Saturday, October 13, 2018

Beech A36 Bonanza 36, registered to and operated by GTA Air Inc, N24LF: Accident occurred July 03, 2017 near El Paso International Airport (KELP), El Paso County, Texas

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Albuquerque, New Mexico
Continental Motors; Mobile, Alabama
Hartzell Propeller; Piqua, Ohio
GTA Air Inc; Addison, Texas

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/N24LF

Location: El Paso, TX
Accident Number: CEN17LA255
Date & Time: 07/03/2017, 2006 MDT
Registration: N24LF
Aircraft: BEECH A36
Aircraft Damage: Substantial
Defining Event: Powerplant sys/comp malf/fail
Injuries: 2 None
Flight Conducted Under: Part 135: Air Taxi & Commuter - Non-scheduled 

On July 3, 2017, about 2006 mountain daylight time, a single engine Beech A36 airplane, N24LF, lost engine power during the initial climb after takeoff from El Paso International Airport (ELP), El Paso, Texas. The commercial pilot and passenger were not injured. The airplane sustained substantial damage. The airplane was registered to and operated by GTA Air, Inc., under the provisions of 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed and a Federal Aviation Administration (FAA) visual flight rules flight plan had been filed for the flight. The non-scheduled domestic cargo flight departed ELP and was en route to Dallas Love Field Airport (DAL), Dallas, Texas.

According to the pilot, he climbed to an altitude of 4,800 ft and the engine lost power. The pilot reversed course towards ELP and intended to land on runway 26R. The glide of the airplane did not reach the runway and the wings and fuselage were substantially damaged during the forced landing to a field.

The airplane was equipped with a Continental IO-520-BB87B engine. The engine had been modified with the addition of a Tornado Alley Turbo Whirlwind system under a supplemental type certificate. Examination of the airframe and engine revealed thermal damage concentrated on the lower left side of the engine. The induction tube, forward of the turbocharger compressor, was melted and the remains were found in the cowling below. The induction wye exhibited a hole emanating outward from the turbine wheel. The engine, magnetos, and related systems were otherwise unremarkable.

The turbocharger on the accident airplane was not part of the original modification. Examination and disassembly of the Hartzell Engine Technologies turbocharger (SN HSGL00002) revealed that the turbocharger had been reconfigured with a different compressor housing and the addition of wear washers. The turbocharger had originally been sold to the operator on a factory remanufactured engine from Continental Motors in 2015 (TSIO-520-EB5B – SN 1031058). According to the operator, they did not repair or modify the turbocharger, they only loosened and tightened the V-band clamp and loosened and tightened the hot side bolts. Investigators were unable to determine who modified the turbocharger prior to its installation on the accident airplane.

Evidence of high temperatures and thermal distress were noted on the turbine housing exhaust flange, the thrust collar, thrust spacer, and back plate. The turbine and compressor wheels exhibited evidence of rub within their housings. The turbine wheel hub exhibited evidence of hard rub with the center housing seal bore area. The turbine housing exhibited red coloring on the internal surfaces, bubbling of the exhaust flange, and spiraling tongue erosion, which according to Hartzell are consistent with high turbine inlet temperatures. 

Pilot Information

Certificate: Flight Instructor; Commercial; Private
Age: 41, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Glider
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 04/18/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 05/02/2017
Flight Time:  1085.5 hours (Total, all aircraft), 206.6 hours (Total, this make and model), 1004.2 hours (Pilot In Command, all aircraft), 212.6 hours (Last 90 days, all aircraft), 101.6 hours (Last 30 days, all aircraft), 3.7 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: BEECH
Registration: N24LF
Model/Series: A36 UNDESIGNATED
Aircraft Category: Airplane
Year of Manufacture: 1980
Amateur Built: No
Airworthiness Certificate: Utility
Serial Number: E-1665
Landing Gear Type: Retractable - Tricycle
Seats: 2
Date/Type of Last Inspection: 06/09/2017, AAIP
Certified Max Gross Wt.: 3780 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:  12899.3 Hours at time of accident
Engine Manufacturer: T.C.M.
ELT: C91A installed, activated, did not aid in locating accident
Engine Model/Series: IO-520-BB87B
Registered Owner: On file
Rated Power: 285 hp
Operator: On file
Operating Certificate(s) Held: On-demand Air Taxi (135)

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Dusk
Observation Facility, Elevation: KELP, 3961 ft msl
Distance from Accident Site:
Observation Time: 1951 MDT
Direction from Accident Site:
Lowest Cloud Condition: Scattered / 12000 ft agl
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 10 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 150°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 29.96 inches Hg
Temperature/Dew Point: 36°C / 6°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: El Paso, TX (KELP)
Type of Flight Plan Filed: Company VFR
Destination: Dallas, TX (KDAL)
Type of Clearance: VFR; VFR Flight Following
Departure Time: 2000 MDT
Type of Airspace: Class C

Airport Information

Airport: El Paso International Airport (KELP)
Runway Surface Type: Asphalt
Airport Elevation: 3961 ft
Runway Surface Condition: Dry
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced Landing

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 1 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude: 31.812222, -106.382778 (est)

NTSB Identification: CEN17LA255
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Monday, July 03, 2017 in El Paso, TX
Aircraft: BEECH A36, registration: N24LF
Injuries: 2 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 July 3, 2017, about 2006 mountain daylight time, a single engine Beech A36 airplane lost engine power after takeoff from El Paso International Airport (ELP), El Paso, Texas. The commercial pilot and passenger were not injured. The airplane sustained substantial damage. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed and a Federal Aviation Administration (FAA) flight plan had been filed for the flight. The flight had departed ELP and was en route to Dallas Love Field Airport (DAL), Dallas, Texas.

According to the pilot, he was climbing to an altitude of 4,800 feet when the engine lost power. The pilot reversed course towards the airport and intended to land on runway 26R. The glide of the airplane did not reach the runway and the wings and fuselage were substantially damaged during the forced landing to the field.

Loss of Engine Power (total): Piper PA-28-140 Cherokee E, N4244T, accident occurred June 30, 2017 near Daniel K. Inouye International Airport (PHNL), Honolulu, Hawaii


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


Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Honolulu, Hawaii

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


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


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


https://registry.faa.gov/N4244T

Location: Honolulu, HI
Accident Number: WPR17LA138
Date & Time: 06/30/2017, 1330 HST
Registration: N4244T
Aircraft: PIPER PA 28-140
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 3 Serious
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis 

The private pilot reported that he conducted a preflight inspection to prepare for the local personal flight and that a minimum of 20 gallons of fuel was on board. He started the engine and taxied the airplane to an open area for a run-up. Shortly after takeoff, about 300 ft above ground level, the engine lost power. He initiated an emergency landing to a riverbed. The airplane subsequently came to rest under a highway overpass and caught fire.

Postaccident visual and engine examinations revealed no evidence of a mechanical malfunction. Further, impact and fire damage precluded a determination of the cause of the loss of engine power.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A total loss of engine power during initial climb for reasons that could not be determined due to impact and fire damage. 

Findings

Not determined
Not determined - Unknown/Not determined (Cause)

Factual Information

History of Flight

Initial climb
Loss of engine power (total) (Defining event)

Landing
Off-field or emergency landing

Post-impact
Fire/smoke (post-impact)

On June 30, 2017, about 1330 Hawaii-Aleutian standard time, a Piper PA-28-140 airplane, N4244T, collided with the ground under a highway overpass following a loss of engine power shortly after takeoff from Daniel K Inouye International Airport (HNL), Honolulu, Hawaii. The private pilot, a commercial pilot rated passenger and a passenger were seriously injured. The airplane was substantially damaged. The airplane was privately owned and operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the local personal flight that departed HNL at 1320.

The pilot reported that a preflight inspection was accomplished and that a minimum of 20 gallons of fuel was on board. The engine was started, and the airplane was taxied to an open area for a run-up. Shortly after takeoff from runway 4 left, about 300 ft above ground level, the pilot noted that the engine lost power. He subsequently initiated an emergency landing to a riverbed; the airplane came to rest under a highway overpass and caught fire.

The rear seat passenger reported to a Federal Aviation Administration (FAA) Inspector that the right seat pilot took control of the airplane just prior to the collision and he had cut off the mixture (and power) just prior to ground impact.

The owner of the airplane reported that the airplane had been flown every day and no issues with the operation of the airplane were reported. He indicated that the fuel tanks would be filled to the tabs (20 gallons in each tank). The airplane would fly one flight with the fuel selector positioned to one fuel tank, and then on the next flight it would be positioned on the other fuel tank. Prior to the accident flight, the owner had instructed the pilots to switch fuel tanks prior to takeoff since they were used to flying in Cessna airplanes that flew with the fuel selector positioned to BOTH. 

Pilot Information

Certificate: Private 
Age: 20, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 None
Last FAA Medical Exam: 02/03/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 04/29/2017
Flight Time:  68 hours (Total, all aircraft), 5 hours (Total, this make and model), 28 hours (Last 90 days, all aircraft), 8 hours (Last 30 days, all aircraft)

Pilot-Rated Passenger Information

Certificate: Commercial
Age: 28, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s):
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 10/04/2015
Occupational Pilot: No
Last Flight Review or Equivalent: 04/12/2016
Flight Time:  775 hours (Total, all aircraft), 657 hours (Pilot In Command, all aircraft) 

The 20-year-old left seat pilot held a private pilot certificate with a rating in airplane single-engine land. The pilot held a Federal Aviation Administration third-class medical certificate issued February 3, 2017 with no waivers or limitations. The pilot's total flight experience was about 68 hours. He logged 28 hours in the previous 90 days, and 8 hours in the previous 30 days. A total of 5 hours were logged in the make and model airplane involved in the accident.

The 28-year-old right seat pilot held a commercial certificate with ratings in airplane single-engine land and instrument airplane. The pilot held a Federal Aviation Administration first-class medical certificate issued October 4, 2015, with no waivers or limitations. The pilot's total flight experience was about 775 hours.

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N4244T
Model/Series: PA 28-140
Aircraft Category: Airplane
Year of Manufacture: 1971
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28-7225103
Landing Gear Type: Tricycle
Seats:4 
Date/Type of Last Inspection:
Certified Max Gross Wt.: 
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: LYCOMING
ELT:
Engine Model/Series: O-320-E30
Registered Owner: MUELLER JAHN P
Rated Power: 140 hp
Operator: On file
Operating Certificate(s) Held: None

The 4-seat, low-wing, fixed-gear airplane, serial number 28-7225103, was manufactured in 1971 and was powered by a 140-horsepower Lycoming O-320 series engine. The owner of the airplane reported that the maintenance logbooks for both the airframe and engine were inside the airplane at the time of the accident and were destroyed in the post-crash fire. No total times nor maintenance inspection documentation was obtained.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: PHNL
Distance from Accident Site: 
Observation Time: 1253 HST
Direction from Accident Site:
Lowest Cloud Condition: Few / 2700 ft agl
Visibility:  10 Miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 17 knots / 25 knots
Turbulence Type Forecast/Actual:
Wind Direction: 79°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.03 inches Hg
Temperature/Dew Point: 29°C / 16°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Honolulu, HI (PHNL)
Type of Flight Plan Filed: Unknown
Destination: Honolulu, HI (PHNL)
Type of Clearance: None
Departure Time: 1320 HST
Type of Airspace:

Airport Information

Airport: Honolulu (PHNL)
Runway Surface Type: N/A
Airport Elevation: 12 ft
Runway Surface Condition: Unknown
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced Landing

Wreckage and Impact Information

Crew Injuries: 2 Serious
Aircraft Damage: Substantial
Passenger Injuries: 1 Serious
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Serious
Latitude, Longitude: 21.316667, -157.916667 (est)

The airplane came to rest under an overpass about 1.5 miles north of the departure end of runway 4 left. The ground was dirt and loose rocks. The first of 3 ground impact points was noted about 55 ft south of the main wreckage. The main wreckage was facing to the south and laying on its belly. The landing gear had separated and was in front of the engine, which remained partially attached at the firewall. The inboard section of the right wing remained partially attached at the fuselage. The outboard wingtip section was separated and within about 13 ft of the wreckage. The left wing, in its entirety, remained attached to the fuselage, however was deformed about mid-section. The empennage remained in place. All flight control surfaces were accounted for. The aft end of the engine and cabin area, aft to the baggage compartment, was consumed by the postimpact fire.

The postaccident engine examination revealed that the engine sustained fire damage primarily to the rear engine compartment. The cockpit controls were destroyed and could not be moved or identified. A visual examination of the engine revealed no evidence of a catastrophic engine failure.

The top and bottom spark plugs were removed and noted that the electrodes displayed normal operating signatures. The magnetos remained in place to their mountings, however were destroyed by heat distress and could not be tested.

The engine valve covers were removed and the crankshaft was turned by hand. Thumb compression was established in each cylinder. Accessory gear and valve train continuity was established. The oil filter/screen was destroyed. The carburetor was destroyed by fire.

The fuel selector valve was burned and melted. The valve position could not be verified.







NTSB Identification: WPR17LA138
14 CFR Part 91: General Aviation
Accident occurred Friday, June 30, 2017 in Honolulu, HI
Aircraft: PIPER PA 28-140, registration: N4244T
Injuries: 3 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 June 30, 2017, about 1330 Hawaii standard time, a Piper PA-28-140, N4244T, sustained substantial damage following a loss of engine power and subsequent hard landing near Honolulu, Hawaii. The private pilot and two passengers sustained serious injuries. The pilot was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The local personal flight departed Honolulu International Airport at 1320. Visual meteorological conditions prevailed, and no flight plan had been filed.

The pilot reported that shortly after takeoff from runway 04L, the engine lost power about 300 feet agl. He made an emergency landing at the nearest clear area, which was a river bed. The airplane impacted the ground and came to rest under a highway bridge and caught fire.

Cessna P210N Pressurized Centurion, registered to and operated by Tridelaw Aviation LLC, N210HG: Accident occurred June 30, 2017 near Eagle County Regional Airport (KEGE), Gypsum, Colorado



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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Denver, Colorado
Continental Motors Inc; Mobile, Alabama

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


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

Location: Eagle, CO
Accident Number: CEN17LA247
Date & Time: 06/30/2017, 1215 MDT
Registration: N210HG
Aircraft: CESSNA P210N
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal 

On June 30, 2017, about 1215 mountain daylight time, a Cessna P210N airplane, N210HG conducted a forced landing near Eagle, Colorado. The pilot was not injured and the airplane was substantially damaged during the landing. The airplane was registered to and operated by Tridelaw Aviation, LLC, under the provisions of 14 Code of Federal Regulations Part 91 as a cross-country flight. Visual meteorological conditions prevailed at the time.

The pilot reported that he departed Montrose, Colorado (KMTJ) en route to the Eagle County Regional Airport (KEGE). He added that he departed KMTJ with 60 gallons of fuel and 8 quarts of oil in the P210. As he approached KEGE, he contacted the tower controller and was directed to enter the downwind. As he entered the traffic pattern and configured the airplane for the landing, the engine lost power. The pilot reported that he followed the 'engine failure during flight' checklist, and switched fuel tanks; however, the engine did not restart. The pilot informed the controller and selected an empty road for the forced landing. During the landing, the left wing impacted a pole, the airplane then exited the road, coming to rest in an upright position. During the impact with the pole, about a 5 ft section was torn from the wing; damage was also noted on the fuselage and to the four-bladed propeller.

Fire department personal arrived on scene and noted fuel leaking from the airplane, so they applied a water-based fire retardant to both wing fuel tanks. The responding Federal Aviation Administration (FAA) inspector also stated that after the recovery of the airplane fuel was leaking from at least one of the wing fuel tanks. It was also reported that the airplane was filled with about 30 gallons of fuel on June 21.

The airplane was recovered and transported to a salvage facility, where an examination was conducted by the NTSB Investigator-in-Charge and a technical representative from the engine manufacturer.

A fuel can was connected to the left-wing fuel line and a visual engine examination was conducted. A slight fuel leak was noted on the fuel metering unit, otherwise no external visual abnormalities were noted with the engine. The top set of sparkplugs were removed; the sparkplugs had normal wear and light grey deposits. Each cylinder was borescoped; the engine crankshaft was rotated by hand, and spark was observed on each ignition lead.

The airplane was equipped with a fuel flow and an JPI engine data monitor (EDM) 700 system. No information could be retrieved from the fuel flow system; however, the EDM contained 28 files, dated from May 27, 2017 to June 30, 2017. A review of the monitor's information revealed that there were two flights on June 19th, one flight on June 20th, and a one-hour flight on June 30th, which corresponded to the accident flight. The June 30th flight was plotted; just before the end of the data, there was a slight rise in exhaust gas temperatures (EGT), followed by a decrease. The rise and decrease in temperatures were uniform across all six cylinders.

In order to conduct an engine run, and due to damage to the engine's propeller, two blades were shortened to provide blade symmetry and balance. Prior to the engine run, the fuel strainer was opened and liquid consistent in appearance with water, was drained from the fuel line.

The engine was started and run to 2,500 rpm; a magneto check was also performed, with no abnormalities noted. During the run, fuel continued to leak from the fuel metering unit. After the run, the unit was disassembled, the internal O-rings appeared flattened or degraded. It was not determined if the O-ring leakage was due to impact to the metering unit during the accident, degradation of the O-rings due to the fire retardant, drying out of the O-rings, or natural degradation of the O-rings over time.

The fuel metering inlet screen was removed and was absent any debris and contamination.

A reason for the loss of engine power was not determined.



Pilot Information

Certificate: Private
Age: 67
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 03/01/2016
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  1950 hours (Total, all aircraft), 80 hours (Total, this make and model), 1940 hours (Pilot In Command, all aircraft), 30.4 hours (Last 90 days, all aircraft), 20.3 hours (Last 30 days, all aircraft), 0.8 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N210HG
Model/Series: P210N N
Aircraft Category: Airplane
Year of Manufacture: 1980
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: P21000569
Landing Gear Type: Retractable - Tricycle
Seats:
Date/Type of Last Inspection: 08/15/2016, Annual
Certified Max Gross Wt.: 4001 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 3422 Hours at time of accident
Engine Manufacturer: CONT MOTOR
ELT: C126 installed, activated, did not aid in locating accident
Engine Model/Series: TSIO-520 SER
Registered Owner: TRIDELAW AVIATION LLC
Rated Power: 310 hp
Operator: TRIDELAW AVIATION LLC
Operating Certificate(s) Held: None 



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KEGE
Distance from Accident Site:
Observation Time: 1250 MDT
Direction from Accident Site:
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 130°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.22 inches Hg
Temperature/Dew Point: 23°C / -4°C
Precipitation and Obscuration: No Precipitation
Departure Point: Montrose, CO (KMTJ)
Type of Flight Plan Filed: None
Destination: Eagle, CO (EGE)
Type of Clearance: VFR
Departure Time:
Type of Airspace:



Airport Information

Airport: Eagle County Regional (EGE)
Runway Surface Type: N/A
Airport Elevation: 6547 ft
Runway Surface Condition:
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced Landing; Traffic Pattern

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude:  39.646111, -106.893056 (est)


NTSB Identification: CEN17LA247
14 CFR Part 91: General Aviation
Accident occurred Friday, June 30, 2017 in Eagle, CO
Aircraft: CESSNA P210N, registration: N210HG
Injuries: 1 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 30, 2017, about 1245 mountain daylight time, a Cessna P210N airplane, N210HG conducted a forced landing near Eagle, Colorado. The pilot was not injured and the airplane was substantially damaged during the landing. The airplane was registered to and operated by Tridelaw Aviation, LLC, under the provisions of 14 Code of Federal Regulations Part 91 as a cross-country flight. Visual meteorological conditions prevailed at the time. 

The pilot reported to the Federal Aviation Administration (FAA) inspector, that he departed Montrose, Colorado (KMTJ) en route to the Eagle County Regional Airport (KEGE). He departed KMTJ with the left fuel tank full of fuel and the right fuel tank half-full of fuel. As he approached KEGE, the engine lost power, so he attempted to restart the engine. The engine restart was not successful, so he selected a road for the forced landing. During the landing, the left wing impacted a light pole, resulting substantial damage. 

The wreckage was retained for further examination.

Loss of Engine Power (total): Eurocopter EC-130B-4 (AS-350B-4), 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 Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


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



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


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 

Analysis

The commercial pilot reported that, during an air tour flight, the engine lost total power. He initiated an autorotation to a nearby helicopter pad, during which the helicopter contacted power lines. He subsequently conducted an emergency landing on up-sloping terrain.

Postaccident on-site engine examination revealed that both the gas generator and power turbine were seized and could not be rotated by hand and that there was a significant amount of heat damage to the turbine blades and thermocouples. The vehicle and engine multifunction display recorded multiple engine temperature exceedances during the accident flight. Metal particles were found on the accessory gearbox magnetic plug. Further, no oil filter was found installed in the airplane.

Subsequent engine examination revealed that there was a hole in the centrifugal compressor. Examination further revealed that the No. 2 oil jet for the axial compressor rear bearing was obstructed, which resulted in oil starvation of the bearing and its subsequent failure. The bearing failure subsequently caused the gas generator rotating assembly to seize and resulted in the centrifugal compressor contacting the cover and creating the hole found in the component. Subsequent oil jet examinations revealed that coke pollution had obstructed the No. 2 oil jet. The lack of an oil filter precipitated the No. 2 oil jet obstruction and resulted in the axial compressor rear bearing deterioration.

The resultant engine inefficiency caused by the bearing failure and obstructed oil jet led to the need for higher fuel flow, which eventually resulted in an overtemperature/high pressure turbine failure and seizure of the gas generator and subsequent flameout; this was confirmed by data downloaded from the digital engine control unit, which recorded exceedances in the gas generator and free turbine speeds and an increase in fuel flow.

The manufacturer conducted the last maintenance, which was planned to be an overhaul of the accessory gearbox, 109.6 hours before the accident. During the maintenance, the oil filter was removed and discarded as part of the normal process for arrival inspection. A maintenance document review revealed that the overhaul was not due and that the manufacturer then sent the accessory gearbox back to the operator as is. However, the manufacturer did not inform the operator that it had removed the engine oil filter before returning the module, which is why no filter was found installed on the airplane.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A loss of engine power due to the failure of the manufacturer to reinstall the oil filter after it was removed for inspection, which led to coke pollution that obstructed the oil jet and resulted in the subsequent oil starvation of the axial compressor rear bearing oil and its subsequent failure.

Findings

Aircraft
Engine (turbine/turboprop) - Failure (Cause)
Oil - Fluid level (Cause)

Personnel issues
Installation - Maintenance personnel (Cause)

Environmental issues
Pole - Contributed to outcome


Factual Information

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.

History of Flight

Enroute
Miscellaneous/other

Enroute-cruise
Loss of engine power (total) (Defining event)

Autorotation
Collision with terr/obj (non-CFIT)

Landing

Off-field or emergency landing

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.