CareFlite

Operated by CareFlite (per NTSB report)

The loss of helicopter control after an in-flight upset, which occurred when the pilot selected the autopilot’s altitude hold mode; the reason for the reported in-flight control anomaly could not be determined during postaccident helicopter examinations. Contributing to the accident was the pilot's delay in transitioning to instrument flight rules flight before entering instrument meteorological conditions.

Operated by CareFlite (per NTSB report)

The fracture of a swashplate drive pin as a result of hydrogen embrittlement due to an unknown source, which resulted in an in-flight breakup of the main rotor system during cruise flight.

Sanction: 7500 · case closed 2012-07-19

Part: BLADE — CRACKED (TAIL ROTOR) · airframe 5,434 hrs · 28,153 cycles

DURING DAILY INSPECTION MECHANIC FOUND A CRACK IN TAIL ROTOR BLADE ABRASION STRIP.

Part: BLADE — CRACKED (TAIL ROTOR) · airframe 4,712 hrs · 16,990 cycles

DURING A 300 HOUR / 12 MONTH, TAIL ROTOR BLADE SERIAL NUMBER BH349016 WAS TO HAVE SERVAL CRACKS IN THE BLADE TIP.

Part: BLADE — CRACKED (TAIL ROTOR) · airframe 4,712 hrs · 16,990 cycles

DURING A 300 HOUR / 12 MONTH, TAIL ROTOR BLADE SERIAL NUMBER BH349016 WAS TO HAVE SERVAL CRACKS IN THE BLADE TIP.

Part: DISPLAY — DEFECTIVE (ZONE 200) · airframe 4,772 hrs · 24,488 cycles

PRIOR TO DEPARTING TE 30 THE RIGHT COCKPIT DISPLAY UNIT EXPERIENCED A CPU FAULT MESSAGE.

Part: COMPUTER — FAULT MESSAGE (AUTOPILOT) · airframe 4,688 hrs · 23,997 cycles

PRIOR TO DEPARTING XA62, THE #2 AUTOPILOT MAINTENANCE AND AUTO TRIM CAUTION MESSAGE ILLUMINATED ON THE CREW ALERTING SYSTEM.

Part: WARNING MESSAGE — ILLUMINATED (AUTOPILOT) · airframe 4,688 hrs · 23,997 cycles

AP2 MAINT. AND AUTO TRIM CAS MESSAGE ILLUMINATED.

Part: AUTOPILOT SYS — FAILED (ZONE 100) · airframe 4,688 hrs · 23,997 cycles

AUTOPILOT FAILED - AP MAINT & AUTOTRIM CAS MESSAGE

Part: SKIN PANEL — DAMAGED (ZONE 100) · airframe 587 hrs · 2,345 cycles

AFT BELLY SKIN, FORWARD OF AFT CROSS TUBE WAS DAMAGE, WHEN THE PILOT ATTEMPTED TO LIFT HELICOPTER WITH HELI-PORTER. LEFT SIDE WAS PUNCTURED IN TWO PLACE, AND THE RIGHT WAS DENTED RESULTING IN TWO AREAS OF DE-LAMINATION.

Part: MOTOR — ARCED (ZONE 200) · airframe 12,526 hrs · 13,125 cycles

DURING A SCHEDULED INSPECTION THE ELECTRICAL CONNECTION ON AIR CONDITIONING COMPRESSOR DRIVE MOTOR WAS FOUND TO BE LOOSE AND SHOWED SIGNS OF ARCING.

Part: TRANSMISSION — MAKING METAL (MAIN ROTOR) · airframe 3,578 hrs · 13,640 cycles

TRANSMISSION CHIP LIGHT ILLUMINATED, FOUND METAL DEBRIS ON LOWER CHIP DETECTOR

Part: NONE — NONE · airframe 4,017 hrs · 20,377 cycles

STANDBY ATTITUDE INDICATOR PRECESSING.

Part: NONE — NONE · airframe 4,017 hrs · 20,377 cycles

PILOTS DU FAILED TO POWER ON.

Part: NONE — NONE · airframe 4,016 hrs · 20,364 cycles

LEFT XMSN CD INOP CAUTION MESSAGE ILLUMINATED.

Part: NONE — NONE · airframe 2,294 hrs · 9,319 cycles

PILOT REPORTED DURING HIS PRE-FLIGHT CHECK THAT THE ENGINE OIL DIFFERENTIAL BYPASS INDICATOR WAS EXTENDED ON THE COMBINED ENGINE FILTER ASSEMBLY (CEFA)

Part: BATTERY — FAILED (FORWARD FUSELAGE) · airframe 2,289 hrs · 9,300 cycles

PILOT REPORTED AIRCRAFT BATTERY HAS LOW VOLTAGE

Part: FRAME — BENT (ZONE 100) · airframe 12,262 hrs · 12,843 cycles

TAIL STAND WAS NOT REMOVED PRIOR TO AIRCRAFT BEING LOWER OFF OF JACKS, SUBSEQUENTLY DAMAGING FUSELAGE FRAME LOCATED AT AIRFRAME STATION 319.0.

Part: BLOWER MOTOR — SHORTED · airframe 1,404 hrs · 5,999 cycles

STRONG BURNING ODOR DETECTED IN FLIGHT. AIRCRAFT WAS RETURNING TO BASE WHEN DETECTED. BLOWER MOTOR FOUND SHORTED.

Part: CAP — MISINSTALLED (FUEL) · airframe 9,080 hrs · 9,379 cycles

FUEL LEAKING FROM RT NACELLE UPPER AREA BY FUEL CAP. DETERMINED UPPER NACELLE FUEL CAP WAS IMPROPERLY SEATED AFTER REFUEL.

Part: TERMINAL — BROKEN (CARGO BAY) · airframe 3,500 hrs · 16,706 cycles

A BROKEN ELECTRICAL WIRE TERMINAL CARRYING 115 VAC CONTACTED THE GROUND SIDE OF THE GFCI ELECTRICAL OUTLET AND MELTED THE PLASTIC BACK OF THE OUTLET. PILOT NOTICED SMELL AND CREW REPORTED SEEING "VISIBLE VAPOR" IN THE AFT CABIN OF THE AIRCRAFT. PILOT MADE AN UNEVENTFUL UNSCHEDULED LANDING.

Part: BLADE — CRACKED (MAIN ROTOR)

A CRACKED IN THE M/R BLADE EROSION STRIP AT APPROXIMATELY MID-SPAN. BOTH UPPER AND LOWER SURFACES WERE CRACKED. (K)

Part: SPAR — CRACKED (TAILBOOM)

A (4) INCH CRACK WAS DISCOVERED IN THE L/E SPAR DOUBLER OF THE VERTICAL FIN. ADDITIONALLY, (2) CRACKS WERE FOUND IN THE VERTICAL STABILIZER ASSY (NOT DETACHABLE). ONE CRACK MEASURED APPROX 5 INCHES AND ONE APPROXIMATELY 7 INCHES. A DETAIL BREAKDOWN OF THIS ASSEMBLY IS NOT PROVIDED AT OPERATOR LEVEL. PN OF INDIVIDUAL CRACKED COMPONENTS ARE NOT AVAILABLE TO THIS OPERATOR. THE APPROXIMATE LOCATION OF DAMAGED AREA IS STATION 9141, LB 1625. TAILBOOM IS BEING RETURNED TO MFG FOR REPAIR EVALUATION. (SW19200509233) (K)

Part: RIB — CRACKED (VERTICAL FIN)

A CRACK WAS FOUND DURING A 300 HOUR INSPECTION OF THE VERTICAL FIN. THE CRACK WAS FOUND ON THE RIB AT APPROX. WL 235.2 MM, STA 9725.0 MM, AND RAN FROM STA 9623.4 MM TO 98266 MM. THE MANUFACTURER WAS CONTACTED FOR INSTRUCTIONS ON SERVICEABILITY. A LETTER FROM ENGINEERING PERMITTED THE AIRCRAFT TO BE FLOWN AN AUDITIONAL 100 HOURS PROVIDED DAILY AND 25 HOUR INSPECTIONS WERE PERFORMED.

Part: TRANSDUCER — INOPERATIVE (NR 2 HYD SYS) · airframe 184 hrs

DURING PATIENT FLIGHT, NR 2 MAIN HYDRAULICS PRESSURE QUICKLY FELL INTO THE CAUTION RANGE. IN ANTICIPATION OF TOTAL LOSS NR 2 SYSTEM. I SLOWED BELOW VIE, EXTENDED GEAR ( 3 GREEN) CONTINUING TO SLOW TO 90 KNOTS. DECLARED AN EMERGENCY, MADE AN UNEVENTFUL PRECAUTIONARY LANDING. SLOW TO VIE, EXTEND LANDING GEAR, LANDED AT NEAREST AIRPORT.

Part: SKIN — CRACKED (TAIL BOOM)

FOUND CRACK ON UPPER SKIN OF TAILBOOM UNDERNEATH NR 4 HANGER BEARING AT STA 473 TO 489, DURING INSPECTION.

Part: BOLT — WORN (STUB WING ATTACH)

INSPECTION FOUND THE STUB WING TO HAVE SLIGHT UP AND DOWN MOVEMENT. REMOVAL OF THE STAB WING FROM THE AIRFRAME REVEALED BOTH UPPER AND LOWER STUB WING ATTACHMENT BOLTS PN 222031830101(UPPER) & PN 222031831101(LOWER). TO HAVE THE LINING MATERIAL WORN OFF, ALMOST ALL AROUND THE ENTIRE CIRCUMFERENCE OF THE BOLT. INSPECTION OF THE STUB WING FITTING BUSHINGS FOUND THEY WERE WORN ON BOTH THE BUSHING O.D. & I.D. THIS RESULTED IN THE ATTACHMENT BOLTS BECOMING LOOSE IN THE BUSHING AND THE BUSHING BEING LOOSE IN THE STUB WING FITTING. PROBABLE CAUSE MAY BE A/C AGE AT 10940.3 TT. RECOMMEND BHT REVISE THE INSPECTION REQUIREMENTS TO INCLUDE ALLOWABLE WEAR/MOVEMENT LIMITS, AND SET INSPECTION INTERVALS.(K)

Part: BUSHING — WORN (STUB WING FITTNG)

INSPECTION FOUND THE STUB WING TO HAVE SLIGHT UP & DOWN MOVEMENT. REMOVAL OF THE STUB WING FROM THE AIRFRAME REVEALED BOTH UPPER & LOWER STUB WING ATTACHMENT BOLTS PN 222031830101(UPPER) & PN 222031331101(LOWER) TO HAVE THE LINING MATERIAL WORN OFF, ALMOST ALL AROUND THE ENTIRE CIRCUMFERENCE OF THE BOLTS. INSPECTION OF THE STUB WING FITTING BUSHINGS FOUND THEY WERE WORN ON BOTH THE BUSHING O.D. & I.D. THIS RESULTED IN THE ATTACHMENT BOLTS BECOMING LOOSE IN THE BUSHING AND THE BUSHING BEING LOOSE IN THE STUB WING FITTING. PROBABLE CAUSE MAY BE A/C AGE AT 10940.3 TT. RECOMMEND BHT REVISE THE INSPECTION REQUIREMENTS TO INCLUDE ALLOWABLE WERE/MOVEMENT LIMITS, AND JET INSPECTION INTERVALS.(K)

Part: BOLT — WORN (STUB WING ATTACH)

INSPECTION FOUND THE STUB WING TO HAVE A SLIGHT UP & DOWN MOVEMENT. REMOVAL OF THE STUB WING FROM THE AIRFRAME REVEALED BOTH UPPER & LOWER STUB WING ATTACHMENT BOLTS PN 222031830101(UPPER) & PN 222031331101(LOWER) TO HAVE THE LINING MATERIAL WORN OFF, ALMOST ALL AROUND THE ENTIRE CIRCUMFERENCE OF THE BOLTS. INSPECTION OF THE STUB WING FITTING BUSHINGS FOUND, THEY WERE WORN ON BOTH THE BUSHING O.D. & I.D. THIS RESULTED IN THE ATTACHMENT BOLTS BECOMING LOOSE IN THE BUSHING AND THE BUSHING BEING LOOSE IN THE STUB WING FITTING. PROBABLE CAUSE MAY BE AIRCRAFT AGE AT 109940.3 TT. RECOMMEND BHT REVISE THE INSPECTION REQUIREMENTS TO INCLUDE ALLOWABLE WEAR/MOVEMENT LIMITS, AND SET INSPECTION INTERVALS.(K)

Part: HUB — CORRODED (MAIN ROTOR)

ON DAILY INSPECTION, FRETTING SUSPECTED BETWEEN M/R GRIPS AND PITCH HORNS. THE TORQUE WAS CHECKED ON ALL FOUR MAIN ROTOR GRIP RETAINING BOLTS. ALL FOUR FAILED THE TORQUE CHECK. DISASSEMBLED M/R GRIPS AND FOUND BUFFER PADS TO BE LOOSE, DISTORTED, AND EVIDENCE OF MOVEMENT BETWEEN GRIPS AND PITCH HORNS IN THE FORM OF MUD. THIS WAS POSSIBLY CAUSED BY IMPROPER INSTALLATION OF BUFFER PADS AND/OR PAINT NOT SET UP ON GRIPS BEFORE ASSEMBLY. ALSO FOUND PITCH HORN DIMENSIONS TO BE BELOW MINIMUM SPECIFICATIONS PER MANUFACTURER''S BLUEPRINTS RETURNED TO SERVICE CENTER FOR DISPOSITION. (X)

Part: BEARING — FAILED (COOLER BLOWER)

IN-FLIGHT 2 OR 3 MINUTES PRIOR TO LANDING, A SEVERE VIBRATION AND LOUD NOISE WAS FELT AND HEARD. THE AIRCRAFT LANDED. IT WAS DISCOVEREDTHE AFT OIL COOLER BLOWER SHAFT AFT BEARING HAD FAILED AND COME APART. THE INNER RACE AND BALL BEARINGS DAMAGED THE IMPELLER. THE OUTER RACE AND HANGAR DAMAGED THE BLOWER SHAFT. POSSIBLE CAUSE WAS OVERHEATING. BEARING WAS LUBRICATED APPROXIMATELY 80 HRS PRIOR TO OCCURRENCE. REPORTED TO BELL HELICOPTER PRODUCT SUPPORT FOR INVESTIGATION. BEARING WAS NEW STYLE TYPE (BLUESEAL).(X)

Part: SUPPORT — CRACKED (TAILBOOM)

PILOT FOUND CRACK ON PRE-FLIGHT CHECK NEAR FORWARD END OF HORIZONTAL STABILIZER MOUNTING BRACKET (UPPER). THIS OEM INSTALLED BRACKET WAS LOADED WHEN INSTALLED. MFG SUPPLIED APPROVED DATA AND BRACKET WAS REPLACED. THIS BRACKET WAS ON THE RIGHT HAND SIDE OF TAILBOOM.

Part: GOVERNOR — MISMANUFACTURED (PROPELLER)

AT INSTALLATION, GOVERNOR WOULD NOT PRODUCE PARTIAL POWER TOPPING. REMOVED AND HAND CARRIED TO ALLIED SIGNAL BENDIX FOR INVESTIGATION. UPON TESTING AND DISASSEMBLY, VERIFIED INCORRECT SIZED PG ORIFACE. UNIT DID NOT MEET SPECS ON BENCH. ALLIED SIGNAL INVESTIGATION TO CORRECT ISSUE.

Part: BATTERY — FAILED (BATTERY TRAY)

NR 2 GENERATOR LIGHT CAME ON. PILOT ABORTED FLIGHT AND LANDED AT NEAREST AIRPORT. TECHNICIAN IDENTIFIED WHAT APPEARED TO BE A SHORTED LEAD ACID BATTERY. BATTERY WAS REPLACED AND NO DEFECTS NOTED AT THIS TIME.

Part: TUBE — CRACKED (FC PY LINE)

REPLACED CRACKED PY LINE AT FUEL CONTROL UNIT.

Part: SHAFT — DESTROYED (NR 2 OIL COOLER)

THE PILOT NOTICED NR 2 ENGINE OIL TEMPERATURE WAS CLIMBING TOWARDS RED LINE. THE PILOT EXECUTED PRECAUTIONARY LANDING. MAINTENANCE PERSONNEL FOUND THE OIL COOLER BLOWER SHAFT HAD SHEARED AND THE FLOPPING AROUND HAD DAMAGED THE DRIVE GEAR IN THE ENGINE AND THE OIL COOLER BLOWER. THE ENGINE AND BLOWER WAS REPLACED.

Part: FITTING — BROKEN (NR 2 ENGINE)

FOUR MINUTES AFTER TAKEOFF, NR 2 ENGINE WENT TO FLT IDLE. A SINGLE ENGINE LANDING WAS INITIATED. MAINTENANCE PERSONNEL FOUND A T-FITTING ON THE PC FILTER HOUSING BROKEN OFF. THE FILTER ASSY WAS REPLACED, THE ENGINE WAS OPERATIONAL CHECKED AND RETURNED TO SERVICE. (M)

Part: SPRING CARRIER — SPALLED (POWER TURBINE)

ENGINE HAD HISTORY OF CHIP LIGHT ILLUMINATION. ALWAYS BURNED OFF. VISUAL INSPECTION FOUND CHIPS EXCEEDING LIMITS IAW SB LT101-77-30-0104. REMOVED ENGINE FOR REPAIR.

Part: SHAFT ASSY — SHEARED (COOLER BLOWER)

DURING FLIGHT, THE PILOT NOTED THE NR 2 ENGINE OIL PRESSURE DROPPING AND THE OIL TEMPRATURE RISING. HE SHUT DOWN THE ENGINE AS A RESULT, AND PERFORMED A SINGLE ENGINE LANDING. WHILE INVESTIGATING THE CAUSE, THE MECHANIC DISCOVERED THE SHAFT OF THE OIL COOLER BLOWER TO HAVE SHEARED NEXT TO THE SPINE ADAPTER. THE IMPELLERS APPEAR TO HAVE SEIZED INSIDE THE HOUSING.

Part: SHAFT ASSY — SHEARED (COOLER BLOWER)

DURING FLIGHT, PILOT NOTED NR 2 ENGINE OIL PRESSURE DROPPING AND THE OIL TEMPERATURE RISING. HE SHUT DOWN THE ENGINE AS A RESULT AND PERFORMED A SINGLE ENGINE LANDING. WHILE INVESTIGATING THE CAUSE, MECHANIC DISCOVERED THE SHAFT OF THE OIL COOLER BLOWER TO HAVE SHEARED NEXT TO THE SPLINE ADAPTER. THE IMPELLERS APPEAR TO HAVE SEIZED INSIDE THE HOUSING.

Part: BLADE — CRACKED (T/R)

DURING C/W TAIL ROTOR BLADE VISUAL INSPECTION IN AD 96-01-08, A 5.3 INCH LONG CORD-WISE CRACK WAS DISCOVERED ON THE CONVEX SURFACE OF THE BLADE .25 INCH BELOW THE END OF THE DOUBLER. CRACK SIZE AND LOCATION IS THE SAME AS SHOWN IN THE ILLUSTRATION CONTAINED IN THE AD.