Updated Factual Report Paints Disturbing Picture

In an updated factual report posted recently, the National Transportation Safety Board says poorly-coordinated maintenance practices by overworked maintenance personnel may have contributed to the fatal March 27, 2007 downing of a Robinson R44 near Jacksonville, FL.

As ANN reported, the Silver State Helicopters helo impacted in a nose-down attitude on Ponte Vedra Beach, killing the two persons onboard. In a Preliminary Report released about 10 days after the accident, the NTSB noted the helicopter had just come out of maintenance... and was missing attachment hardware to its control system.

In its updated report, the NTSB details repairs made to the helicopter's mast fairing ribs during a routine inspection.

"The helicopter's most recent inspection, a 100/300-hour inspection, was completed on March 26, 2007," the report states. "At the time of the inspection, the total aircraft time was 861.6 hours. The airframe and engine were inspected in accordance with their respective manufacturer's maintenance manuals. According to the airframe logbook entry for the inspection, the mast fairing ribs were removed and replaced. A review of the Robinson Maintenance Manual Inspection Checklist used by the mechanic for the 100/300-hour inspection revealed that the mechanic initialed the blocks, "Unairworthy" and "Repaired" for the mast fairing rib inspection item.

"During the mast fairing rib replacement, the two forward swashplate push/pull tubes were removed from their respective hydraulic servos. Prior to the aircraft being returned to service, the mechanic and a company pilot performed a 0.5-hour maintenance test flight. The accident flight was the first flight performed after the maintenance test flight."

The NTSB then summarizes statements made by mechanics at Silver State's facility in Jacksonville, who worked on the helicopter shortly before instructor Tamara Williams, 38, and student Justin Wyatt Duncan, 24, took off on the fateful flight, according to the Florida Times-Union.

Part of that summary reads as follows:

"Upon informing the mechanic of the investigation's findings, the mechanic stated, "I can tell you exactly why that happened." The mechanic then proceeded to explain to the NTSB IIC his reasons for the investigation's findings, which included 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. A couple of nights prior to the completion of the inspection and the maintenance test flight, the apprentice wanted to stay late (with the mechanic) and finish a certain section of the inspection which involved the mast fairing area. 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."

Those statements were backed up by the lead mechanic, according to the NTSB, which added there was apparent pressure on the maintenance staff to expedite repairs to the accident aircraft... while they were also being pulled away for other duties:

"The lead mechanic reported that the mechanic who performed the inspection on the helicopter was first "under the impression" that only a 100-hour inspection was required, and approximately 70 percent through the 100-hour inspection, he realized the aircraft needed a 300-hour inspection as well. During the inspection, the mechanic noticed the cracked mast ribs and the lead mechanic provided assistance with that during the course of the inspection.

"A visiting pilot notified the lead mechanic that the accident helicopter needed to be ready to fly on March 25th, as it was due to be in Texas on March 26th. Between March 19th and the day of the accident, the lead mechanic reported that several aircraft required maintenance and he also was involved in "shopping for tools" and preparing a crash repair estimate in Melbourne, Florida. On March 23rd, two new Robinson R22 helicopters were received at the Jacksonville facility. The lead mechanic reported that the Jacksonville facility was the "receiving station for the southeast" and all new incoming helicopters required offloading, receiving inspections, blade installations, track and balancing, [operations] checks, and flight checks. In addition to the flight academy helicopter maintenance, the lead mechanic reported that there were two transient Bell 206 helicopters in the facility. One of these helicopters required a 50-hour inspection and the other required maintenance to the avionics system."

The lead mechanic then took the somewhat unusual step of making three recommendations to the NTSB "to prevent future accidents:"

1. "Have at least two permanent mechanics at each site allowing one to act as [Quality Control] to the other.
2. "When scheduling additional aircraft at a location, provide additional maintenance personnel.
3. "Set mandatory show time for salaried personnel."

Silver State Helicopters was formed in 1999 in Henderson, NV, and has since grown its operations to several states. The company focuses primarily on flight training, but also conducts air tour and charter operations.

The company has faced several lawsuits over the years, including a November 2006 lawsuit accusing the company of false advertising, in its claims students could earn a rotary-wing certificate in 12 to 18 months, and then get a job as an instructor. Plaintiffs said the company couldn't keep its end of the bargain, due to a lack of qualified instructors, and helos.

FMI: Read The NTSB Factual Report, www.silverstatehelicopters.com