Aircraft Accident/Incident Report

Ponce, Puerto Rico 00715
Thursday, January 12, 2006 3:43 AST

NTSB Narrative Summary Released at Completion of Accident

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 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 Narrative

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.

Event Information

Type of Event Accident
Event Date 1/12/2006
Event Day of the Week Thursday
Time of Event 343
Event Time Zone Atlantic Standard Time
Event City Ponce
Event State PUERTO RICO
Event Country --
Zipcode of the event site 00715
Event Date Year 2006
Event Date Month 1
MidAir Collision Indicator --
On Ground Collision occurred ? --
Event Location Latitude 180000N
Event Location Longitude 0663300W
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 --
Investigator's weather source Weather Observation Facility
Time of the weather observation 350 Atlantic Standard Time
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID TJPS
Elevation of weather observation facility 23
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation AST
Lighting Conditions Night
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
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) 21
Dew Point at event time (in degress fahrenheit) 18
Wind Direction (degrees magnetic) 120
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 6
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.98
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Minor
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor 1
Injury Total None 3
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 22787
NTSB Notification Source FAA ATL Comm. Center
NTSB Notification Date Jan 12 2006 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Dec 20 2007 6:59AM
User who most recently changed record NTSB\johb
Basic weather conditions Visual Meteorological Cond
FAA District Office San Juan, Puerto Rico

Aircraft Involved

Aircraft #1

Aircraft Registration Number N495LF
NTSB Number MIA06LA044
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 135: Air Taxi & Commuter
Type of Flight Plan filed Company VFR
Flight plan Was Activated? --
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name MBB
Aircraft Model BO-105S
Aircraft Series Identifier --
Aircraft Serial Number S645
Certified Max Gross Weight 5512
Aircraft Category Helicopter
Aircraft Registration Class --
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 Annual
Date of Last Inspection Dec 1 2005 12:00AM
Airframe hours since last inspection --
Airframe Hours 7566
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name MSE Air Group Inc.,
Aircraft Owner Street Address P.O. Box 9066313
Aircraft Owner City San Juan
Aircraft Owner State PR
Aircraft Owner Country USA
Aircraft Owner Zipcode 00917
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 Q6WA
Owner has at least one certificate --
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 Non-scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board No
Departure Point Same as Event Yes
Departure Airport Code --
Departure City Ponce
Departure State PR
Departure Country USA
Departure Time 343
Departure Time Zone AST
Destination Same as Local Flt --
Destination Airport Code --
Destination City San Juan
Destination State PR
Destination Country USA
Specific Phase of Flight Takeoff - initial climb
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Nov 29 2007 2:25PM
User who most recently changed record KENJ
Since inspection or accident Last Inspection
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight Yes
Medical Flight --