Primary finding
Probable cause
Insufficient lubrication within the tail rotor gearbox, which resulted in the seizure of the duplex ball bearing and a fixed pitch setting of the tail rotor. Also causal, was the pilot's loss of control, which was the result of a relative low speed/high power combination during a go-around attempt. A factor was the manufacturer's lack of procedures for fixed tail rotor pitch settings.
Investigator assessment
Analysis narrative
The pilot stated he that performed a pre-flight inspection, checked the fluids, and ensured that the cowlings were closed and secured prior to conducting the helicopter's post-maintenance track and balance flight. In flight, after conducting several maneuvers, and while the helicopter was flying straight and level at 120 knots, the pilot noticed he had no anti-torque pedal control. He declared an emergency, and attempted numerous approaches to two different runways. Every time the helicopter slowed to 80-100 knots, the nose would swing to the left. During the final approach, while nearing touchdown on the runway, the pilot added collective, and the helicopter climbed while spinning to the left. The pilot reduced power, and the helicopter descended to, and impacted the ground while still in a left spin. Post-accident examination revealed that the bellcrank fitting at the tail servo input was broken, and there was very little oil in the tail rotor gearbox. There was no evidence of oil leakage at the seals or the filler cap. A small amount of oil was recovered, which was black in appearance. The oil level sight gage was marked with a black line, 6 to 7 mm below the minimum fill level. The output drive shaft duplex bearing displayed no evidence of lubrication. The inner races of the duplex bearing were removed and one displayed signs of wear and heat damage. The outer races contained metal transfers similar to the bearing cage, and the duplex bearing was seized. The flight manual did not contain any emergency procedures for a stuck (fixed pitch) tail rotor. -
Source record
Factual narrative
HISTORY OF FLIGHT On December 18, 2000, at 1530 eastern standard time, an Aerospatiale (Eurocopter) SA365-N1, N89SM, was destroyed during an attempted go-around at Allegheny County Airport (AGC), West Mifflin, Pennsylvania. The certificated airline transport pilot and one onboard maintenance technician were seriously injured, while another onboard maintenance technician received minor injuries. There was no flight plan filed for the flight, which was conducted under visual meteorological conditions. The post-maintenance test flight was conducted under 14 CFR Part 91. According to the pilot, he was conducting a track and balance flight. He completed a pre-flight inspection, checked the fluids, and ensured the cowlings were closed and secured. He started the helicopter, lifted off, and completed a hover check. After departing the airport, the onboard maintenance technicians requested that the pilot put the helicopter in an 80-knot, 1,000 foot-per-minute climb for about 30 seconds. He then flew the helicopter straight and level at 80 knots for an additional 30 seconds. He was next requested to fly the helicopter straight and level at 120 knots, and as it accelerated, he noticed that his right pedal input was not compensating for the additional power. He then applied full right and full left pedal with no response from the helicopter. The pilot then told the maintenance technicians that he had "no rudder control," and that he was going to see what helicopter control he had while making a 70-knot approach. The pilot called the air traffic control tower, apprised the controller of the situation, declared an emergency, and asked that fire trucks be dispatched. The tower controller advised him that he could use whatever runway he wanted, and the pilot opted for runway 28 since "the winds were not a factor with only 4 knots and 28 was the widest runway." During the first approach, the pilot maintained airspeeds between 70 and 80 knots, and approaching the runway, the helicopter's nose was out to the right. When the helicopter was 2 to 3 feet above the runway and still descending, the pilot eased the collective down to bring the nose around for a run-on landing; however, "the nose came from right to left so fast that a safe run-on landing could not be made." Then pilot attempted "numerous" approaches to runway 28, and then "tried runway 23 for more favorable winds," but found that the helicopter would not respond "as per tail rotor loss procedures of the flight manual." During his last approach, the helicopter "became uncontrollable and the only good thing about the final landing was that we all lived to tell the story." One of the onboard maintenance technicians noted that, during the return to the airport, the pilot stated that he thought he had regained some control. The pilot attempted to do a run-on landing; however, when the airspeed dropped below 100 knots, the helicopter began to rotate to the left. At that point, the pilot was sure he had no control of the tail rotor. The pilot attempted 8 or 10 approaches to runway 28, and after talking to two of the company's other pilots on the radio, he decided to try to land on runway 23. After the first approach, the pilot advised the assisting pilots that he "thought it would better on the new runway." During the next approach, the maintenance technician looked out the front windshield, when the helicopter "was almost level with the runway." When the helicopter was over the runway threshold, it was about 6 to10 feet off the ground. The maintenance technician thought the pilot was going to land, "but [the pilot] turned it hard left and leaned into it pulling collective to kill airspeed. It worked, but we started to spin 360, climbing and pitching up and down all at the same time." The helicopter then pitched "hard nose up and the ground was coming up fast." The maintenance technician then heard one of the assisting pilots on the headset yelling, "get the nose down" several times, then the helicopter impacted the ground. According to one of the assisting pilots, the accident pilot confirmed over the radio that he had no tail rotor control. Also, after the accident pilot switched runways, he found that "the aircraft seemed to behave better during the approach with the right crosswind but the wind was less than 10 knots and did not help much." He also stated that every time he slowed below 100 knots, the nose of the helicopter would swing to the left. The assisting pilot thought the accident pilot made three approaches to runway 23. They discussed the possibility of an autorotation, "but the recommended procedure in the RFM is the running landing." The accident pilot also stated several times that the nose of the aircraft would just not stay to the right at airspeeds below 100 knots. During the last approach, the accident pilot appeared to slow the helicopter, and attempted a go-around. However, as he added power, the nose pitched up and the aircraft began a climbing left spin. Another assisting pilot told him to lower the collective and get the nose down "which [he] appeared to do prior to impact." Another assisting pilot stated that the accident pilot made some low approaches to determine what airspeed the nose of the helicopter would begin to turn. "The [accident pilot]...stated that the slowest he could get before the aircraft started to turn was about 80 knots." The assisting pilot asked the accident pilot to turn off the autopilot yaw channels to eliminate possibility of an AFCS yaw actuator problem. He also advised the accident pilot of the procedure for loss of tail rotor drive/control failure in flight., which included making a shallow approach at 90-100 knots and at 15-20 feet agl. "Start a collective reduction and keep the descent going to 1-2 feet above the runway. As the nose of the aircraft aligns, lower collective and allow main and nose landing wheels to touch down, and subsequently use differential braking for directional control." In addition: "On the [accident] pilot's last approach, he appeared to almost touch down, but then started a go-around. He climbed and started to turn left. His speed was too slow to have the airflow over the side fins and vertical fins to be effective in counteracting the torque of the main rotor. The aircraft began spinning to the left. I transmitted to lower his nose and lower the collective. He did so and descended, and the spinning appeared to slow. The aircraft then nosed up. I did not have a good view of the actual contact with the ground. I did get permission to assist the FAA inspectors later. I observed that both AFCS yaw channel buttons were in the raised or off position, and that the yaw auto trim switch was off." Another, non-company helicopter pilot also observed the accident. During the accident approach: "...the aircraft slowed more than before, and it appeared the pilot was attempting to land.... When the aircraft was approximately 5 feet above the surface, with an estimated airspeed of 15-20 knots, the pilot pulled pitch in an apparent attempt to go around. The nose began to yaw left, and the aircraft entered a rapid climbing turn through approximately 150 degrees of arc and 30-40 feet of altitude. It began a rapid left spin while climbing another 50-70 feet. The aircraft made 4 or 5 complete rotations accompanied by pitch oscillations of approximately 20-30 degrees above and below a level attitude and roll oscillations of approximately 5-10 degrees. The aircraft then descended to the ground, impacting in a tail-low attitude." According to a Federal Aviation Administration (FAA) inspector, the helicopter impacted the ground while still in a left spin, and with the nose tucked, but came to rest in an upright position. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate, with single engine land airplane, multi-engine lan