Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Ponte Vedra Bch, Florida 32082
Tuesady, March 27, 2007 10:30 EDT
NTSB Narrative Summary Released at Completion of Accident
The local instructional flight was scheduled for a east departure from the airport and a flight south along the coastline. Several witnesses observed the helicopter approximately 200-500 feet above ground level (agl) in cruise flight along the coastline on a south heading. One witness, a former pilot and mechanic, reported he observed the helicopter in straight and level flight, then heard a change in "rotor noise, followed by a bang/pop/twang sound." The helicopter then "snap-rolled" to the left and descended into the terrain in a nose low attitude. Examination of the helicopter's flight control system revealed that the right forward servo to swashplate push-pull tube joint was disconnected and the attach hardware (bolt, lock nut, two washers, pal nut) was missing. The left forward servo to swashplate push-pull joint was connected; however, the nut was found partially engaged on the bolt threads, and the torque was "finger tight"; no pal nut was noted. Material analysis of the components revealed that only one of the two nuts for the left and right connections were installed, and then only finger tight. The nut on right servo connection rotated off during flight which allowed the bolt to extract itself and disconnect the servo from the push-pull tube. Prior to the accident flight, an inspection, which required the push-pull tubes to servo connections to be disassembled, was performed on the helicopter, and a 0.5-hour maintenance test flight. The mechanic who preformed the inspection, stated he forgot to properly secure the hardware for the left and right servo connections. The mechanic stated the reasons for the error were the following: 1. He was pulled," in all directions" by company personnel since his arrival at that facility; 2. The "reassembly was not opposite of the disassembly," which was a personal maintenance practice he used to eliminate errors; 3. Two nights prior to the completion of the inspection and the maintenance test flight, the apprentice providing assistance, wanted to stay late to finish with the mechanic a certain section of the inspection. As a result, the mechanic forgot to go back and secure the hardware connecting the two push-pull tube to servo joints; 4. The company was understaffed with maintenance personnel. According to the company's maintenance quality control program, any maintenance completed on a helicopter was to be inspected by another mechanic. A review of the program revealed that the mechanics were not following the program, and the company was not providing oversight and enforcing the program.
NTSB Probable Cause Narrative
the mechanic's improper installation of the attachment hardware for the servo to swashplate push-pull tube joint which resulted in a disconnection, subsequent loss of control, and impact with terrain. Contributing factors were the company management's inadequate surveillance and enforcement of maintenance procedures, the excessive maintenance workload due to inadequate staffing of maintenance personnel, and the insufficient management of maintenance tasks.
Event Information
| Type of Event | Accident |
| Event Date | 3/27/2007 |
| Event Day of the Week | Tuesday |
| Time of Event | 1030 |
| Event Time Zone | Eastern Daylight Time |
| Event City | Ponte Vedra Bch |
| Event State | FLORIDA |
| Event Country | -- |
| Zipcode of the event site | 32082 |
| Event Date Year | 2007 |
| Event Date Month | 3 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 301354N |
| Event Location Longitude | 0812232W |
| 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 | Witness |
| Time of the weather observation | |
| Direction of event from weather observation facility (degrees) | -- |
| Weather Observation Facility ID | -- |
| Elevation of weather observation facility | -- |
| Distance of event from weather observation facility (units?) | -- |
| Time Zone of the weather observation | -- |
| Lighting Conditions | Day |
| 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) | 24 |
| Dew Point at event time (in degress fahrenheit) | -- |
| Wind Direction (degrees magnetic) | 360 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 10 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | -- |
| Density Altitude (feet) | -- |
| 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 | 2 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 2 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 22975 |
| NTSB Notification Source | NTSB-Communications Center |
| NTSB Notification Date | Mar 27 2007 12:00AM |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | Jan 30 2008 4:08PM |
| User who most recently changed record | NTSB\johb |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | Orlando, Florida |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N744SH |
| NTSB Number | DEN07FA079 |
| 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 | Ground |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Robinson |
| Aircraft Model | R44 II |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 10830 |
| Certified Max Gross Weight | 2500 |
| 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 | 4 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | 100 Hour |
| Date of Last Inspection | Mar 1 2007 12:00AM |
| Airframe hours since last inspection | 1 |
| Airframe Hours | 861.6 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | Silver State Helicopters LLC |
| Aircraft Owner Street Address | 500 East Cheyenne |
| Aircraft Owner City | North Las Vegas |
| Aircraft Owner State | NV |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 89030 |
| 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 | -- |
| 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) | Instructional |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | CRG |
| Departure City | JACKSONVILLE |
| Departure State | FL |
| Departure Country | USA |
| Departure Time | 1010 |
| Departure Time Zone | EDT |
| Destination Same as Local Flt | dest & departure same, accident can occur anywhere |
| Destination Airport Code | -- |
| Destination City | -- |
| Destination State | -- |
| Destination Country | -- |
| Specific Phase of Flight | Cruise |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jan 15 2008 4:11PM |
| User who most recently changed record | BOWL |
| Since inspection or accident | Last Inspection |
| Event Location Runway Number and Location | NA |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |