Aviation Investigation Final Report
Location: Eden, North Carolina Accident Number: ERA21FA195
Date & Time: April 28, 2021, 13:24 Local Registration: N53DE
BELL HELICOPTER TEXTRON
Aircraft: Aircraft Damage: Destroyed
CANADA 429
Defining Event: Part(s) separation from AC Injuries: 1 Fatal, 2 Serious
Flight Conducted Under: Part 91: General aviation - Aerial observation
Analysis
The helicopter departed and flew cross-country to begin a powerline patrol, which included
flying adjacent to powerlines at an altitude of about 100 ft above ground level and with the
helicopter gaining altitude during turns and when flying between line inspections.
During the final minutes of flight, the helicopter was traveling at an airspeed between 50 and
60 kts along powerlines at an altitude between 700 and 775 ft above mean sea level (msl). As
the helicopter flew south, near the end of the north-south powerline’s right of way, the
helicopter began a climbing right turn towards the west. A utility lineman in the helicopter’s
front left seat recalled that the pilot was reversing course and the helicopter was in a banking
turn to the right when he heard a very loud noise, “almost cannon-like, very deep, within a
second or two we were heading into the trees.” Onboard data recovered from the helicopter
showed rotor speed suddenly increased to 107% about 1.5 seconds before the end of recorded
data. Examination of the wreckage showed evidence the main rotor blades impacted the tail
rotor drive system. Therefore, it is likely the loud noise heard by the onboard lineman was
caused by the main rotor blades impacting the tail rotor drive system, resulting in a severance
of the tail rotor drive shaft and subsequently a loss of directional control. Successful recovery
of the helicopter after the loss directional control at a low altitude was unlikely and resulted in
impact with terrain. Based on analysis of flight data and a scan of the local terrain, it is unlikely
the helicopter impacted powerlines or nearby trees at the time the main rotor blades impacted
the tail rotor drive system.The loss of clearance between the main rotor and the tail of the
helicopter can be caused by sudden aft cyclic control inputs, usually in conjunction with a
reduction in collective pitch that would reduce main rotor thrust and increase downward
flapping of the blade. The lack of flight control parametric data precluded analysis of flight
control inputs at the time the main rotor blade contacted the tail boom. However, it is likely the
Page 1 of 12
pilot was not maneuvering to avoid trees based on the increasing distance between the
accident helicopter and treetops near the end of the accident flight. Examinations of the
helicopter wreckage found no evidence of any preimpact anomalies or malfunctions that
would have precluded normal operation of the helicopter.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The impact of the main rotor blades with the tail boom during low-altitude maneuvers, which
severed the tail rotor drive shaft and resulted in a loss of control and impact with terrain.
Findings
Aircraft Tail rotor drive shaft - Damaged/degraded
Aircraft Directional control - Attain/maintain not possible
Page 2 of 12 ERA21FA195
Factual Information
History of Flight
Uncontrolled descent Part(s) separation from AC
Maneuvering-low-alt flying Loss of control in flight
Maneuvering-low-alt flying Part(s) separation from AC (Defining event)
On April 28, 2021, about 1324 eastern standard time, a Bell 429 helicopter, N53DE, was
destroyed when it was involved in an accident near Eden, North Carolina. The commercial pilot
was fatally injured, and two passengers were seriously injured. The helicopter was operated as
a Title 14 Code of Federal Regulations Part 91 aerial observation flight.
The helicopter was equipped with a GPMS Foresight MX Health and Usage Monitoring System
(HUMS), which captured data for the accident flight. The HUMS device recorded position,
attitude, acceleration, rotor speed (Nr), and engine data.
The HUMS data showed the helicopter departed Danville, Virginia, about 1233 and flew cross-
country south-west into North Carolina. By 1245, the helicopter was flying a powerline patrol
around Eden, North Carolina. The powerline inspection was accomplished at an altitude of
about 100 ft above the terrain with the helicopter gaining altitude during turns and when flying
between line inspections.
During the final minutes of flight, the helicopter was traveling at an airspeed between 50 and
60 kts parallel to powerlines at an altitude between 700 and 775 ft msl (Figure 1). Nr was near
100%, torque varied between 15% and 25%, and the engine gas generator (N1) speeds were
between 84 and 88%.
Page 3 of 12 ERA21FA195
Figure 1- Combined map of flight track with corresponding flight parameters.
A utility lineman seated in the front left seat recalled that the pilot was reversing course and
the helicopter was in a banking turn to the right when he heard a very loud noise, “almost
cannon-like, very deep, [and] within a second or two we were heading into the trees.” Several
ground witnesses nearby observed the accident flight. One witness driving westbound
observed the helicopter cross the road heading southbound, flying low over the trees along the
powerlines. The helicopter made a right turn before it disappeared behind trees. Two other
witnesses observed the helicopter flying from east to west over the trees before making a
steep “left turn” as seen from their vantage point; however, as the helicopter pointed toward
the witnesses, it was in a right turn. The witnesses stated they could see the underside of the
helicopter and skids before it “slid at an angle downward and disappeared into the woods.”
The Bell 429 is a light, twin-engine helicopter. It was maintained by the operator under the
manufacturer’s recommended inspection program. Log sheet 1071, which was found at the
accident site and, although undated, was presumably from the day of the accident, showed
that at the start of the day the helicopter had an airframe total time of 283.5 hours and both
engines had an engine total time of 283.5 hours.
There were abnormalities in the recovered HUMS data that led to the attitude and acceleration
data being unreliable for use in this investigation. The accident helicopter was not equipped
with, nor was it required to be equipped with a cockpit voice/flight data recorder (CV/FDR),
which is an available option offered by Bell.
The flight was also recorded by Automatic Dependent Surveillance-Broadcast (ADS-B) data
provided by the Federal Aviation Administration (FAA). ADS-B broadcasts an aircraft’s Global
Positioning System (GPS) position and other data to the ground where it is recorded.
Page 4 of 12 ERA21FA195
The helicopter impacted wooded terrain at an elevation of 570 ft and came to rest on a
heading of about 251° magnetic and about 393 ft from the powerlines the crew was observing.
All major components of the helicopter were accounted for at the accident site. A post-crash
fire occurred and damaged the majority of the fuselage. The overall concentrated debris path
was about 200 ft long on a 245° heading with several pieces scattered in multiple directions
outside the main debris path. Remnant carbon fiber layup was present in the area of the upper
cowlings, fuselage skin, and doors. The cockpit, cabin floor, and the transmission and engine
deck were present but sustained heavy thermal damage. The avionics and wiring were strewn
outside the nose section, with pieces of wood branches embedded within the wiring.
The main rotor hub remained attached to the main rotor mast. The two yoke assemblies
remained installed with the mast nut intact. The main rotor blades remained installed to their
respective grips via blade pins. All blade attachment hardware was present and secured. All
four blade tips exhibited impact damage and their spars exhibited a “broom straw”
appearance. Three separated leading edge pieces near the tip end, including the tip cap lap
joint, were found in the debris field (surrounding the main wreckage). All four main rotor blade
pitch horns remained intact, and all four pitch change links were connected to their respective
pitch horns and the rotating swashplate. The main rotor transmission was partially separated
from the airframe.
The tail boom had fractured into multiple pieces, the majority of which were found adjacent to
and behind the fuselage. The tail rotor was hanging to one side of the gearbox due to
fracturing of the output shaft and bending of the pitch control rod. The two tail rotor yokes
remained installed on the tail rotor output shaft and were whole. All four tail rotor blades
remained installed on the yokes. None of the tail rotor drive shaft covers remained installed on
the tail boom. The horizontal stabilizer remained attached to a separated portion of the tail
boom. The left horizontal stabilizer was generally whole with a puncture near the inboard side
of its lower surface as well as a puncture near the outboard side of its upper surface. The left
finlet remained attached with the lower portion intact and the upper portion fractured and
partially separated. The right horizontal stabilizer was generally whole on its inboard end but
was fractured at its outboard end. The lower portion of the right finlet was fractured and
partially separated, remaining attached only by wiring. The upper portion of the right finlet was
fractured and completely separated. The leading edge slats were present on the inboard
portions of both left and right horizontal stabilizers but were fractured and separated on their
outboard sections. Pieces of blue-colored composite fairing consistent with the tail rotor drive
shaft cover were found in the flight path leading up to the main wreckage. The leading edge of
the upper vertical fin showed evidence of impact deformation and separation above its
attachment point.
The four main rotor blades were reconstructed in their respective positions and laid out by
their designated colors, Green, Red, Orange, and Blue (Figure 2). Three separated leading edge
pieces near the tip end, including the tip cap lap joint, were found in the debris field
surrounding the main wreckage. Two swept tip ends, which were fractured and separated,
Page 5 of 12 ERA21FA195
were reconstructed by the investigation team to the ‘blue’ and ‘orange’ main rotor blades. Two
additional swept tip ends, also fractured and separated, exhibited impact damage with a width
consistent with contact with the tail rotor drive system aft snubber and belonged to the ‘red’
and ‘green’ main rotor blades (Figure 3). All four swept tip ends were found in the debris field
leading up to and around the main wreckage.
Figure 2- A reconstruction of the four main rotor blades; From top to bottom, Green, Red, Orange, and Blue.
Page 6 of 12 ERA21FA195
Figure 3- An approximate reconstruction of rotor blade impact damage on the blade tip that is consistent with the dimensions of
the snubber housing.
The yaw hydraulic actuator remained attached to both the airframe and its control bell crank
within the tail boom. The lower portion of the right finlet was fractured and partially separated,
remaining attached only by wiring. The upper portion of the right finlet was fractured and
completely separated. The leading edge slats were present on the inboard portions of both left
and right horizontal stabilizers but were fractured and separated on their outboard sections.
Pieces of blue-colored composite fairing consistent with the tail rotor drive shaft cover were
found along flight path leading up to the main wreckage.
The steel tail rotor drive shaft was continuous to the fan blower shaft. The fan blower shaft
and oil cooler blower remained installed on the airframe but were crushed from impact forces.
The drive shaft was attached at its forward end to the shaft segment running through the oil
cooler blower assembly, one of the lobes (or “ears”) on the adapter assembly was fractured.
The forward segmented drive shaft was fractured about 25 inches aft of its forward
attachment flange. Two additional pieces from the forward segmented drive shaft were
recovered: 1) the midsection of the forward segmented drive shaft, containing the stainless
steel snubber sleeve, was found in the wreckage adjacent to the tail boom and 2) the aft
section of the forward segmented drive shaft, about 40 inches in length, remained attached to
a separated section of the tail boom and remained connected to a forward portion of the aft
segmented drive shaft, about 23 inches in length, and the hanger bearing between them. The
segmented drive shaft hanger bearing and its mount remained attached to the tail boom. A 34-
inch -long section of the aft segmented drive shaft was found embedded near-vertically into
the ground, with about 18 inches buried. The aft portion of the 34-inch section of the aft
segmented drive shaft exhibited an angled cut (Figure 4).
Page 7 of 12 ERA21FA195
Figure 4 - The 34-inch section of the aft segmented drive shaft, the aft end of which exhibited the angular cut.
A piece of a tail rotor drive shaft, semi-circular in its cross-section, was found about 172 ft
from the main wreckage. Additional multiple smaller fragments of composite tail rotor drive
shaft were found in the debris field along the flight path leading up to the main wreckage.
The helicopter was configured with only the pilot flight controls installed in the right cockpit
seat. Various thermally degraded control clevis connections and bell cranks were found in the
main wreckage site, but the majority of the cockpit flight control system was consumed by the
post-crash fire. None of the connection points between linkages and bell cranks exhibited
evidence of fastener disconnection or separation.
The three main rotor servo actuators were found separated on the ground near the forward
end of the main transmission. All three main rotor servo actuators exhibited thermal damage.
The hydraulic lines remained connected to the three servo actuators, allowing for identification
of their positions. The tail rotor servo actuator was found in the tail boom wreckage and its
hydraulic lines remained connected.
The right integrated hydraulic module (IHM) was found on the ground in front of the main
transmission and was partially melted. The left IHM was found within the transmission deck
wreckage, closer to the swashplate assembly, and was whole but covered in soot and
otherwise exhibited no anomalies or debris in the reservoir.
Page 8 of 12 ERA21FA195
The right hydraulic pump was partially melted but the splines and springs, although deformed
due to thermal stress, did not show any anomalies. The left hydraulic pump was whole, and its
exterior was thermally damaged but remained whole and showed no evidence of anomalous
wear.
The lateral, longitudinal, and collective flight control servos exhibited thermal damage. The tail
rotor servo actuator sustained no thermal damage. The flight control servo actuators were
imaged and examined under the direction of the NTSB, and subsequently shipped to
Woodward, Inc. for additional teardown examination. Examination of the four servo actuators
revealed no preimpact or anomalous damage. All components within the valves were present
and all O-rings and backup rings exhibited thermal degradation but were present and no
scoring was noted.
The helicopter was equipped with two Pratt and Whitney PW207D1 engines, both of which
remained installed on the engine deck. The No. 1 engine exhibited thermal damage, and the
No. 2 engine exhibited thermal and impact damage. Both electronic engine controls (EECs)
and data collection units (DCUs) for the Nos. 1 and 2 engines were removed for download but
usable data could not be retrieved from either of the units due to thermal and impact damage.
Postaccident examination of both engines and their respective components revealed no
evidence of any preimpact mechanical malfunctions or failures that would have precluded
their normal operation.
The North Carolina Department of Health and Human Services, Office of the Chief Medical
Examiner performed the pilot’s autopsy. According to the autopsy report, the cause of death
was smoke inhalation and thermal injuries with blunt forces contributing.
The FAA Forensic Sciences Laboratory performed toxicological testing of postmortem
specimens from the pilot. There were no findings of a contributory nature.
A performance study was accomplished utilizing the HUMS data along with ADS-B data,
weather data, and published Bell performance data. The HUMS data did not record flight
control inputs, so the pilot inputs during the final climb and maneuver at the time of the
accident were unknown. The helicopter was not near the edge of its operating performance
envelope for speed, altitude or temperature and reported weather at the time of the accident
was clear with 10 statute miles visibility.
A LIDAR (“light detection and ranging” or “laser imaging, detecting, and ranging”) scan was
conducted in the area of the accident by Duke Energy to record the location of powerlines and
surrounding terrain, including the trees. Analysis of the accident flight path using the HUMS
data and the LIDAR scan showed the accident helicopter’s distance from the treetops
increasing near the end of recorded data.
Page 9 of 12 ERA21FA195
Pilot Information
Certificate: Airline transport; Commercial Age: 47,Male
Airplane Rating(s): None Seat Occupied: Front
Other Aircraft Rating(s): Helicopter Restraint Used: 4-point
Instrument Rating(s): Helicopter Second Pilot Present: No
Instructor Rating(s): Helicopter Toxicology Performed: Yes
Medical Certification: Class 2 With waivers/limitations Last FAA Medical Exam: January 4, 2021
Occupational Pilot: Yes Last Flight Review or Equivalent: January 12, 2021
Flight Time: 4520 hours (Total, all aircraft), 139 hours (Total, this make and model), 4476 hours (Pilot In
Command, all aircraft), 120 hours (Last 90 days, all aircraft), 40 hours (Last 30 days, all aircraft), 8
hours (Last 24 hours, all aircraft)
Other flight crew Information
Certificate: None Age: Male
Airplane Rating(s): None Seat Occupied: Front
Other Aircraft Rating(s): None Restraint Used: 4-point
Instrument Rating(s): None Second Pilot Present: No
Instructor Rating(s): None Toxicology Performed:
Medical Certification: Last FAA Medical Exam:
Occupational Pilot: No Last Flight Review or Equivalent:
Flight Time:
Other flight crew Information
Certificate: None Age: Male
Airplane Rating(s): None Seat Occupied: Rear
Other Aircraft Rating(s): None Restraint Used:
Instrument Rating(s): None Second Pilot Present: No
Instructor Rating(s): None Toxicology Performed:
Medical Certification: Last FAA Medical Exam:
Occupational Pilot: No Last Flight Review or Equivalent:
Flight Time:
Page 10 of 12 ERA21FA195
Aircraft and Owner/Operator Information
Aircraft Make: BELL HELICOPTER TEXTRON Registration: N53DE
CANADA
Model/Series: 429 Aircraft Category: Helicopter
Year of Manufacture: 2019 Amateur Built:
Airworthiness Certificate: Normal Serial Number: 57380
Landing Gear Type: None; Skid Seats: 3
Date/Type of Last Inspection: March 10, 2021 Continuous Certified Max Gross Wt.: 7000 lbs
airworthiness
Time Since Last Inspection: 18.4 Hrs Engines: 2 Turbo shaft
Airframe Total Time: 265.1 Hrs as of last inspection Engine Manufacturer: Pratt & Whitney Canada
ELT: C126 installed, not activated Engine Model/Series: PW207D1
Registered Owner: Rated Power: 572 Horsepower
Operator: Operating Certificate(s) None
Held:
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual (VMC) Condition of Light: Day
Observation Facility, Elevation: SIF,693 ft msl Distance from Accident Site: 7 Nautical Miles
Observation Time: 13:15 Local Direction from Accident Site: 241°
Lowest Cloud Condition: Visibility 10 miles
Lowest Ceiling: Visibility (RVR):
Wind Speed/Gusts: 7 knots / Turbulence Type None / None
Forecast/Actual:
Wind Direction: 220° Turbulence Severity N/A / N/A
Forecast/Actual:
Altimeter Setting: 30.04 inches Hg Temperature/Dew Point: 27°C / 15°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Danville, NC (DAN) Type of Flight Plan Filed: Company VFR
Destination: Burlington, NC (BUY) Type of Clearance: None
Departure Time: 12:32 Local Type of Airspace: Class G
Page 11 of 12 ERA21FA195
Wreckage and Impact Information
Crew Injuries: 1 Fatal Aircraft Damage: Destroyed
Passenger Injuries: 2 Serious Aircraft Fire: On-ground
Ground Injuries: N/A Aircraft Explosion: None
Total Injuries: 1 Fatal, 2 Serious Latitude, 36.497132,-79.718455(est)
Longitude:
Administrative Information
Investigator In Charge (IIC): Mccarter, Lawrence
Additional Participating Persons: Hazen Rowe; FAA - FSDO; Greensboro, NC
Nora Vallee; Transportation Safety Board of Canada; Gatineau
Merryn Spielman; Pratt & Whitney Canada
Mona Polson; Bell Flight Safety; Ft Worth, TX
Philip Kangagy; Duke Energy Aviation; Charlotte, NC
Jason Sponsel; Duke Energy Aviation; Charlotte, NC
Allen Blankenship; Duke Energy Aviation; Charlotte, NC
Garrett Scott; Duke Energy Aviation; Charlotte, NC
Original Publish Date: August 30, 2023 Investigation Class: 3
Note:
Investigation Docket: https://data.ntsb.gov/Docket?ProjectID=102994
The National Transportation Safety Board (NTSB), established in 1967, is an
independent federal agency mandated by Congress through the
Independent Safety Board Act of 1974 to investigate transportation
accidents, determine the probable causes of the accidents, issue safety
recommendations, study transportation safety issues, and evaluate the
safety effectiveness of government agencies involved in transportation. The
NTSB makes public its actions and decisions through accident reports,
safety studies, special investigation reports, safety recommendations, and
statistical reviews.
The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b),
precludes the admission into evidence or use of any part of an NTSB report
related to an incident or accident in a civil action for damages resulting
from a matter mentioned in the report. A factual report that may be
admissible under 49 U.S.C. § 1154(b) is available here.
Page 12 of 12 ERA21FA195
