Saturday, August 8, 2015

Knowledge of emergency procedures and aircraft limitations...A non-negotiable requirement for any pilot...

NTSB Identification: ERA13LA421
Nonscheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Thursday, September 19, 2013 in Canton, MS
Probable Cause Approval Date: 02/04/2015
Aircraft: AMERICAN EUROCOPTER LLC AS350B2, registration: N810LE
Injuries: 1 Serious, 3 Minor.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
As the helicopter departed the helipad, a witness saw dark black smoke coming out of the engine exhaust. (This smoke would not have been visible to the pilot.)

(Sidebar: Does your AMRM training include everyone involved in your operations? Would a hospital security guard know what to do, who to call, what to say if she saw something wrong with your aircraft as you were leaving her hospital's helipad? )

The pilot reported that, about 10 minutes after departure, he noticed the illumination of the low engine oil pressure warning light. He noted that the oil pressure gauge was also showing low pressure but that there was no rise in the oil temperature or the exhaust gas temperature. Because the pilot had recently experienced an intermittent oil pressure gauge problem in another helicopter, he assumed the accident helicopter was experiencing a similar problem and continued toward the intended destination while attempting to verify the loss of engine oil pressure. Several minutes later, the pilot noticed a low-torque indication but no rise in the oil temperature or exhaust gas temperature. About 25 minutes after departure, the pilot saw a rise in the exhaust gas temperature and lowered the collective to reduce power. After briefly decreasing, the exhaust gas temperature began rising again, and the pilot located an open field to perform an off-airport landing. The engine experienced a total loss of power before the helicopter reached the open field; the pilot performed an autorotation, and the helicopter landed hard.
Postaccident examination revealed that the engine oil tank was empty and that the engine had sustained heat damage consistent with overtemperature due to oil exhaustion. An obstruction of solidified oil carbon was found in the rear bearing chip detector housing union, which would have restricted the oil scavenge of the rear bearing. According to the engine manufacturer, failure to scavenge the oil in the rear bearing would cause overpressurization of the rear bearing housing area, which would force engine oil out of the rear bearing vent line. In addition, oil overpressurization could overcome the labyrinth seal of the piston shaft, which would allow oil to flow into the gas exhaust path. It is likely that this occurred because oil flowing into the exhaust path would result in black smoke coming from the engine exhaust as was observed by the witness. The continued operation of the engine in this condition likely resulted in the depletion of the oil reservoir, the illumination of the low engine oil pressure warning light, and, subsequently, as the flight continued, a total loss of engine power.

A review of data recovered from a flight recorder installed in the helicopter indicated that, about 2 minutes after departure (about 26 minutes before the accident), the oil pressure dropped from about 4 bars to about 0.2 bar, which would have illuminated the low engine oil pressure warning light. The flight manual and the cockpit emergency checklist both directed that, when the low engine oil pressure warning light was illuminated and the engine oil pressure gauge indicated low oil pressure (as reported by the pilot), the procedure was to land immediately. If the pilot had followed this procedure instead of continuing the flight with the warning light illuminated, it is likely that the accident would have been prevented. Review of the helicopter’s maintenance records indicated that, about 12 flight hours before the accident flight, the engine’s 2nd-stage turbine disk (T2) was replaced. During the replacement of the T2, the maintenance technician determined that the rear bearing was “clean”; therefore, he did not clean the rear bearing even though the maintenance procedures required a systematic cleaning when the T2 was replaced regardless of the condition of the bearing. If the cleaning had been performed, as called for in the maintenance procedures, it is likely that the oil carbon deposit in the rear bearing chip detector housing union would have been discovered and removed, thus averting the accident.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
  • The pilot’s improper decision to continue flight with a low engine oil pressure warning light instead of landing immediately in accordance with the flight manual emergency checklist. Contributing to the accident was the maintenance technician’s failure to clean the rear bearing in accordance with the engine manufacturer’s guidance when replacing the 2nd-stage turbine wheel, which resulted in an obstruction of solidified oil carbon in the rear bearing chip detector housing union, subsequent oil exhaustion, and engine failure. 

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