Pilot Debrief

BELL OH 58A near Sacramento, CA — 2016-12-04

Final reportWPR17LA034
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Date
2016-12-04
Location
Sacramento, CA, USA
Airport
MCC
Aircraft
BELL OH 58A
Registration
N916PD
Category
Helicopter
Highest injury
None
Fatalities
0

Probable cause

The failure of the vertical stabilizer due to fatigue.

NTSB narrative

The pilot reported that during the takeoff, flight, and landing for a local routine helicopter patrol flight, he did not experience any turbulence nor did any of the flight controls reveal an indication that something was wrong. The pilot reported that during the postflight inspection, the vertical stabilizer was found bent downward away from the tail rotor. A postaccident examination of the vertical stabilizer revealed a fatigue crack that initiated at the aft end of the inboard skin at about the middle of the span. A stop-drill hole was present above the upper aft attachment hole, indicating that the vertical stabilizer was allowed to continue in service after a crack had been detected that extended about 1 1/4 inches from the aft edge of the inboard edge. The crack intersected the lower side of the stop-drill hole, and a fatigue crack reinitiated from the forward side of the stop-drill and continued to propagate towards the leading edge. The operator acquired the helicopter as US Army surplus. Since 2003, the US Army’s daily inspection checklist included inspection for cracks originating from the four attachment inserts on the inboard of the vertical stabilizer. The operator’s maintenance vendor was not aware of the US Army aviation safety action message for the daily inspection for cracks inboard of the vertical stabilizer. Had those daily inspections of the vertical fin attachment area been accomplished, these cracks would likely have been identified.

Analysis

Primary failure mode
Maintenance
First missed decision gate
Failure to conduct daily inspections of the vertical stabilizer for cracks.

NTSB coding

Evidence available

  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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