0
Uninjured
3
Total Aboard
3

Probable Cause and Findings

A partial loss of engine power on takeoff due to separation of the diffuser assembly as a result of incomplete braze joint surfaces on the vane airfoils.

Aircraft Information

Registration
Make
BELL
Serial Number
45551
Engine Type
Turbo-shaft
Model / ICAO
206B06
Aircraft Type
Rotorcraft
No. of Engines
1
Seats
7
FAA Model
206L-1

Registered Owner (Current)

Name
AIR EVAC EMS INC
Address
1001 BOARDWALK SPRINGS PL STE 250
City
O FALLON
State / Zip Code
MO 63368-4100
Country
United States

Analysis

On April 15, 2019, at 0351 eastern daylight time, a Bell 206-L1+ helicopter, N395AE, sustained substantial damage when it was involved in an accident near Fairview Park Hospital Heliport (48GA), Dublin, Georgia. The pilot, flight nurse, and paramedic were not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 135 emergency medical services flight.

The pilot stated that the purpose of the flight was to pick up a patient in Macon, Georgia, for transfer to a hospital in Augusta, Georgia. He said he completed a preflight inspection, and the engine start was normal. Once the preflight checklists were completed, the pilot applied power and pulled the helicopter into a hover. He then turned the helicopter into the wind and prepared to make an "altitude over airspeed" takeoff. The pilot completed a power check with a torque reading of 74.8% then used about 86% torque to accomplish the altitude over airspeed takeoff to clear obstacles. As the helicopter started to accelerate forward and gain climbout airspeed, the pilot heard a loud report from the engine deck area. The engine then made a "clicking" noise that he described as sounding like paper on fan blades. The pilot said the helicopter immediately began to descend then hit the ground and bounced. It traveled to the right before it came to rest upright. The pilot rolled the throttle to idle and shut down the engine.

A postaccident examination of the helicopter revealed the vertical fin was separated by contact with the main rotor blades and the skids were spread. Fuel samples taken from the helicopter were absent of debris and water, and there were no obvious signs of foreign debris in the engine intake area.

Examination of the Rolls Royce M250-C30P engine revealed no obvious mechanical anomalies. It was placed on a test stand to be run. The engine did not start on the first two attempts. The fuel nozzle was removed, inspected, and then reinstalled. Another start was attempted, and the engine started. Once the engine was stabilized at idle it, was observed to run at a higher temperature than normal and the test run was stopped. The compressor module was then disassembled, and the diffuser was found separated into two sections, exposing the vanes (whereas these components are normally brazed together as one piece). The braze joints from the event engine were no longer securing the forward annular plate to the remainder of the diffuser.

Metallurgical examination of the separated plate and ring section was conducted by the National Transportation Safety Board's Materials Laboratory. The examination revealed that the ring section separated through the braze joint at the forward interfaces of the vanes. Orange paint was observed on the vanes and varied in widths to almost the entire cross-section of the vane airfoil. Braze filler metal buildup was observed along the edges of some of the vanes. A metallurgical cross-section was prepared perpendicularly through several vane airfoils. Gaps were observed at the interface between the braze metal and the airfoil surface. The gaps between the braze metal and the vane surfaces were consistent with incomplete filler metal wetting in the braze joint. The presence of the orange paint on the vane cross-sections indicated areas where the braze metal did not wet the base metal. The separation of the ring from the plate was likely due to the large amount of incomplete braze joint surfaces on the vane airfoils.

The vane assembly was marked with Federal Aviation Administration (FAA) parts manufacturing approval (PMA) number: 23051119AL Rev. F, Serial number: AEC12-070, FAA-PMA Il9D9. A search of the manufacturing history of the diffuser revealed that EXTEX Engineered Products (formally Timken Alcor Aerospace Technologies) sold/shipped the diffuser to Action Aircraft Overhauled Engines (AAEO) in Dallas, Texas, on April 5, 2006. AAEO does not retain work order records longer than 10 years (only required to keep for 2 years), so there was no additional data available. EXTEX also had a 10-year retention policy. As such, any detailed information regarding the manufacturing history of the diffuser was no longer available.

A review of the compressor logbook revealed an entry by AAEO on April 7, 2006, indicating the diffuser, which was zero-timed, was installed in the compressor and sent to Air Evac EMS, Inc. A review of the engine logbook revealed that the diffuser had not been removed/repaired since it was installed. According to the operator, the diffuser had accrued a total of 5,763.1 hours at the time it failed.

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA19LA152