Friday, May 12, 2017

Federal Aviation Administration investigation warned of 'potential tragedies'

This photo shows the part of the tail on an Allegiant MD-83 where a rod connects the elevator to the pilot's flight controls. The rod is supposed to be secured in the connecting space by a nut and a cotter pin, but a Federal Aviation Administration investigation found that errors by workers at AAR Aircraft Services led to the rod working its way free in August 2015, forcing an aborted takeoff.



Before the jet's pilots nearly lost control of their plane as it hurtled down a Las Vegas runway, it flew for weeks with a problem that could have killed everyone on board.

It never should have happened, according to a report by the Federal Aviation Administration inspector who reviewed the August 2015 incident.

AAR Aircraft Services, part of North America's largest aviation maintenance company, had improperly recorded its work, skipped maintenance steps and bungled critical inspections on the Allegiant Air plane, he found.

"Every stop gap in place to enhance safety to a critical flight control was skipped, bypassed or improperly done," the inspector, Carlos Flores, wrote in the FAA's official report on the incident.

Flores recommended that the FAA fine AAR the maximum amount it could, to prevent "potential tragedies" in the future.

FAA managers reviewed the investigation and decided to handle the situation differently.

They didn't fine the company.

They didn't demand any additional changes at AAR, even though one acknowledged Flores' belief that "the conditions that created the safety risk originally" hadn't changed.

They didn't assign anyone to investigate further.

Instead, they wrote AAR a "letter of correction" and signed off on the fixes it had already put in place.

Then they closed the case, and told the public the problem had been solved, a Tampa Bay Times review of the FAA's full investigative file shows.

AAR continues to be a major maintenance contractor for Allegiant and other large airlines.

Today, FAA officials say they made the right call. FAA spokesman Ian Gregor said in a statement that "inspectors and managers from several offices in the FAA safety oversight division agreed that AAR Aircraft Services took the appropriate actions to correct the root cause of the incident."

But two former FAA officials who reviewed the full investigation at the Times' request said Flores' findings were alarming and should have triggered a larger investigation into AAR.

"It's really disturbing from a safety perspective," said Loretta Alkalay, an aviation attorney who spent 30 years as a regional counsel prosecuting enforcement cases for the FAA.

AAR spokeswoman Kathleen Cantillon said it "is fully compliant with FAA requirements."

"AAR's first priority is safety of flight," she said in a statement. "We have worked closely with Allegiant and the FAA to take corrective actions."

Gregor said the agency "thoroughly reviewed" AAR's procedures when it performed a "wide-ranging review of Allegiant's operations" in spring 2016.

"The FAA and Allegiant continue to closely monitor AAR's operations," he said.




Allegiant Air, which operates the vast majority of flights at St. Pete-Clearwater International Airport, declined to comment.

The FAA never intended for the full results of its investigation to become public.

Last year, the Times published an investigation showing Allegiant's planes were four times as likely to fail during flight as those operated by other major U.S. airlines, and another that focused on FAA's lax oversight of Allegiant.

The Times first requested the FAA's investigative file while reporting those stories. The FAA provided a version of the report that was heavily redacted, hiding Flores' concern that the Las Vegas incident was a symptom of a dangerous, ongoing problem.

The Times appealed. The FAA responded last week and declined to release most of the redacted information.

But along with its response, the agency accidentally sent the Times the entire unredacted report.

[Click to read the full report]

• • •

On August 17, 2015, Allegiant Flight 436 rolled down a Las Vegas runway. As the plane picked up speed, its nose started rising, even as the pilots pushed the yoke all the way down. At about 138 miles per hour, the captain aborted the takeoff and the plane screeched to a halt.

When Allegiant mechanics inspected the plane, it was clear what had gone wrong.

A nut had slipped off the rod that connects the plane's controls to its elevators — flaps on the plane's tail that controls its pitch. A cotter pin on the rod should have kept the nut in place, but there was no evidence it had been installed when the plane went in for maintenance at an AAR repair facility in Oklahoma City three months before.

If the plane had made it off the ground — or the nut had slipped off in flight — the pilots would have lost control in the air.

The FAA assigned Flores, one of its senior inspectors overseeing Allegiant, to lead the investigation.

About six months later, the FAA said that employees at AAR working on the Allegiant plane had missed steps and improperly documented their work when installing one of the elevators.

But AAR had made changes since the incident, the FAA said. Where two inspectors had failed to notice the botched maintenance, the company added a third inspector. Workers would only be allowed to work on critical parts of the plane after watching a safety video.

The fixes were "appropriate and sufficient to prevent future violations of this nature," Gregor said.

The heavily redacted investigation detailed several mistakes by mechanics at AAR, but didn't detail systemic issues.

But underneath the blackouts, the report said the FAA's investigator did not believe AAR's changes would keep the problem from happening again.

A thorough audit of the plane's paperwork by Allegiant could have caught the problem, Flores wrote.

But he singled out AAR's employees for "egregious complacent behavior" that led to the incident.

Mechanics didn't fill out required maintenance logs, and technicians either skipped inspections or did them so superficially it defeated the point of the inspections altogether.

He chronicled five separate times AAR employees should have caught the flaw before the plane left the station. But over and over, required paperwork proving the maintenance had been done was missing.

It added up to "careless (and possibly reckless) conduct" by AAR, he wrote — "deliberate and systemic acts of noncompliance" with Allegiant's maintenance procedures and federal aviation rules.

"They are clearly a repeat offender that show an unwillingness to admit errors unless it will not cost the company money," he wrote.

• • •

Government watchdogs have been warning for years that the FAA's oversight of repair stations like the one in Oklahoma City is lacking.

In 2013, the Department of Transportation's Office of Inspector General released an audit that said the agency wasn't catching and fixing serious problems at repair stations. In one case it cited, an FAA inspector noted the same infraction at the same repair station three years in a row, but accepted the same fix for the problem all three times.

U.S. airlines are only becoming more dependent on outsourced maintenance, an industry that the watchdog office estimated had more than tripled in less than two decades.

According to AAR's spokeswoman, the company "has performed over 24 million man hours of maintenance work on aircraft for dozens of airlines" over the last five years.

The station in Oklahoma City works on 17 air carriers, including Alaska Air. In Indianapolis an AAR station does maintenance on Delta Air Lines' jets. And before U.S. Airways merged with American, it sent planes to AAR's station in Miami.

AAR's parent company also pulls in billions of dollars of federal taxpayer money for services that include aircraft maintenance, aircraft leasing and airlift services. In September, less than a year after the FAA finalized its investigation, it won a $10 billion, 11.5 year contract to maintain the fleet of aircraft the State Department uses to combat international narcotics trafficking.

• • •

Flores submitted his report in November 2015. It landed on the desk of David Ibarra, a technical specialist based out of the FAA's regional office in Van Nuys, Calif. He was responsible for recommending the agency's next course of action.

He acknowledged Flores' concerns, but recommended against fining the company.

Ibarra's decision relied on the agency's "new compliance philosophy," which the FAA introduced in 2015. It encourages airlines and their employees to report safety problems by punishing them less harshly after mistakes.

"Our evolved approach to oversight does not suggest that we are going easy on compliance," the FAA's website says about the policy. "However, FAA will not use enforcement as the first tool in the toolbox."

This was not, however, the first time these issues had come up at AAR.

In 2014, another Allegiant plane went in for service at an AAR repair station. But a day after it was returned to Allegiant, its right engine flooded with fuel on takeoff, causing it to rev uncontrollably. The pilot had to shut it down and make an emergency landing back at the airport.

The investigation into that incident concluded an AAR mechanic had skipped maintenance steps, and neither Allegiant nor AAR's inspectors noticed before the plane returned to service.

After the Las Vegas incident, Flores noted that AAR "had two very similar situations that risked lives and property within a one year period, only to find the corrective action by the repair station had no effect."

The FAA declined to answer questions about its decision to not sanction AAR. Flores declined to comment.

But former FAA inspector Mary Rose Diefenderfer said the FAA should have fined the company, based on its own policies, and that the agency could have gone as far as revoking its certificate to operate.

AAR "should have been at least temporarily shut down while an FAA white-glove team came in to investigate," she said. "That would have occurred if blood had been shed, but it's the FAA way not to be proactive."

Click to read the full report

Original article can be found here:   http://www.tampabay.com

Williamsport Regional Airport (KIPT) authority has no comment

Passengers exit a plane at Williamsport Regional Airport south of Montoursville, Pennsylvania.



The Williamsport Regional Airport Authority declined to comment during its Thursday evening meeting on why the Lycoming County commissioners are holding a bill payment for the airport’s new terminal project.

Tom Hart, executive director for the airport, said a meeting is set with the commissioners later this month to discuss the bill, but so far neither he nor the authority have been told the reason the bill was withheld.

During their Tuesday morning meeting, the commissioners broke for a private session and when they returned voted not to pay the $82,113 bill to the airport, citing legal reasons. According to Hart, the bill would have been for engineering or architectural fees related to the terminal.

At the Thursday morning meeting, Commissioner Jack McKernan said the bill would “remain in a ‘on hold’ position at this time.” He and the rest of the commissioners declined to offer further comment.

The total terminal project is estimated at roughly $16.5 million, and in October the commissioners voted to provide a local match of $2 million to the project. The funds are provided incrementally as the authority submits its bills for reimbursement pending a review by the county.

On April 13, the authority awarded contracts to four bidders for different sections of the project.

The construction of the terminal, at $7.9 million, was awarded to Lobar Inc. Construction Services, Dillsburg, but with a local office at 565 Beautys Run Road, Cogan Station. During their Thursday morning meeting, the commissioners said they began litigation with Lobar a few months prior over a project Lobar did for the county landfill, which the landfill claims was not completed to the contract’s specifications.

Matt McDermott, director of administration for the county, said the litigation with Lobar has nothing to do with the commissioner’s decision to withhold the bill for the terminal.

Three other contracts for the terminal went to LTS Plumbing and Heating, at $476,000 for plumbing; Master Mechanical, at $1.9 million, for heating, ventilating and air conditioning; and Tra Electric, at $1.9 million, for electrical work.

In other business, the authority approved bid advertising for a new project to relocate an electrical control vault on the airport property. Hart said the project is federally funded and while it was previously awarded to Tra Electric, it must now be rebid because Tra was unable to stay within the bid requirements due to rate increases from the time the bid originally was awarded.

The authority also approved three payments for its ongoing project to lower the flight minimums for aircraft approaching the runway. The payments were for general construction and electric to Glenn O Hawbaker, at $121,145, and Bronder Technical Services at $134,785.

The next authority meeting will be at 7:30 a.m. June 7.

The authority members present were Christopher Logue, Atwood Welker, Frank Pellegrino, Rebecca Burke and state Rep. Garth Everett, R-Muncy. Ryan M.Tira and William Martin were absent.

Original article can be found here:   http://www.sungazette.com

Champion 7EC, N9089B, PF Flyers Inc: Incident occurred May 11, 2017 at Wittman Regional Airport (KOSH), Oshkosh, Winnebago County, Wisconsin

Federal Aviation Administration / Flight Standards District Office; Milwaukee, Wisconsin 

PF Flyers Inc: http://registry.faa.gov/N9089B

Aircraft on landing, ground looped.  

Date: 11-MAY-17
Time: 21:20:00Z
Regis#: N9089B
Aircraft Make: CHAMPION
Aircraft Model: 7EC
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: UNKNOWN
Flight Phase: LANDING (LDG)
City: OSHKOSH
State: WISCONSIN

Lancair 320, N320AG: Incident occurred May 10, 2017 at Blanding Municipal Airport (KBDG), San Juan County, Utah

Federal Aviation Administration / Flight Standards District Office; Salt Lake City, Utah 

http://registry.faa.gov/N320AG

Aircraft force landed on runway.

Date: 10-MAY-17
Time: 20:50:00Z
Regis#: N320AG
Aircraft Make: LANCAIR
Aircraft Model: LANCAIR 320
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: UNKNOWN
Flight Phase: LANDING (LDG)
City: BLANDING
State: UTAH

Boeing 737, C-GWCM, WestJet, flight WJA1200: Incident occurred May 11, 2017 at LaGuardia Airport (KLGA), New York

Federal Aviation Administration / Flight Standards District Office; New York

Canadian registered aircraft on taxi. Wing clipped the wing of a passing aircraft, N867RW E170 RPA5899.  No injuries. Damage minor.  

Date: 11-MAY-17
Time: 12:35:00Z
Regis#: CGWCM
Aircraft Make: BOEING
Aircraft Model: B737
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: MINOR
Activity: COMMERCIAL
Flight Phase: TAXI (TXI)
Aircraft Operator: WESTJET
Flight Number: WJA1200
FAA FSDO: NEW YORK
City: NEW YORK
State: NEW YORK

Beechcraft Baron BE55, N711FA: Incident occurred May 10, 2017 in Jackson County, Michigan

Federal Aviation Administration / Flight Standards District Office; Grand Rapids, Michigan 

http://registry.faa.gov/=N711FA

Aircraft on approach, struck a bird and sustained unknown damage. Landed without incident.  

Date: 10-MAY-17
Time: 20:30:00Z
Regis#: N711FA
Aircraft Make: BEECH
Aircraft Model: BE55
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: UNKNOWN
Flight Phase: LANDING (LDG)
City: JACKSON
State: MICHIGAN

Zenair CH-601 HDS Zodiac, N1041N: Accident occurred May 11, 2017 in Orangeville, Stephenson County, Illinois

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Dupage, Illinois

Aviation Accident Preliminary Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
  
http://registry.faa.gov/N1041N

NTSB Identification: CEN17LA180
14 CFR Part 91: General Aviation
Accident occurred Thursday, May 11, 2017 in Orangeville, IL
Aircraft: BROKAW BERGON F ZODIAC, registration: N1041N
Injuries: 1 Serious.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On May 11, 2017, about 1945 central daylight time, a Brokaw Bergon Zodiac airplane, N1041N conducted a forced landing near Orangeville, Illinois. The private rated pilot received serious injuries and the airplane was substantially damaged. The airplane was registered to and operated by a private individual under the provisions of the 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time. 

Initial information from the responding Federal Aviation Administration (FAA) inspector, indicated the pilot was on a return flight. During cruise, the engine lost power, and the pilot selected a hay field for the forced landing. The airplane landed hard and came to rest up right. The inspector noted substantial damage to the airplane's fuselage and fuel was present on site. 

The airplane was retained for further examination.

ORANGEVILLE, Illinois - An Orangeville man is recovering from non-life threatening injuries after force landing his plane.

The Stephenson County Sheriff's Office says Mark Baker was flying a Zenair CH-601 HDS Zodiac when the engine loss power Thursday just before 8:00 P.M. 

Baker landed the plane in a field west of 12977 North Hogback Road in Orangeville. 

Baker was taken to Monroe Clinic and treated for his injuries.

Rans S6S, N922DN: Accident occurred May 11, 2017 at Frasca Field Airport (C16), Urbana, Champaign County, Illinois

Federal Aviation Administration / Flight Standards District Office; Springfield, Illinois 

http://registry.faa.gov/N922DN

Aircraft stopped on taxiway. The one (1) person on board sustained serious injuries under unknown circumstances.  

Date: 11-MAY-17
Time: 00:50:00Z
Regis#: N922DN
Aircraft Make: RANS
Aircraft Model: S6S
Event Type: ACCIDENT
Highest Injury: SERIOUS
Aircraft Missing: No
Damage: UNKNOWN
Activity: UNKNOWN
Flight Phase: TAXI (TXI)
City: URBANA
State: ILLINOIS

Cirrus SR22T, N941CS, Ascension Air Management Inc: Incident occurred May 10, 2017 at Florida Keys Marathon International Airport (KMTH), Monroe County, Florida



Federal Aviation Administration / Flight Standards District Office; Fort Lauderdale, Florida 

Ascension Air Management Inc: http://registry.faa.gov/N941CS

Aircraft on landing, nose gear collapsed.

Date: 10-MAY-17
Time: 17:10:00Z
Regis#: N941CS
Aircraft Make: CIRRUS
Aircraft Model: SR22
Event Type: INCIDENT
Highest Injury: NONE
Aircraft Missing: No
Damage: UNKNOWN
Activity: UNKNOWN
Flight Phase: LANDING (LDG)
City: MARATHON
State: FLORIDA 





MARATHON, Fla. - A small airplane's nose gear collapsed Thursday afternoon while it was landing in Marathon.

The incident was reported at 1:10 p.m. at Florida Keys Marathon International Airport.

Monroe County spokeswoman Cammy Clark said two people were aboard the Cirrus SR22T. 

The pilot was identified as Steven Toffler, 53, and his passenger was identified as Diane Toffler, 49.

Neither were injured in the landing.

Clark said the plane and debris were removed from the runway, which reopened at 2 p.m.

She said four international arrival flights circle the airport until they were permitted to land.

Story and photo gallery:  https://www.local10.com

Piper PA-18-135, N1258C: Accidents occurred May 11, 2017 and May 21, 2016 in Seward, Alaska

Federal Aviation Administration / Flight Standards District Office; Anchorage, Alaska 

http://registry.faa.gov/N1258C

NTSB Identification: GAA17CA275
14 CFR Part 91: General Aviation
Accident occurred Thursday, May 11, 2017 in Seward, AK
Aircraft: PIPER PA18, registration: N1258C

NTSB investigators will use data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator, and will not travel in support of this investigation to prepare this aircraft accident report.

Aircraft during taxi, sustained substantial damage.  

Date: 11-MAY-17
Time: 20:55:00Z
Regis#: N1258C
Aircraft Make: PIPER
Aircraft Model: PA18
Event Type: ACCIDENT
Highest Injury: MINOR
Aircraft Missing: No
Damage: SUBSTANTIAL
Activity: UNKNOWN
Flight Phase: TAXI (TXI)
City: SEWARD
State: ALASKA

Additional Participating Entity: 
Federal Aviation Administration / Flight Standards District Office; Anchorage, Alaska 

Aviation Accident Final Report - National Transportation Safety Board: http://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: http://dms.ntsb.gov/pubdms

Aviation Accident Data Summary - National Transportation Safety Board: http://app.ntsb.gov/pdf

http://registry.faa.gov/N1258C

NTSB Identification: GAA16CA264
14 CFR Part 91: General Aviation
Accident occurred Saturday, May 21, 2016 in Seward, AK
Probable Cause Approval Date: 08/03/2016
Aircraft: PIPER PA18, registration: N1258C
Injuries: 2 Uninjured.

NTSB investigators used data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator and did not travel in support of this investigation to prepare this aircraft accident report.

The flight instructor reported that during an instructional flight, while on short final, the headwind dissipated and the airplane started to slow and sink. He instructed the pilot receiving instruction in the front seat to add power, but she did not complete the action immediately. After realizing the action was not complete the flight instructor added full power, but the airplane continued to descend at an accelerated rate and touched down hard upon landing. Subsequently, the main landing gear collapsed and the fuselage was substantially damaged. 

The flight instructor did not report any mechanical malfunctions or failures with the airplane that would have precluded normal operation.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot receiving instruction's failure to maintain proper airspeed and descent rate, and the flight instructor's delayed remedial action during the landing flare, which resulted in a hard landing and landing gear collapse.

Fairchild Hiller FH-1100, N4035G, Helicopter Connection LLC: Fatal accident occurred October 06, 2016 in Lino Lakes, Anoka County, Minnesota

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

NTSB Identification: CEN17FA012
14 CFR Part 91: General Aviation
Accident occurred Thursday, October 06, 2016 in Lino Lakes, MN
Probable Cause Approval Date: 05/16/2017
Aircraft: FAIRCHILD HILLER FH 1100, registration: N4035G
Injuries: 2 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The airline transport pilot was conducting a local flight with one passenger. The accident flight was the pilot's third flight in the helicopter on the day of the accident; before that day, he had not flown the helicopter in nearly one year. One witness stated that he saw the helicopter rocking back and forth before it "spun sideways" and "a bunch of parts" departed the airframe. Some reported hearing a "clunk" sound, and others reported hearing a "pop" sound. Another witness saw the main rotor blades "seize," then "snap off," followed by the tail rotor departing the helicopter. The witness stated that the helicopter then "dropped out of the sky." The fuselage impacted in an open field, and a postcrash fire erupted. The separated main rotor blades and hub were found in a pond about 500 ft south of the main wreckage.

Examination of the rotor mast showed deformation and fractures consistent with overstress under bending and torsion loads but no evidence of preexisting cracks or corrosion. The observed deformation of the mast was consistent with a mast bumping event. Mast bumping can occur in low acceleration of gravity (G) flight conditions, causing the rotor blade to exceed its flapping limits and resulting in the main rotor hub bumping into the rotor shaft. This often results in structural failure of the rotor shaft and a subsequent separation of the main rotor.

Due to the extensive thermal damage to the wreckage, only a limited examination could be conducted; however, no mechanical malfunctions or anomalies were noted that would have precluded normal operation.

The pilot had accumulated about 15,000 flight hours in airplanes but only had about 55 hours flight time in helicopters, most of which were accumulated more than 1 year before the accident. Although the pilot had received instruction on how to avoid mast bumping, given his low helicopter experience relative to his airplane experience, it is possible that he made a large, abrupt flight control input that resulted in a low-G flight condition and led to the observed mast bumping. However, the pilot's control inputs are unknown, and the initiating event for the mast bumping could not be determined.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The separation of the main rotor assembly due to mast bumping.

Deborah J. 'Deb' (Swanson) Smith

 
Matthew Gerald Hayes


The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Minneapolis, Minnesota 
Rolls Royce; Indianapolis, Indiana 

Aviation Accident Factual Report- National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board:   https://dms.ntsb.gov/pubdms

Helicopter Connection LLC: http://registry.faa.gov/N4035G



NTSB Identification: CEN17FA012 

14 CFR Part 91: General Aviation
Accident occurred Thursday, October 06, 2016 in Lino Lakes, MN
Aircraft: FAIRCHILD HILLER FH 1100, registration: N4035G
Injuries: 2 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

HISTORY OF FLIGHT

On October 6, 2016, about 1645 central daylight time, a Fairchild Hiller FH-1100 helicopter, N4035G, was destroyed when it impacted the ground near Lino Lakes, Minnesota, following an in-flight separation of the main rotor assembly. The airline transport pilot and passenger sustained fatal injuries, and the helicopter was destroyed. The helicopter was registered to Helicopter Connection LLC, and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as personal flight. Day visual meteorological conditions prevailed, and no flight plan was filed for the local flight, which originated from the Anoka County-Blaine Airport (ANE), near Minneapolis, Minnesota, about 1620.

According to a pilot-rated passenger who had flown with the accident pilot in the helicopter earlier in the day, the accident pilot had not flown the helicopter for about a year and wanted the passenger to "ride along" as a safety pilot. Both the pilot and passenger performed a preflight inspection of the helicopter, which revealed no anomalies. About 1000, they departed on a 5-minute flight then returned and went to lunch. After lunch, they departed on a local flight, which lasted about 45 minutes. After the flight, the passenger asked the pilot if he wanted help moving the helicopter into the hangar, and the pilot indicated that he may fly the helicopter later.

Later that day, several witnesses saw the helicopter flying in a northerly direction. One witness stated that he observed the helicopter rocking back and forth before it "spun sideways" and "a bunch of parts" departed the helicopter. Some reported hearing a "clunk" sound, and others reported hearing a "pop" sound. One witness saw the main rotor blades "seize," then "snap off," followed by the tail rotor departing the helicopter. The witness stated that the helicopter then "dropped out of the sky." Several of the witnesses saw parts departing the helicopter as it descended to ground contact.

PERSONNEL INFORMATION

The 48-year-old pilot held an airline transport pilot certificate with an airplane multi-engine land rating. He held commercial pilot privileges in airplane single engine land, airplane single engine sea, and rotorcraft-helicopter. The pilot also held a flight instructor certificate with airplane single- and multi-engine and instrument airplane ratings. He held a flight engineer certificate with a turbojet rating. The pilot held a Federal Aviation Administration (FAA) special issuance first class medical certificate, dated August 16, 2016, with limitations for corrective lenses and not valid for any class after February 28, 2017. The pilot reported that he had accumulated 15,000 total hours of flight time and 400 hours of flight time during the six months before the medical exam. The last entry in the pilot's logbook was dated September 4, 2015, which was the date he passed his commercial rotorcraft-helicopter checkride. The pilot accumulated 55.5 hours of total flight experience in helicopters at the time of that entry, of which about 38 hours were in the accident helicopter make and model.

The pilot's helicopter flight instructor reported that, from April 15, 2015, to August 4, 2015, he provided instruction to the pilot in the accident helicopter to prepare him for his checkride to obtain a rotorcraft-helicopter rating. The flight instructor stated that the pilot had some trouble at first in the transition from fixed wing to helicopter and that this is fairly common for high-time fixed-wing pilots, such as the accident pilot. After some time, the accident pilot seemed to handle the transition as well as any other of his students that had previous fixed-wing time.

The instructor stated that he gave the pilot ground instruction on teetering rotor systems. When asked how the pilot responded during training situations that could precipitate mast bumping, the instructor stated that the pilot responded correctly to flight in turbulent conditions. He added that, during power loss simulations, the pilot initially was slow to lower the collective and would allow the nose to drop. Eventually, the pilot demonstrated proper entry into and proficiency in autorotations.

The pilot's helicopter flight instructor reported that all the instruction he provided to the pilot took place near Lake Charles, Louisiana, and, after passing his rotorcraft-helicopter checkride, the pilot trailered the helicopter to the Minneapolis area. During the trip, one of the doors of the helicopter came open and cracked the windshield of the helicopter. According to the flight instructor, the pilot had just completed replacement of the windshield a short time before the accident.

AIRCRAFT INFORMATION

The accident helicopter was issued an FAA standard airworthiness certificate on October 20, 1982, and was certificated for normal category operations. The Allison (Rolls Royce) model M250-C20B engine powered a two-bladed, teetering main rotor system. The engine manufacturer indicated that the rated horsepower for the M250-C20B engine is 420 shaft horsepower. According to the helicopter's type certificate data sheet, the engine had a takeoff power rating of 274 shaft horsepower (hp) for a maximum of 5 minutes, and a maximum continuous power rating of 233 shaft hp. The helicopter had a maximum gross weight of 2,750 lbs and could be configured to accommodate a pilot, another pilot or passenger in the cockpit, and three passengers in the cabin. The helicopter's flight manual had limitations to prohibit acrobatic flight and to avoid abrupt control movements when flying in turbulence. The helicopter's most recent annual inspection was completed on June 18, 2015, at a total time in service of 501.7 hours.

In January 2004, the helicopter manufacturer issued Alert Service Letter 23 - 5. The letter indicated that several instances of internal and external mast corrosion had been discovered even when the mast was properly sealed. The corrective action was to remove the transmission top case, with the mast attached, and ship the assembly to the factory for non-destructive inspections. A special coating was to be applied on the interior surfaces. This process is only approved at the factory and cannot be performed in the field. Subsequent to the initial inspection, this process must be done at each overhaul of the transmission or every 10 years whichever comes first.

METEOROLOGICAL INFORMATION

At 1645, the recorded weather at ANE, about 4 miles southwest of the accident site, included wind from 010° at 6 knots, visibility 10 statute miles, overcast clouds at 6,000 feet; temperature 15°C, dew point 6°C, and an altimeter of 29.95 inches of mercury.



WRECKAGE AND IMPACT INFORMATION

The main wreckage came to rest on its right side about 4 nautical miles and 52° magnetic from ANE, on a heading about 20° magnetic. The area around the main wreckage was discolored and charred, consistent with a postaccident ground fire. The remaining sections of wreckage did not exhibit any evidence of pre- or postimpact fire.

The initial piece of wreckage was a section of composite material located about 1,675 ft south of the main wreckage. A debris path extended to the main wreckage and contained the floor mats, a section of white interior material, an exhaust stack, exhaust duct, a section of the tailboom, the engine cowl, a section of exterior metal with the rotating beacon, a seat cushion, and a section of the tail, including the tail rotor and its gearbox. The separated main rotor blades and hub were found east of this debris path in a pond about 500 ft south of the main wreckage. All major components were accounted for at the scene.

The main wreckage, consisting of the cockpit and cabin, was destroyed by impact and postimpact fire. Cyclic, collective, and tail rotor control continuity could not be established due to substantial damage to the cockpit and cabin areas. However, all observed control discontinuities were consistent with overload or thermal damage.

The engine, transmission, and tail rotor driveshafts exhibited separations. All observed separations were consistent with torsional overload and overload. Circumferential witness marks were observed on the exterior of the tail rotor driveshaft.

The main transmission exhibited sections with thermal melting damage, soot-colored discoloration, and deformation. The separation surface at the top of the mast exhibited overload fractures. The mast could not be rotated by hand.

The main rotor blades and hub exhibited overload fractures on the separation surface. Examination of the main rotor system and components found outside the main wreckage site did not exhibit soot colored discoloration or thermal damage.

Examination of the engine revealed that several compressor blades were missing. The remaining compressor blades were found bent opposite the direction of rotation.

A section of the transmission's main rotor mast and the section of mast from the main rotor hub were removed and were sent to the National Transportation Safety Board (NTSB) Materials Laboratory for detailed examination.

MEDICAL AND PATHOLOGICAL INFORMATION

An Anoka County Coroner arranged for the Midwest Medical Examiner's Office, Ramsey, Minnesota, to conduct an autopsy on the pilot. Toxicological samples were taken during the autopsy. The cause of death was listed as multiple blunt force injuries and the manner of death was indicated as an accident.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on the pilot. Testing was negative for carbon monoxide, ethanol, and all tested-for drugs.

TESTS AND RESEARCH

The retained sections of rotor mast were examined by the NTSB Materials Laboratory. The mast showed deformation and fractures on slant angles consistent with an overstress fracture under bending and torsion loads. Deformation to the mast associated with impact marks adjacent to the fracture were consistent with mast bumping. No evidence of preexisting cracks or corrosion was observed.

ADDITIONAL INFORMATION

The NTSB database was queried for previous mast bumping accidents with Fairchild-Hiller FH 1100 helicopters. The FTW68A0085, NYC83FA102, LAX83FA362, IAD98FA049, and DFW07FA198 investigations listed occurrences of mast bumping findings and their reports are appended to the docket material associated with this investigation.

The NTSB database also contained the CHI00FA266 investigation. Internal corrosion was observed within the main rotor mast on that helicopter. This previous investigation report is also appended to the docket material associated with this investigation.

The FAA Helicopter Flying Handbook (FAA-H-8083-21A), in part, stated:

Low-G Conditions and Mast Bumping
Low acceleration of gravity (low-G or weightless) maneuvers create specific hazards for helicopters, especially those with semirigid main rotor systems because helicopters are primarily designed to be suspended from the main rotor in normal flight with only small variations for positive G load maneuvers. Since a helicopter low-G maneuver departs from normal flight conditions, it may allow the airframe to exceed the manufacturer's design criteria. A low-G condition could have disastrous results, the best way to prevent it from happening is to avoid the conditions in which it might occur.

Low-G conditions are not about the loss of thrust, rather the imbalance of forces. Helicopters are mostly designed to have weight (gravity pulling down to the earth) and lift opposing that force of gravity. Low-G maneuvers occur when this balance is disturbed. An example of this would be placing the helicopter into a very steep dive. At the moment of pushover, the lift and thrust of the rotor is forward, whereas gravity is now vertical or straight down. Since the lift vector is no longer vertical and opposing the gravity (or weight) vector, the fuselage is now affected by the tail rotor thrust below the plane of the main rotor. This tail rotor thrust moment tends to make the helicopter fuselage tilt to the left. Pilots then apply right cyclic inputs to try to correct for the left. Since the main rotor system does not fully support the fuselage at this point, the fuselage continues to roll and the pilot applies more right cyclic until the rotor system strikes the mast (mast bumping), often ending with unnecessary fatal results. In mast bumping, the rotor blade exceeds its flapping limits, causing the main rotor hub to "bump" into the rotor shaft. The main rotor hub's contact with the mast usually becomes more violent with each successive flapping motion. This creates a greater flapping displacement and leads to structural failure of the rotor shaft. Since the mast is hollow, the structural failure manifests itself either as shaft failure with complete separation of the main rotor system from the helicopter or a severely damaged rotor mast.

In situations like the one described above, the helicopter pilot should first apply aft cyclic to bring the vectors into balance, with lift up and gravity down. Since helicopter blades carry the helicopter and have limited motion attachment, care must be given to those attachment limits. Helicopter pilots should always adhere to the maneuvering limitations stated in the [rotorcraft flight manual]. There may be more than one reason or design criteria which limits the helicopter's flight envelope. Heed all of the manufacturer's limitations and advisory data. Failure to do so could lead to dire, unintended consequences.


NTSB Identification: CEN17FA012
14 CFR Part 91: General Aviation
Accident occurred Thursday, October 06, 2016 in Lino Lakes, MN
Aircraft: FAIRCHILD HILLER FH 1100, registration: N4035G
Injuries: 2 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On October 6, 2016, about 1645 central daylight time, a Fairchild Hiller FH 1100 helicopter, N4035G, impacted terrain during an in-flight breakup and collision with terrain while maneuvering near Lino Lakes, Minnesota. The cockpit and cabin areas were consumed by a post-crash fire. The airline transport pilot and his passenger sustained fatal injuries. The helicopter was destroyed during the impact and fire. The helicopter was registered to Helicopter Connection LLC. and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as personal flight. Day visual meteorological conditions prevailed for the flight, which did not operate on a flight plan. The local flight originated from the Anoka County-Blaine Airport (ANE), near Minneapolis, Minnesota, about 1620.

In preliminary information given to the Federal Aviation Administration (FAA), several witnesses said the helicopter was maneuvering from an east bound heading to a north bound heading. They heard a loud noise, saw pieces separate from the helicopter, saw the rotor blade separate, and saw a fire.

The 48-year-old pilot held an FAA airline transport pilot certificate with an airplane multi-engine land rating. He held commercial pilot privileges in airplane single engine land, airplane single engine sea, and rotorcraft helicopter. The pilot held a flight Instructor certificate with airplane single and multi-engine land and instrument airplane ratings. He held a flight engineer certificate with a turbojet rating. The pilot held a FAA special issuance first class medical certificate, dated August 16, 2016, with the following limitations: Must wear corrective lenses. Not valid for any class after 02/28/2017. The pilot reported that he had accumulated 15,000 hours of total flight time and 400 hours of flight time in the six months before the exam. The last entry in the pilot's logbook was dated September 4, 2015. The pilot accumulated 55.5 hours of total flight time in a helicopter at the time of that entry.

N4035G, was registered as a Fairchild-Hiller FH 1100 helicopter with serial number 502. According to FAA airworthiness records, the helicopter was issued a FAA standard airworthiness certificate on October 20, 1982, and was certified for normal category operations. The accident helicopter's data plate was not located in the wreckage. However, according to logbook records, the engine's serial number was listed as CAE823229. The information on the installed engine's data plate indicated the engine was an Allison (Rolls Royce) C20B engine with serial number CAE823229F, which powered a two-bladed, teetering rotor system. According to the type certificate data sheet, it had a maximum gross weight of 2,750 lbs and could be configured to accommodate a pilot, another pilot or passenger in the cockpit, and three passengers in the cabin. The last recorded annual inspection was completed on June 18, 2016, and the endorsement indicated that the helicopter had accumulated 501.7 hours of total time.

At 1645, the recorded weather at ANE was: Wind 010 degrees at 6 knots; visibility 10 statute miles; sky condition overcast clouds at 6,000 feet: temperature 15 degrees C; dew point 6 degrees C; altimeter 29.95 inches of mercury.

The main wreckage was found resting on its right side about 1,600 feet and 130 degrees from the intersection of Main Street and Sunset Avenue. Its resting heading was about 020 degrees magnetic. The wreckage found furthest south was a section of composite material, which was about 2,775 feet and 163 degrees from the same intersection. The heading and distance from the composite material to the main wreckage was about 15 degrees and 1,675 feet. Along this path, major components were found that included the floor mats, a section of white interior material, an exhaust stack, exhaust duct, a section of the tailboom with danger and an arrow printed on it, the engine cowl, a section of exterior metal with the rotating beacon, a seat cushion, a section of the tail that included the tail rotor and its gearbox, and the main wreckage at the end of this path. However, the separated main rotor blades and hub were found east of this debris path about 500 feet south of the main wreckage in a pond. All major components were accounted for at the scene.

The cockpit and cabin were deformed, discolored, charred, and melted consistent with a ground fire and impact damage. Cyclic, collective, and tail rotor control continuity could not be established due to this sustained damage to the cockpit and cabin areas. All observed control discontinuities were consistent with overload or thermal damage.

Engine, transmission, and tailrotor driveshafts exhibited separations. All observed separations were consistent with torsional overload and overload. Circumferential witness marks were found on the exterior of the tailrotor driveshaft.

The main transmission exhibited sections with thermal melting damage, soot colored discoloration, and deformation. The separation surface at the top of the mast exhibited overload fractures. The mast could not be rotated by hand.

The main rotor blades and hub that were recovered from the pond exhibited overload fractures on its mast's separation surface. Examination of the main rotor system and components outside the main wreckage did not exhibit soot colored discoloration or thermal damage.

Examination of the engine revealed that some compressor blades were missing. The observed remaining compressor blades were bent opposite the direction of rotation.

The coroner was asked to arrange for an autopsy to be performed on the pilot and take samples for toxicological testing.

A section of the transmission's mast and the section of mast from the main rotor hub were removed and were sent to the National Transportation Safety Board's Materials Laboratory for detailed examination.