Pilot Debrief

BELL 214ST near Avalon, TX — 2012-08-07

Final reportCEN12LA525
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Date
2012-08-07
Location
Avalon, TX, USA
Aircraft
BELL 214ST
Registration
N409SB
Category
Helicopter
Highest injury
None
Fatalities
0
Phase of flight
Maneuvering

Probable cause

Maintenance personnel’s failure to properly torque the retaining nut and install the cotter pin that secured the helicopter’s tail rotor counterweight bellcrank. Contributing to the accident was the lack of detailed maintenance records that documented previous maintenance actions.

NTSB narrative

The helicopter was on its third test flight when the tail rotor 90-degree gearbox broke in two and separated from the helicopter. The crew conducted an autorotation to a field, and the helicopter came to rest on its side. Examination of the helicopter and components revealed that one of the tail rotor's two counterweight bellcranks and associated hardware were missing. Impact marks consistent with a counterweight bellcrank were found at the base of its associated tail rotor blade and on the aft right side of the helicopter. The remaining counterweight bellcrank was in place; however, the cotter pin for the castellated nut was missing. A review of the aircraft maintenance records revealed that the tail rotor assembly had been removed and reinstalled after the installation of test instrumentation. The maintenance records lacked specific details on whether the unit and its components were previously handled as a subassembly or as individual components when the tail rotor assembly was initially removed. Because the records did not indicate whether the unit should be handled as individual parts, the tail rotor was reinstalled as a complete subassembly, meaning that individual components, such as the nut and cotter pin, were not individually inspected before or after reinstallation on the helicopter. Reinstalling the tail rotor assembly in this manner led to the counterweight bellcrank retaining nut not being properly torqued and secured with a cotter pin.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Proper inspection and assembly of the tail rotor components before installation.

NTSB coding

Evidence available

  • Photos
  • 6 docket documents
View NTSB final reportView NTSB docket

Docket documents6

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