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January 12, 2006 · Mbb BO-105S · N495LF

Ponce, PR

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
January 12, 2006
Injury Outcomes
1 injury (1 minor injury), 3 uninjured
Location
Ponce, PR
Aircraft
Mbb BO-105S
Tail Number
N495LF
Operator
Aviane Air Ambulance
Injuries
Minor
Aircraft Damage
Substantial
NTSB Number
MIA06LA044

After the patient was placed aboard the helicopter, the pilot started the engines and performed a hover check. He then moved the helicopter forward to gain airspeed and initiated a climb to cruise altitude. After reaching an altitude of about 100 feet, the main rotor rpm light and audio warning system activated, and the number 2 engine N1 rpm and torque began to decay. The pilot attempted to regain normal engine parameters, but was unable to regain engine rpm. The pilot maneuvered to avoid several light poles as he attempted to land in a parking lot. By this time, main rotor rpm had bled off sufficiently to prevent the hydraulic pumps from pressurizing the hydraulic system, and all flight controls locked in a slight right banked attitude. This prevented the helicopter from reaching the parking lot. The helicopter impacted a construction area in a right bank, nose down attitude. An on-site and later follow-up investigation by FAA and Rolls-Royce investigators revealed a B-nut on the Pc line connecting the power turbine governor (PTGOV) to the fuel control unit (FCU) had become loose at the T-fitting end. It was partially torqued and could be moved with the fingers. The female end was threaded onto the male end three-quarters of a turn. There was no cross-threading. The torque stripe was broken. According to Rolls-Royce Allison, "This line serves a critical function to the engine control system and when leakage occurs will cause the engine to roll back to an idle or near idle condition."

NTSB Probable Cause

A loose B-nut on the PC line connecting the power turbine governor (PTGOV) to the fuel control unit (FCU) that created a leak and caused the engine to roll back to an idle condition, causing a low hydraulic system pressure and subsequent control lock. A contributing factor was the unsuitable terrain (construction area) on which to make a forced landing.

Full Narrative

On January 12, 2006, at 0343 Atlantic standard time, a Eurocopter Messerschmitt-Boelkow-Blohm BO-105S, N495LF, registered to and operated by MSE Air Group, Inc., as Aviane Air Ambulance, and piloted by a commercial-certificated pilot, was substantially damaged when it collided with terrain during an attempted forced landing following a loss of power in one of its engines during takeoff from San Cristobal Hospital, Ponce, Puerto Rico. Night visual meteorological conditions prevailed at the time of the accident. The air ambulance flight was being conducted under the provisions of Title 14 CFR Part 135, and a company visual flight rules (VFR) flight plan had been filed. The pilot sustained minor injuries, and two medical flight crew members and one passenger were not injured. The flight had originated in San Juan, Puerto Rico, at 0141. The pilot stated that the flight from San Juan to Ponce had been uneventful, and landed at 0205. After the patient was placed aboard the helicopter, the pilot started the engines and performed a hover check. He then moved the helicopter forward to gain airspeed and initiated a climb to cruise altitude. After reaching an altitude of about 100 feet, the main rotor rpm light and audio warning system activated, and the number 2 engine N1 rpm and torque began to decay. The pilot attempted to regain normal engine parameters, but was unable to regain engine rpm. The pilot maneuvered to avoid several light poles as he attempted to land in a parking lot. By this time, main rotor rpm had bled off sufficiently to prevent the hydraulic pumps from pressurizing the hydraulic system, and all flight controls locked is a slight right banked attitude. This prevented the helicopter from reaching the parking lot. The helicopter impacted a construction area in a right bank, nose down attitude. An on-site and a later follow-up investigation by FAA and Rolls-Royce investigators revealed a B-nut on the Pc line connecting the power turbine governor (PTGOV) to the fuel control unit (FCU) had become loose at the T-fitting end. It was partially torqued and could be moved with the fingers. The female end was threaded onto the male end three-quarters of a turn. There was no cross-threading. The torque stripe was broken. According to Rolls-Royce Allison, "This line serves a critical function to the engine control system and when leakage occurs will cause the engine to roll back to an idle or near idle condition."

Flight

Event TypeAccident
Event Time03:43 AST
Nearest Airport0nm
Flight Plan FiledCvfr
Flight Plan ActivatedUnknown
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftMbb BO-105S
Tail NumberN495LF
Aircraft CategoryHeli
DamageSubstantial
OperatorAviane Air Ambulance
Operating RulePart 135
Engines2
Engine TypeTurboshaft
Engine DetailsAllison · 250-C20B · Turboshaft · 715 | Allison · 250-C20B · Turboshaft · 715
Seats3

People & Injuries

Injury Summary1 injury (1 minor injury), 3 uninjured
Fatal0
Serious0
Minor1
Uninjured3
Total4
Crew 1Age 59 · Third Class · Minor

Conditions

ConditionsVMC
LightNight
Wind120° @ 6 kt
Visibility10 sm
CeilingNone
Temperature / Dew Point70 F / 64 F
Altimeter29.97 inHg
Observation Time07:50
Weather SourceWFAC

Appendix: Source Data