Aircraft Accident/Incident Report

Salt Lake City, Utah 84101
Saturday, June 7, 2003 20:12 MDT

NTSB Narrative Summary Released at Completion of Accident

The helicopter flight crew had just finished rescuing a lost hiker and was preparing to return to their home base. The pilot informed the flight nurse that dispatch wanted them to proceed home because the helicopter was due its 25-hour inspection. The pilot mentioned that he first needed to return to the location where they picked up the hiker so he could get an altitude reading. Before taking off, search and rescue personnel warned the pilot of paragliders in the area. The flight nurse said the pilot acknowledged them, and then took off and proceeded southbound. The flight nurse said they were climbing out when she heard a loud noise. She said it seemed to come from beneath the helicopter. She said she heard the pilot say, "Oh no" and then the helicopter began spinning clockwise out of control. The flight nurse said she was being tossed around, but was trying to get into a position for the crash. Then the helicopter impacted the ground. The flight nurse said she got out through the front of the helicopter. She said she checked the paramedic and the pilot, and then went for the radio to call for help. She said that the engines were still running and she smelled fuel. At that point she noticed the tail rotor was missing. Several witnesses on the ground heard and saw the helicopter. The witnesses recalled the helicopter took off and made a right turn to proceed south. Some of the witnesses said they heard a loud bang. Most of the witnesses described the helicopter as doing a 360-degree counter clockwise turn, then the nose of the helicopter pitched up, the tail rotor came off, and the helicopter continued to spin and descend until it impacted the hillside. An examination of the helicopter's broken tail rotor trunnion showed four separate fatigue areas originating from the inner splines. The exam also showed that the fatigue occurred due to stresses that exceeded the design spectrum. Excessive heating was noted due to friction between the trunnion and blade grip bushings. The tail rotor trunnion had a published service life of 2,700 hours. At the accident, the trunnion had 698.0 total hours.

NTSB Probable Cause Narrative

Fatigue of the tail rotor trunnion resulting in complete trunnion failure and subsequent tail rotor separation from the helicopter. Factors contributing to the accident were the low altitude, low airspeed, excessive tail rotor loading, and the worn tail-rotor blade grip bushings.

Event Information

Type of Event Accident
Event Date 6/7/2003
Event Day of the Week Saturday
Time of Event 2012
Event Time Zone Mountain Daylight Time
Event City Salt Lake City
Event State UTAH
Event Country --
Zipcode of the event site 84101
Event Date Year 2003
Event Date Month 6
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 404326N
Event Location Longitude 1114314W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 2056 Mountain Daylight Time
Direction of event from weather observation facility (degrees) 130
Weather Observation Facility ID SLC
Elevation of weather observation facility 4227
Distance of event from weather observation facility (units?) 14
Time Zone of the weather observation MDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height 25000
Sky/Lowest/Cloud Conditions Few
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 24
Dew Point at event time (in degress fahrenheit) -11
Wind Direction (degrees magnetic) --
Variable Wind Indicator Variable
Wind Speed (knots) 3
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.95
Density Altitude (feet) 6261
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 1
Injury Total Minor 1
Injury Total None 1
Injury Total Serious --
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 20091
NTSB Notification Source Frontier Air Lines
NTSB Notification Date Jun 7 2003 12:00AM
NTSB Notification Time 2047
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record May 30 2006 1:54PM
User who most recently changed record NTSB\JOHB
Basic weather conditions Visual Meteorological Cond
FAA District Office Salt Lake City, Utah FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N123RX
NTSB Number DEN03FA099
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed Company VFR
Flight plan Was Activated? Yes
Damage Destroyed
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Agusta
Aircraft Model A109K2
Aircraft Series Identifier --
Aircraft Serial Number 10018
Certified Max Gross Weight 6283
Aircraft Category Helicopter
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 3
Number of Engines 2
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection May 28 2003 12:00AM
Airframe hours since last inspection 22.5
Airframe Hours 4833.3
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name IHC Hospitals, Incorporated DBA
Aircraft Owner Street Address Eighth Avenue and C Street
Aircraft Owner City Salt Lake City
Aircraft Owner State UT
Aircraft Owner Country USA
Aircraft Owner Zipcode 84143
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country --
Operator Zip code --
Operator Code I7LA
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Positioning
Second Pilot on Board No
Departure Point Same as Event Yes
Departure Airport Code --
Departure City Salt Lake City
Departure State UT
Departure Country USA
Departure Time 2011
Departure Time Zone MDT
Destination Same as Local Flt --
Destination Airport Code SLC
Destination City Salt Lake City
Destination State UT
Destination Country USA
Specific Phase of Flight Takeoff - initial climb
Report sent to ICAO? Yes
Evacuation occurred No
Date of most recent change to record Jan 16 2004 2:23PM
User who most recently changed record MCBM
Since inspection or accident Time of Accident
Event Location Runway Number and Location --
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight Yes
Medical Flight Discretionary