Saturday, October 13, 2018

Eurocopter EC-130B-4 (AS-350B-4), registered to American Helicopters LLC and operated by Papillon Grand Canyon Helicopters as an air tour flight, N151GC: Accident occurred June 27, 2017 in Boulder City, Clark County, Nevada

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

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Las Vegas, Nevada

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


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

http://registry.faa.gov/N151GC


Location: Boulder City, NV
Accident Number: WPR17LA133
Date & Time: 06/27/2017, 1403 PDT
Registration: N151GC
Aircraft: EUROCOPTER EC 130 B4
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 2 Minor, 5 None
Flight Conducted Under: Part 135: Air Taxi & Commuter - Non-scheduled - Sightseeing 

On June 27, 2017, about 1403 Pacific daylight time, a Eurocopter EC 130 B4 helicopter, N151GC, sustained substantial damage following a loss of engine power and subsequent forced landing near Boulder City, Nevada. The commercial pilot and four passengers were not injured, and two passengers sustained minor injuries. The helicopter was registered to American Helicopters LLC, and operated by Papillon Grand Canyon Helicopters as an air tour flight under the provision of Title 14 Code of Federal Regulations, Part 135. Visual meteorological conditions prevailed for the flight, and a company flight plan had been filed. The flight originated from Boulder City Municipal Airport, Boulder City, Nevada at 1348, and was destined for Grand Canyon West Airport, Peach Springs, Arizona.

The pilot reported that, as he executed an "S-turn" about 3,000 ft mean sea level, the helicopter made a subtle yaw to the right, which was accompanied by an audible "gong." The pilot lowered the collective and simultaneously noted a yellow engine parameter failure indication on the instrument display. Moments later, the main rotor rpm warning horn activated and was followed by warning lights on the caution warning display. The helicopter began to descend immediately. The pilot elected to perform an autorotation to a nearby helicopter pad. In the attempt to steer away from power lines, the pilot made a left cyclic input; however, the retreating main rotor blade contacted a power line. The pilot continued to maneuver the helicopter and subsequently made an up-slope emergency landing on rising mountainous terrain. The helicopter was recovered to the operator's hangar for further examination.

The last maintenance performed on the engine was 109.6 hours prior to the accident at the Safran HE USA facility, Grand Prairie, Texas. On June 30, 2016, the facility received the accessory gearbox for an overhaul. The oil filter was removed and discarded as part of the normal process for arrival inspection. During the document review, it was determined that the overhaul was not due, and the operator agreed to have the accessory gearbox sent back as is. The operator received the accessory gearbox with no tags, and an entry on a log card that stated "Equipment returned repairable, not repaired, not airworthy as is". This statement was subsequently voided by Safran HE USA after being questioned by the operator thus reverting the airworthiness back to the previous entry. The manufacturer did not inform the operator that they had performed maintenance on the accessory gearbox and pulled the engine oil filter prior to sending the module back to the operator. The engine was then rebuilt with the existing accessory gearbox and operated for 109.6 hours without an oil filter installed.

On June 28 and 29, 2017, representatives from the Federal Aviation Administration (FAA), Papillon Grand Canyon Helicopters, and Safran HE conducted an engine examination. The engine did not exhibit any visual external damage. All fuel, oil, and air lines were found secured; oil was present in the oil tank. Both the gas generator and power turbine were seized and could not be rotated by hand. There was no evidence of foreign object debris on the axial compressor. The high pressure turbine was examined with a borescope and revealed a significant amount of heat damage to the turbine blades and thermocouples. The Vehicle and Engine Multifunction Display noted exceedances in engine temperature. Metal particles were found on the accessory gearbox magnetic plug. Sludge was present on the reduction gearbox magnetic plug and electric chip detectors. Upon inspection of the engine oil filter it was revealed that the filter was not installed. The complete onsite examination report is appended to this accident in the public docket.

On July 6 and 7, 2017, at the Safran HE USA facility, the engine was further disassembled by its modules, and the Digital Engine Control Unit (DECU) data was downloaded. All magnetic sensors, strainers, magnetic plugs and the main oil strainer were removed and inspected. All were clean except for the accessory gearbox magnetic plug. The thermocouple harness had sustained thermal damage. The reduction gearbox was freely rotated by hand. The free turbine module was seized at the blade tip/shroud section and its bearings were able to rotate freely by hand. Evidence of thermal and impact damage was present on the leading edge of the free turbine blades. The accessory gearbox was rotated by hand and continuity was established throughout the gear train. The axial compressor could be rotated by hand; however, it was rough and noisy. The gas generator was unable to rotate. After removal of the axial compressor from the gas generator, a hole in the centrifugal compressor was observed. The axial compressor rear bearing was shattered. The oil jet for the rear bearing was obstructed and subsequently sent for further examination to Safran HE factory laboratory in France. The gas generator rear bearing appeared normal and rotated freely. There was no damage to the piston shaft or rear bearing housing. The Safran HE air safety investigator (ASI) stated that this would indicate that the rear of the gas generator stayed in alignment during the failure of the axial compressor bearing.

The DECU download revealed 3 faults recorded during the accident flight. The first recorded fault indicated a P3 drift. Within the same second the next fault was a raw t4 fault which, according to the Safran HE ASI was most likely caused by the thermal damage to the thermocouple harness. The third fault recorded 6 seconds later was a helicopter t4 indication fault, which was most likely also caused by the thermal damage to the thermocouple harness. During those 6 seconds, the gas generator speed and free turbine speed decreased, and the fuel flow increased. Torque indication recorded at the last fault was .52%, which is consistent with the helicopter freewheeling at this point.

On October 9, 2017, the obstructed axial compressor oil jet was examined at the Safran HE factory laboratory, Bordes, France. The double oil jet was found blocked on only one side and was subsequently tested to identify the cause of the obstruction. A borescope examination of the obstruction revealed that it was composed of carbon oxygen and phosphor, which was significant of oil cokefaction. Oil cokefaction appears in the presence of oil in a hot temperature environment. Coke pollution moved through the scavenge circuit to the oil tank, and then through the oil filter to the lubrication circuit of the engine. Due to a lack of the engine oil filter, coke pollution migrated to the oil jet.

The axial compressor bearing and its external housing were analyzed and revealed that all the balls were deformed with flat zones. The two-half internal race had material transfer which led to seizure and jamming. The outside race and the separating cage were stuck together with the outside housing. The complete onsite examination reports, and the engine and oil jet examination reports are appended to this accident in the public docket.

Pilot Information

Certificate: Commercial
Age: 33, Male
Airplane Rating(s): None
Seat Occupied: Front 
Other Aircraft Rating(s): Helicopter
Restraint Used:
Instrument Rating(s): Helicopter
Second Pilot Present:
Instructor Rating(s): Helicopter
Toxicology Performed: No
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 03/07/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 05/10/2017
Flight Time: (Estimated) 3827 hours (Total, all aircraft), 1634 hours (Total, this make and model), 3748 hours (Pilot In Command, all aircraft), 118 hours (Last 90 days, all aircraft), 42 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: EUROCOPTER
Registration: N151GC
Model/Series: EC 130 B4 B
Aircraft Category: Helicopter
Year of Manufacture: 2007
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 4402
Landing Gear Type: Skid
Seats: 8
Date/Type of Last Inspection: 06/22/2017, 100 Hour
Certified Max Gross Wt.: 5350 lbs
Time Since Last Inspection:
Engines: Turbo Shaft
Airframe Total Time: 12536.2 Hours as of last inspection
Engine Manufacturer: Turbomeca
ELT: C126 installed, not activated
Engine Model/Series: Arriel 2B1
Registered Owner: AMERICAN HELICOPTERS LLC
Rated Power: 592 hp
Operator: Papillon Grand Canyon Helicopters
Operating Certificate(s) Held: Commercial Air Tour (136); Rotorcraft External Load (133); On-demand Air Taxi (135) 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KBVU, 2202 ft msl
Distance from Accident Site: 2 Nautical Miles
Observation Time: 1335 PDT
Direction from Accident Site: 129°
Lowest Cloud Condition:
Visibility: 10 Miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 7 knots / 13 knots
Turbulence Type Forecast/Actual: / Unknown 
Wind Direction: 190°
Turbulence Severity Forecast/Actual: / Unknown
Altimeter Setting: 29.82 inches Hg
Temperature/Dew Point: 39°C / -8°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: BOULDER CITY, NV (BVU)
Type of Flight Plan Filed: Company VFR
Destination: BOULDER CITY, NV (BVU)
Type of Clearance: None
Departure Time: 1348 PDT
Type of Airspace: Class G

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 2 Minor, 4 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Minor, 5 None
Latitude, Longitude:  35.967500, -114.892222 (est)

NTSB Identification: WPR17LA133
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Tuesday, June 27, 2017 in Boulder City, NV
Aircraft: EUROCOPTER EC 130 B4, registration: N151GC
Injuries: 2 Minor, 5 Uninjured.

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 June 27, 2017, about 1403 Pacific daylight time, a Eurocopter EC 130 B4, N151GC, sustained substantial damage following a loss of engine power and subsequent forced landing, during which the helicopter contacted power lines, near Boulder City, Nevada. The pilot and four passengers were not injured, and two passengers sustained minor injuries. The helicopter was registered to American Helicopters LLC, and operated by Papillion Grand Canyon Helicopters as an air tour flight under the provision of 14 Code of Federal Regulations, Part 135. Visual meteorological conditions prevailed for the flight, and a company flight plan had been filed. The flight originated from Boulder City Municipal Airport, Boulder City, Nevada at 1348 with a planned destination of Grand Canyon West Airport, Peach Springs, Arizona.

The pilot reported that as he executed an "S-turn" about 3,000 feet mean sea level, the helicopter made a subtle yaw to the right, which was accompanied by an audible "gong." The pilot lowered the collective and simultaneously noted a yellow engine parameter failure indication on the instrument display. Moments later, the main rotor rpm warning horn activated and was followed by warning lights on the caution warning display. The helicopter began to descend immediately. The pilot elected to perform an autorotation to a nearby helicopter pad. In the attempt to steer away from power lines, the pilot made a left cyclic input; however, the retreating main rotor blade contacted a power line. The pilot continued to maneuver the helicopter and subsequently made an up-slope emergency landing on rising mountainous terrain.

The helicopter was recovered to a secure location for further examination.

2 comments:

Anonymous said...

How the heck is it even possible to operate an engine like this without an oil filter? Annnddd... Why would anyone do such a thing?

Anonymous said...

any engine will operate without an oil filter. this one lasted 100 hours. as to why the filter was removed... the shop followed their approved procedure. unfortunately they did not follow it once the work stoppage was requested by the operator. at the end, both entities failed to follow basic regulatory requirements. thankfully the operator had a good pilot on the controls.