Aviation safety investigations & reports

Total power loss - Pilatus PC-12/45, VH-NWO, 11 km NE of Derby Airport, WA, 29 January 2010

Investigation number:
AO-2010-006
Status: Completed
Investigation completed

Summary

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At about 2010 Western Standard Time on 29 January 2010, a single-engine Pilatus PC-12 aircraft, registered VH-NWO, was being operated on a night medical evacuation flight from Derby to Kununurra, Western Australia with four persons on board. The pilot reported that about 56 km after takeoff, as the aircraft was passing through flight level 180, the engine exhibited a number of problems before the pilot turned the aircraft back to the departure airport. The engine failed and the pilot glided the aircraft to land at Derby. There were no injuries. Subsequent inspection confirmed that the engine propeller reduction gearbox had seized.

The investigation found that four of the six first-stage reduction gearbox bolts had failed due to fatigue. As a result of this failure, and a number of previous similar events, the engine manufacturer commenced its own investigation. That investigation included the review of a number of issues relating to engine overhaul practices. Subsequently, the manufacturer recommended withdrawal from service of an engine from one aircraft in the Australia fleet for examination as part of the its investigation.

The manufacturer determined that a quantity of in-service first stage reduction assembly carrier bolts had not undergone cold rolling of the head-to-shank fillet radius during manufacture. As a result, the engine manufacturer issued a number of service bulletins that identified affected gearboxes and provided recommended compliance times for the removal of suspect carrier bolts from service.

A review of the Society of Automotive Engineers (SAE) specification AS7477D found it was ambiguous in respect of the need to cold roll the head-to-shank fillet radius of MS9490-34 carrier bolts. A revised copy of the specification, Revision E, was published by the SAE in October 2011, clarifying the need for cold rolling of the head-to-shank fillet radius of those bolts.

Download Final Report
[Download  PDF: 2.68MB]
 
 
Alternate: [Download  DOC: 9.01MB]
 

Preliminary

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Preliminary report released 17 May 2010

On 29 January 2010, at about 2010 Western Standard Time a single-engine Pilatus PC-12 aircraft, registered VH-NWO, was being operated on a medical evacuation flight from Derby to Kununurra, Western Australia with four persons on board. The flight was being conducted under the Instrument Flight Rules.

At a position about 30 NM (56 km) after takeoff, the pilot reported engine problems and turned the aircraft back to the departure aerodrome. The engine subsequently failed and the pilot glided the aircraft to the aerodrome and landed safely with no reported injuries. A subsequent inspection confirmed that the engine propeller reduction gearbox had seized.

The investigation found that a number of first - stage reduction gearbox carrier bolts had failed. As a result, the engine manufacturer has reviewed a number of issues relating to engine overhaul practices and has recommended withdrawal from service of an engine from one aircraft in the Australian fleet for examination.

Download Preliminary Report
[Download  PDF: 303KB]
 
 
 

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General details
Date: 29 January 2010   Investigation status: Completed  
Time: 2010 WST    
Location   (show map): 11 km NE of Derby Airport   Investigation type: Occurrence Investigation  
State: Western Australia   Occurrence type: Engine failure or malfunction  
Release date: 17 November 2011   Occurrence class: Technical  
Report status: Final   Occurrence category: Serious Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Pilatus Aircraft Ltd  
Aircraft model PC-12  
Aircraft registration VH-NWO  
Serial number 396  
Type of operation Aerial Work  
Damage to aircraft Nil  
Departure point Derby WA  
Destination Kununurra WA  
Last update 14 November 2018