AI2013-3

AIRCRAFT SERIOUS INCIDENT

INVESTIGATION REPORT

ACADEMIC CORPORATE BODY HIRATAGAKUEN

J A 1 3 5 E

September 27, 2013

 The objective of the investigation conducted by the Japan Transport Safety Board in accordance
with the Act for Establishment of the Japan Transport Safety Board (and with Annex 13 to the
Convention on International Civil Aviation) is to prevent future accidents and incidents. It is not the
purpose of the investigation to apportion blame or liability.

Norihiro Goto
Chairman,
Japan Transport Safety Board

Note:
This report is a translation of the Japanese original investigation report. The text in Japanese shall
prevail in the interpretation of the report.
 AIRCRAFT SERIOUS INCIDENT
INVESTIGATION REPORT

ENGINE DAMAGE
TO
A EUROCOPTER EC135T2 (ROTORCRAFT), JA135E
OPERATED BY
ACADEMIC CORPORATE BODY HIRATAGAKUEN
OVER
THE SEA ABOUT 6 NM (ABOUT 11 KM) NORTHWEST
OF KERAMA ISLANDS, OKINAWA PREFECTURE
AT
10:20, MARCH 28, 2009

August 23, 2013

Adopted by the Japan Transport Safety Board
Chairman Norihiro Goto
Member Shinsuke Endoh
Member Toshiyuki Ishikawa
Member Sadao Tamura
Member Yuki Shuto
Member Keiji Tanaka
 SYNOPSIS

<Summary of the Serious Incident>

A Eurocopter EC135T2, registration JA135E, operated by academic corporate body
HIRATAGAKUEN, took off from Kumejima Helipad at 10:07 local time*1 on March 28,
2009 for emergency patient transportation. When the helicopter was flying over the sea en
route to Shuri Helipad on the main island of Okinawa, its left engine stopped around 10:20
at about 800 ft (about 240 m) about 6 nm (about 11 km) northwest of the Kerama Islands.
It changed the destination to Naha Airport and landed there at 10:46.
There were six persons on board, consisting of the pilot in command (PIC) and a
mechanic, a doctor and a nurse as medical personnel, and an emergency patient and an
attendant, but no one was injured.
The inside of the left engine of the helicopter was destroyed, but there was no outbreak
of fire.

<Probable Causes>
It is very likely that in this serious incident, the clogged injectors located relatively
lower part of the left engine combustion chamber caused uneven fuel injection and
combustion limited in the upper part, lead to a heat concentration to the Upper Structure
resulting in engine interior damage.
Sea salt accumulation on fungicide with increased viscosity by heat probably clogged
the fuel nozzles. Improper use of fungicide is probable. The JTSB could not determine the
route of the sea salt penetration.

<Safety Recommendations>
In view of the result of this serious incident investigation, the JTSB recommends the
European Aviation Safety Agency (EASA) should take the following measures:

It is recommended that the European Safety Agency directs Eurocopter and

Turbomeca to cooperatively study the helicopter operational environment and the effects of
fungicide to inform helicopter customers of the proper dosing instructions and precautions.

*1 Japan Standard Time (TST): UTC+9hr. Unless otherwise stated all times are indicated in JST based on a
24-hour clock
Abbreviations used in this report are as follows:

AMM: Aircraft Maintenance Manual

BEA: Bureau d’ Enquetes et d’ Analyses
EASA: European Aviation Safety Agency
EMM: Engine Maintenance Manual
FLI: First Limit Indicator
RFM: Rotorcraft Flight Manual
TOT: Turbine Outlet Temperature
TRQ: Torque
VFR: Visual Flight Rules

Unit Conversion Table

1 ft: 0.3048 m
1 nm: 1,852 m
1 μm: 10−6 m
1 Gal (UK): 4.546 ℓ
1 ppm: 0.0001 %
1. PROCESS AND PROGRESS OF THE INVESTIGATION

1.1 Summary of the Serious Incident

The occurrence covered by this report falls under the category of “Damage of engine
(limited to major damage which occurred inside the engine) as stipulated in Article 166,
Paragraph 4,Item 6 of the Ordinance for Enforcement of the Civil Aeronautics Act of
Japan and is classified as an aircraft serious incident.
The Eurocopter EC135T2, registered JA135E, operated by academic corporate body
HIRATAGAKUEN took off from Kumejima Helipad at 10:07 on March 28, 2009 for
emergency patient transportation. When it was flying over water en route to Shuri Helipad
on the main island of Okinawa, its left engine stopped around 10:20 at about 800 ft (about
240 m) about 6 nm (about 11 km) northwest of the Kerama Islands. It changed the
destination to Naha Airport and landed there at 10:46.
There were six persons on board, consisting of the PIC and a mechanic, a doctor and a
nurse as medical personnel, and an emergency patient and an attendant, but no one was
injured.
The inside of the left engine of the helicopter was destroyed, but there was no outbreak
of fire.

1.2 Outline of the Incident Investigation

1.2.1 Investigation Organization
On March 28, 2009, the JTSB designated an investigator-in-charge and another
investigator to investigate this serious incident.

1.2.2 Representatives of the Relevant States

Accredited representatives of Germany and France, the former as the State of Design
and Manufacture of the helicopter, and the latter as the State of Design and Manufacture
of the engines, participated in this investigation.

1.2.3 Implementation of the Investigation

March 29 to 31, 2009 Helicopter examination and interviews
April 6 to 7, 2009 Helicopter examination
April 6 to June 30, 2009 Fuel examination
June 2 to 4, 2009 Engine teardown inspection
July 1 to 31, 2009 Helicopter and fuel examinations
September 17,2009 Helicopter examination
September 18 to October 30, 2009 Filter and fungicide examinations
September 29, 2009 Interviews
November 13, 2009 Interviews
December 11, 2009 Interviews
December 22, 2009 Fungicide examination
December 28, 2009 Interviews
March 15, 2010 Interviews
March 17 to 31, 2010 Examination of engine cleaning water
April 1, 13, and 16, 2010 Interviews

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 October 20 to December 28, 2010 Examination of fuel system components
December 28, 2010 Interviews
February 18 to March 31, 2011 Examinations of substances left in the fuel
system components and fungicide
April 13, 2011 Examination of cut injectors
May 16, 2011 Examination of the injector interior
May 30 to June 7, 2011 Examination of sedimentation process of
fungicide and salt in fuel

1.2.4 Interim Report

On July 30, 2010, the interim report based on the fact-finding investigation up to that
date was submitted to the Minister of Land, Infrastructure, Transport and Tourism.

1.2.5 Comments from Parties Relevant to the Cause of the Serious Incident
Comments were invited from parties relevant to the cause of the serious incident.

1.2.6 Comments from the Relevant States

Comments on the draft final report were invited from the relevant States.

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2. FACTUAL INFORMATION

2.1 History of the Flight

On March 28, 2009, the Eurocopter EC135T2, registered JA135E, operated by an
Aviation Operation Division*2, academic corporate body HIRATAGAKUEN (hereinafter
referred to as “the Academic Corporate Body”), took off from Yomitan Heliport at 09:12 for
emergency patient transportation to the main island of Okinawa responding to a request
from a hospital on Kumejima Island, with a PIC sitting in the right pilot seat, a mechanic
in the left pilot seat, a doctor and a nurse in rear seats. It landed at Kumejima Helipad at
09:40.
After boarding an emergency patient and an attendant the helicopter it took off from
Kumejima Helipad at 10:07.
The outline of the flight plan for the Helicopter was as follows:
Flight rules: Visual flight rules (VFR)
Departure aerodrome: Kumejima Helipad
Estimated off-block time: 09:55
Cruising speed: 120 kt
Cruising altitude: VFR
Route: Zamami
Destination aerodrome: Shuri Helipad
Estimated elapsed time: 0 hr 45 min
Fuel load expressed in endurance: 1 hr 50 min

The history of the flight up to the

occurrence is summarized as below, based on
the statements of the PIC, the mechanic and an
air traffic controller at Naha Airport
(hereinafter referred to as "the Controller"),
who received an emergency report from the
helicopter.
(1) PIC
Upon receiving a request from the
hospital for emergency patient
transportation, the PIC left Yomitan
Heliport at 09:12 and the Helicopter landed
Figure: Example of Indication of Engine
at Kumejima Helipad within the hospital Instruments of the Helicopter
compound at 09:40. When he stopped the
The values of the TQR, TOT and NI
engines, the doctor, the nurse and the for the left and right engines are indicated
mechanic went to the hospital building to on the corresponding side of the display.
“ ■ ”(FLI) emerges near the
pick up the patient. When they all boarded parameter whose value is nearing the
the helicopter, it took off from Kumejima operating limitation, attracting the pilot’s
attention to the parameter.
Helipad at 10:07. At 10:16, when the
Helicopter was flying at about 1,000 ft at

*2 The division operates the helicopter for emergency medical service (EMS).

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 about 130 kt, the first limit indicator (FLI) (See the explanation on the right) for right
engine torque (TRQ) and turbine outlet temperature (TOT) began to blink alternately.
The PIC and the mechanic confirmed the engine instruments together. But because all
instrument indications were within the normal range, they concluded that it was an
instrument error. After a little while, the TOT on the left engine instrument rose to
880 ºC, slightly exceeding the limit value of 879 ºC for the maximum continuous power.
The PIC slightly reduced the power at mechanic’s request.
Later, the PIC descended its altitude to 800 ft and decelerated to 100 kt to avoid
clouds ahead. After a while, the left engine came to a shutdown. At that time, the
helicopter was about 6 nm northwest of the Kerama Islands (about 27 nm west of
Naha Airport) and the time was 10:20. The PIC tried to restart the engine, but to no
avail with no response. Therefore, he performed an engine shutdown procedure. The
indications on the right engine instrument were normal, and the helicopter was able to
maintain a level flight. The PIC had an option to land at Kerama Airport, but because
of his mission and the deteriorating weather, he decided to fly to the main island of
Okinawa considering the alternate transportation means and easy transfer of the
patient to a medical facility. Because the flight route was dotted with small islands
toward the main island, the PIC told the doctor and the nurse that they would land on
a small island nearby in case of abnormal indication of the right engine on the
instrument and then, he changed the direction to Naha Airport.
The PIC declared an emergency and asked the controller to arrange for an
ambulance for the transportation of the patient. At 10:46, the Helicopter landed on the
Naha Airport taxiway and handed the patient to the ambulance standing by there.
(2) Mechanic
Shortly after the helicopter took off from Kumejima Helipad, the mechanic found
that the right engine FLI was blinking alternately for the TRQ and the TOT. When
the mechanic was wondering what was going on, a similar phenomenon occurred for
the left engine FLI indication. The TOT rose to show a yellow underline indicating
that the value surpassed the maximum continuous power limit, he asked the PIC to
reduce the engine power. The engine conditions worried the mechanic and he jotted
down the engine parameters for both engines. The TRQ values for both engines were
equal at 47.5 %, while the left TOT was 865 °C and the right TOT was 795 °C. The left
N1 (the compressor rotating speed) was 88.9 %, while the right N1 89.6 %. The outside
air temperature was 19.8 °C. There were no major differences in the values for the two
engines, except for the TOTs. Sometime later, the left engine TOT quickly rose and the
left engine stopped.
Right engine parameters remained within normal range with slightly high TOT
until the helicopter arrival at Naha Airport.
(3) Controller
At 10:25, the helicopter declared an emergency. When the Controller confirmed
the situation, the helicopter requested an emergency landing at the airport because its
left engine stopped while it was transporting an emergency patient. It was flying
about 22 nm west of the airport at about 800 ft. The Controller instructed the
helicopter to land on the taxiway, to restrict its influence on the operation of the Naha
airport.

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 This serious incident occurred at about 10:20 on March 28, 2009, at about 800 ft about
6 nm northwest of the Kerama Islands (near a point Latitude 26º 16' N, Longitude 127° 10'
E).
(See Figure 1: Estimated Flight Route, Photo 2: Display Example of Engine Instrument)

2.2 Injuries to Persons

There were no injuries.

2.3 Information about Damage to the Helicopter

The interior of the left engine was destroyed.
(See Photo 3: Left Engine Interior Damage)

2.4 Personnel Information

PIC (Male, Age 58)
Commercial Pilot Certificate (Rotorcraft)
Rating for multi-turbine engine (land): August 7, 1992
Class 1 Aviation Medical Certificate:
Validity: until November 30, 2009
Total flight time: 9,746 hr 11 min
Flight time in the last 30 days: 20 hr 49 min
Total flight time on the type of helicopter: 316 hr 12 min
Flight time in the last 30 days on the type of helicopter: 20 hr 49 min

2.5 Aircraft Information

2.5.1 Aircraft
Type: Eurocopter EC135T2
Serial number: 0443
Date of manufacture: November 23, 2005
Certificate of airworthiness: DAI-20-356
Validity: until October 18, 2009
Category of airworthiness: Rotorcraft, Normal N
Total flight time: 841 hr 18 min
Total cycles: 2,521
Flight time since last periodical check (100 hr check on January 8, 2009):
58 hr 19 min
(See Figure 2: Three angle view of Eurocopter EC135T2, Photo 1: Serious Incident
Aircraft)

2.5.2 Engines
(1) Left engine
Type: Turbomeca ARRIUS2B2
Serial number: 32225
Date of manufacture: July 21, 2005
Total time of usage: 841 hr 18 min
(2) Right engine

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 Type: Turbomeca ARRIUS2B2
Serial number: 32226
Date of manufacture: July 28, 2005
Total time of usage: 841 hr 18 min

2.5.3 Weight and Balance

When this serious incident occurred, the helicopter’s weight was estimated to have
been 2,625 kg and the center of gravity (CG) was estimated to have been longitudinally
4,298 mm aft of the datum and laterally 1 mm left of the airframe symmetry plane, both of
which were estimated to have been within the allowable ranges (maximum takeoff weight
of 2,835 kg and the CG range for the weight at the time of the serious incident:
longitudinally 4,215 to 4,415 mm aft of the datum and laterally from 100 mm to the left to
100mm to the right).

2.5.4 Fuel and Lubricating Oil

Fuel onboard was Jet A-1 aviation fuel, and lubricating oil was Mobil Jet Oil II for jet
engine.

2.6 Meteorological Information

2.6.1 General Weather Outlook
According to the surface analysis chart as of 09:00 on March 28, 2009, a low was in the
southern part of the East China Sea, while a front was extending from the East China Sea
to the Continent of China. According to the cloud imagery as of 10:30 on the same day,
cloud areas accompanying the low and the front were seen broadly spreading from the
Continent to the Okinawa region via the East China Sea, and the flight route of the
helicopter was on the southern end of the cloud areas.
According to the radar echo intensity data as of 10:20, around the time when this
serious incident occurred, there were precipitation areas around the flight route, and an
area of strong precipitation was moving eastwardly toward the flight route.

2.6.2 Aeronautical Weather Observations

Aeronautical weather observations at Naha Airport around the time when this serious
incident occurred were as follows:
10：53 Wind direction 160°, Wind velocity 12 kt, Visibility 10 km
Shower rain
Cloud: Amount 2/8, Type Cumulus, Cloud base 1,500 ft
Amount 5/8, Type Stratocumulus, Cloud base 4,500 ft
Amount 7/8, Type Altocumulus, Cloud base 7,000 ft
Temperature 22°C, Dew point 19 °C
Altimeter setting (QNH) 29.90 inHg

2.7 History of Engine Inspection and Maintenance

2.7.1 Engine Time Between Overhaul (TOB) and Engine Maintenance/Inspection at the
Academic Corporate Body

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 According to a technical material issued by the engine manufacturer, the TOB for the
engines involved is satisfied by 3,500 hours of operation or 15 years of duration, whichever
comes first.
According to the engine flight log, the two engines were installed on the helicopter
when it was manufactured. Their total time of use until the occurrence of this serious
incident was 841 hr 18 min (the remaining time: about 2,658 hr) and their period of use
was about three years and eight months (the remaining period: about 11 years and four
months) – well before the TOB.
The helicopter maintenance records show that major maintenance work was done at
the Academic Corporate Body’s main maintenance base at Kobe Heliport. Inspection and
maintenance which must be made with a frequency of every 200 hours or shorter (200 hr,
100 hr, 50 hr and 20 hr inspections), such as the engine power check and the lubricant oil
system inspection, had been performed at Yomitan Heliport and other operation sites, in
accordance with the engine maintenance manual (EMM) established by the engine
manufacturer.

2.7.2 Latest Major Inspection and Maintenance Performed Before the Serious Incident
The helicopter maintenance records show that an engine inspection and
maintenance were done at the Academic Corporate Body’s main maintenance
base about seven months before (September 13, 2008) the serious incident. The
800-hour inspection and second 400-hour inspection after the manufacturing
were done including borescope inspections for the engine interiors (400-hour
inspection item) and new installation of the preference injector, fuel manifolds
and fuel filters on either side of engine. These maintenance works found no
anomalies. The post-maintenance engine run demonstrated normal values.

2.8 Operational History of the Helicopter

2.8.1 Operational History at Yomitan Heliport
According to the flight log for the helicopter, the Academic Corporate Body installed
medical equipment on the helicopter about one year after its production. The helicopter
was stationed alternately at Yomitan Heliport and at a hospital in Nagasaki Prefecture to
fly EMS missions.
The operational history of the helicopter at Yomitan Heliport was summarized as
below:
Number of tours: Three
Total period: 530 days from March 2007 to March 2009
Flight time in total: 492 hr 05 min (about 59 % of total flight
times)
Flight cycles in total: 1,421 (about 56 % of the total)
Average flight time: About 21 minutes
Characteristics of flights: Over-water flight between the Main Island
and remote islands account for about 90 %.
Its landing sites were mostly within 1 km
from the coastlines.

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2.8.2 History of Flight Operations after Replacement of Fuel System Components
As described in 2.7.2, about seven months had elapsed before the incident from
September 13, 2008, when both engines received the endoscope inspections with
replacement of the fuel system components. The total flight time during the period was 154
hr 40 min and the flight cycles were 517.
After the fuel system component replacement the helicopter flew EMS missions for a
hospital in Nagasaki Prefecture followed by the ferry to Yomitan Heliport via Kobe
Heliport. The helicopter started EMS missions there on December 1, 2008. It took about
four months before the occurrence of the serious incident. The flight time of the helicopter
during the period was 91 hr 22 min with 271 flight cycles.

2.9 Daily Helicopter Operations at Yomitan Heliport

2.9.1 Helicopter EMS Missions
The EMS missions at Yomitan Heliport was summarized as below, according to the
statements of the director of Yomitan Heliport, mechanics and hospital personnel.
Yomitan Heliport operational hour begins at 09:00 and ends at 17:00. Before the start
of daily operations, the helicopter is towed out of the hangar followed by a pre-flight check
including a check for water in the fuel tank. Then the helicopter remains parked on the
helipad to respond to any request of transportation. The helicopter is loaded with about
330 kg of fuel (equals to about 423 ℓ accounting for about 60 % of the total fuel tank
capacity of 710 ℓ) for a flight time of 1 hr and 40 min to cover a shuttle flight between the
heliport and remote islands.
The helicopter flies at 1,000 ft or below not to expose patients to big difference of
atmospheric pressure. It takes about 10 min for ground reception and release of patients.
The helicopter always stops its engines after landing. Upon completing a mission, it
immediately returns to Yomitan Heliport to stand by for the next mission. The helicopter
starts and stops its engines three times per mission.
The engine conditions are monitored every day and the 100 hr engine inspection done
in February 2009 found no anomalies.
Frequent over-water flying and the proximity of Yomitan Heliport to the sea required
post-flight engine compressor cleaning to wash down the accumulated floating sea salt
particles*3 with water. When salt accumulation was found on the helicopter skin, the
helicopter surface was rinsed with fresh water from water purifier. The helicopter was
stored in the hangar with the doors shut after the end of the operational hours.

2.9.2 Facility and Stored Fuel

Yomitan Heliport is located on the western coast in the central part of the main island
of Okinawa. It sits about 50 m away from the sea shore and it includes an office, a helipad,
a hangar and a fuel storage facility.
Fuel at the facility is stored in metallic drums with a capacity of about 200 ℓ. Opened
drums and fresh ones are separated. A drum is sealed with screwed plugs. An inventory
record showed that 10 new drums (about 2,000 ℓ in total) were brought in every nine days
on average.

*3 The sea salt particles are microparticles of salt as small as 3 to 18μm, which are emitted into the atmosphere
following the rupture of sea water bubbles which emerge on the sea surface mainly due to sea water splashes

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2.9.3 Servicing Procedures
Several mechanics stated the servicing procedures at the heliport as follows.
The helicopter was usually refueled after the end of its daily flights. When it flew more
than once, it was refueled as the need arises. Average refueling quantity was about one and
a half drums (about 300 ℓ). When a fresh drum was opened, mechanics did a visual check of
the content and tested it for water deposit. Then they added fungicide into the fuel, stirred
it and fed it to the aircraft with an electric fuel pump.
Visual checks had found small foreign objects in the fuel several times before the
occurrence of this serious incident. When large amount of foreign objects were found, the
fuel drum involved was not used.
They checked for water deposit by applying paste-type water detecting agent on the tip
of a testing stick and stirred the fuel with it. No water had been detected in the fuel.
(See Photo 6: Bird’s-eye View of Yomitan Heliport)

2.10 Fungicide (KATHON FP 1.5) Used at Yomitan Heliport

Couples of mechanics stated why and how they used fungicide at Yomitan Heliport.
The statements are summarized as below.
During the course of a helicopter operation, it began to get mildewed on its fuel filter
support. As a countermeasure they started to add the EMM-approved fungicide in the fuel
drum on and after December 1, 2008. But in-house instruction about the fungicide was not
precise before the occurrence of this serious incident. Therefore, not all fuel drums were
dosed with fungicide. Although the EMM specified to add the fungicide with a
concentration of 100 ppm (20 mℓ of the fungicide for 200 ℓ of fuel), there was the possibility
of mechanics’ erroneous calculation. Furthermore there were no records about the amount
of the fungicide actually added to the fuel.
The fungicide used at Yomitan Heliport was KATHON FP 1.5, a product of Fuel
Quality Service, Inc. of the United States of America. The fungicide is contained in a
container of 1UK gal (4.55 ℓ). The container carried a list of ingredients and handling
remarks, but not the remarks on the usage or dosage.
The manufacture’s document included the following description about the usage.

(Excerpt)
Kathon™ FP 1.5 Microbicide is effective and economic to use and begins working
within 5 hours. However, preferred soak time is 12-24 hours.

2.11 Descriptions on Fungicide in Manuals

The TC data sheet (a document of design specifications) prepared by the European
Aviation Safety Agency (EASA) which had authorized the helicopter design, calls for
referring to the EASA authorized rotorcraft flight manual (RFM) to find approved fuel,
lubricant oil and fungicide. But descriptions about fungicide were not in the RFM. There
were no descriptions about the use of fungicide, either, in the aircraft flight manual (AFM)
and the aircraft maintenance manual (AMM).
However, the engine maintenance manual (EMM) for the helicopter had descriptions
as mentioned below about fungicide usage, separately showing dosage for preventive

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 treatment and curative treatment. The phrase “Refer to the conditions given in the
Maintenance Manual” comes at the top of the paragraph “4 Fungicide Additive” shown
below, had no corresponding description in the AMM as described above.

TURBOSHAFT ENGINE ARRIUS 2B2 MAINTENANCE MANUAL

(Excerpts from related clauses are shown below, with applicable remarks
underlined.)

71 POWER PLANT
71-00-02 FUEL/LUBRICANTS/SPECIAL PRODUCTS-GENERAL
- Omitted -
2 Fuels-Lubricants-Special products-General
- Omitted -
(c) Approved fuel additives
- Omitted -
4 Fungicide additives
Refer to the conditions given in the Maintenance Manual.
- Omitted -
KATHON FP 1.5
- Preventive treatment: 50ppm
- Curative treatment: 100ppm

2.12 Test and Research

2.12.1 Examination of the Engine Interior
Both engines were shipped to Turbomeca, the manufacturer in France for teardown
inspection with the oversight of French accident investigation authority (hereinafter
referred to as “BEA”). The inspection found the following engine interior conditions.
(1) Left engine interior
a. The upper part of the inner wall of the combustion chamber (viewed from the
front and the top is aligned to 12 o’clock) was discolored black in an area from
10 to 4 o’clock (hereinafter referred to as “the Upper Structure”), showing signs
of uneven combustion.
b. The high pressure (HP) nozzle guide vanes for smoothing the flow of
combustion gas was discolored due to overheating toward the Upper Structure
and the rear edges of the guide vanes were damaged.
c. All the HP turbine blades, which rotate the compressor, were fractured from the
middle section, while the turbine ring and the rear bearing support, which
form the flow path of combustion gas was damaged toward the Upper
Structure.
d. The pressure turbine (PT) nozzle guide vanes were damaged toward the Upper
Structure, while all the blades of power turbine were fractured.
e. The exhaust diffuser and its struts were fractured toward the Upper Structure,
and the fractured sections were melted.
(2) Right engine interior
The rear edge of three HP nozzle guide vane had heat damages, but there was

10
 no major damage to the interior structure.
(3) Left engine fuel system components
Accumulated white and brown foreign substances covered all of the 10 fuel
injector outlets. A fuel flow test confirmed that five of them (No. 3 to No. 7) were
clogged and one (No. 9 injector) demonstrated insufficient amount of flow.
Accumulated foreign material was found near the inlet of the fuel filter upstream
of fuel manifold.
(4) Right engine fuel system components
Like the left engine, accumulated foreign substances covered all of the 10 fuel
injector outlets. A fuel flow test confirmed that four of them (No. 3 to No.) were
clogged and the three (No. 2, 9 and 10 injectors) demonstrated insufficient amount
of flow. Accumulated foreign material was found near the inlet of the fuel filter.

(See Figure 3: The Structure of the Engine and Main Sections Damaged in the
Left Engine Inside, Photo 4: Left Engine Interior Damage, Photo 5: Contaminated
Fuel System Components)

2.12.2 Examination of Engine Fuel System Components

Engine system components (injectors and fuel filters) for both engines and fuel on
board fuel sample were shipped to the BEA for examination. The summary of the
examination are as follows:
(1) Injectors
Most of the injector heads were covered with foreign substances and fuel
nozzles of the left and right injectors were clogged entirely or partially. Main
ingredients of the substances were chlorine and sodium, in a form of crystallized
sodium chloride.
(2) Fuel Filters
About half of the surface of the left and right fuel filters was covered with
sodium chloride.
(3) Fuel
The sample proved to be Jet A-1 aviation fuel with no traces of salt. Salt is not
fuel-soluble, but it can be water-soluble with the presence of water in the fuel.
(See Photo 5: Contaminated Fuel System Components)

2.12.3 Fuel Quality Loaded on the Helicopter

After this serious incident, fuel sample from the helicopter was analyzed. The sample
proved to be Jet A-1 aviation fuel satisfying the fuel specification with no traces of salt.

2.12.4 Detailed Examination of Fuel Drums and Foreign Substances in Fuel

As described in 2.9.3 the foreign objects in the fuel drums stored at Yomitan Heliport
had been known even before the occurrence of this serious incident.
The detailed examination found three kinds of foreign substances in several unused
Fuel Drums: filaments, small thin sheets and translucent films. The result of the detailed
examination was as follows:
(1) Main ingredient of the filaments was iron. In view of their shapes, they were

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 found to be broken pieces of screw threads of the flanges or the plug screws.
(2) A component analysis revealed that the small thin sheet was a piece of inner wall
coating for the drum.
(3) As a result of the comparative analysis with the inner wall substance, the
translucent film was found to have the same contents as that of the small thin
sheet.
An infrared (IR) absorption spectrum analysis of the transparent liquid deposited at
the bottom of the fuel drums in use revealed that the resultant absorption signature was
identical to that of the fungicide.
Quality checks for all the fuel remained, including fungicide-dosed one and
contaminated one with metallic pieces, revealed no quality deficiencies.
(See Photo 7: Transparent Liquid Taken From a Fuel Drum in Use)

2.12.5 Examination of Electric Fuel Pump

As described in 2.9.3, the helicopter was serviced at Yomitan Heliport with an electric
fuel pump. The filter of this pump (hereinafter referred to as “the Pump Filter”) was
replaced with a new one in March 2008, about one year before this serious incident.
The Pump Filter is a sheet of silicon-coated paper. Many foreign objects were trapped
on the inlet side of filter surface. The analysis revealed that they were metallic pieces
having their origins in the fuel drums. No fungicide ingredients were detected.

2.12.6 Fungicide Dissolution in the Fuel

An amount of the fungicide, which creates a concentration of 50 ppm as specified in
the EMM, was added to 10 ℓ of fuel in a transparent container, stirred and left as it was for
observation. After the stirring the fungicide became invisible dissolving into the fuel. After
about 20 min of stationary condition, transparent substance precipitated at the bottom of
the container. The condition of the mixture was observed for seven days stirring it once a
day, but the precipitated transparent substance remained on the bottom.
The substance was put to an IR absorption spectrum analysis. The analysis revealed
that the absorption peaks were consistent with that of the fungicide.
(See Photo 8: Fungicide Dissolution in the Fuel)

2.12.7 Examination of Fungicide Permeation Through the Pump Filter

When the fungicide alone was poured onto the filter set on the filter holder, it did not
permeate through the filter. Then the fuel was added onto it and stirred, the mixture
permeated through the filter and dropped into a flask placed below. The mixture in the
flask was poured into another flask and was left stationary. The fungicide precipitated at
the bottom of the flask.
(See Photo 9: Permeation of the Fungicide Through the Pump Filter)

2.12.8 Transformation of the Heated Fungicide

As the fungicide-dosed fuel is sprayed into the engine combustion chamber through
hot injectors, heat influence on the fungicide was observed. When the fungicide in a beaker
was heated, its viscosity gradually increased. When the applied temperature exceeded 200
ºC, the fungicide transformed into dark brownish gum on the bottom.

12
 (See Photo 10: Transformation of the Heated Fungicide)

2.12.9 Reexamination of Injectors

The injectors and the fuel filters installed on both engines were shipped back from
BEA. The JTSB did a teardown inspection of them to study sediment distribution in the
fuel flow path.
(1) Sediments on Injectors
An analysis confirmed the presence of chlorine, sodium, magnesium,
potassium and calcium, being consistent with the ingredients of the sea salt.
Trace of viscous sulfur was also detected.
The fuel and the fungicide additive were separately heated and their residues
were analyzed. The fuel residues contained no sulfur; the fungicide residues did.
(2) Sediment Distribution
Sediments were exclusively found near the inside of the fuel nozzles of the
injectors.

2.13 Post-Serious-Incident Fuel System Follow-Up

The Academic Corporate Body resumed EMHS at Yomitan Heliport after installing
spare engines on the helicopter without using the fungicide additive. Its fuel system was
checked around 50 and 100 flight hours after resuming the service. The checks revealed as
follows:
(1) The check after 58 flight hours (at Yomitan Heliport, on July 1, 2009)
a. The visual inspection of fuel injectors removed from both engines under
magnifier found no anomalies. No foreign substance had accumulated on the
injectors. Each nozzle was clean and had no indication of clogging.
b. An analysis of a liquid sample taken from the drain port at the bottom of the
fuel tank revealed that it was Jet A-1 aviation fuel meeting the fuel
specifications. The analysis detected a water content of less than 0.01 %. This
amount of water didn’t precipitate in the fuel causing no problem without salt.
No germs were detected in the fuel sample.
(2) The check after 123 flight hours (at Kobe Airport, on September 17, 2009)
a. The fuel tank was emptied and residual fuel at the bottom of the tank was
wiped off with absorbent paper to examine the residue at the bottom. No
metal fragments or crystallized salt were found. An infrared absorption
spectrum analysis of the residual fuel absorbed in the paper detected no
ingredients of the fungicide.
b. The examination of screened objects on the engine fuel filters detected silicon,
potassium, calcium and magnesium. Chlorine and sodium as main
ingredients of sea salt were not detected.

2.14 Other Related Matters

2.14.1 Fuel Flow After the Engines Shutdown
The engines are so designed that when the main engine switch is turned off,
compressed air in the combustion chamber pushes fuel back to the tank to prevent fuel
inside the injectors from being discharged into the atmosphere. But this does not mean

13
 that the whole amount of fuel inside the injectors returns to the tank; some amount of fuel
remains in the fuel flow path.
The fuel pump continues to work until the engine stops, and fuel remained in the fuel
flow path is returned to the low-pressure fuel pump inlet. The fuel filters in the fuel flow
path are filled with fuel regardless of fuel pump operation.
(See Figure 4: Fuel Flow at the Engine Start, Figure 5: Fuel Flow at the Engine Shutdown)

2.14.2 Fuel Tank Air Vent

The fuel tank has an air vent to equalize the interior pressure with the atmospheric
pressure.

2.14.3 Emergency Procedures for One Engine Operable in Flight Stipulated in the AFM
A PIC shuts down the failed engine while flying the helicopter maintaining the one
engine operable limit of the healthy engine. Although a PIC is required to land as soon as
possible considering the situation, but a decision of where to land and whether to continue
flying are left to the his discretion.

14
3. ANALYSIS

3.1 Airman Competence Certificate

The PIC held a valid airman competence certificates and a valid aviation medical
certificate.

3.2 Airworthiness Certificate

The helicopter had a valid airworthiness certificate and had been inspected and
maintained as prescribed.

3.3 Relations to Meteorological Conditions

It is highly probable that the meteorological condition at the time had no bearing with
this serious incident.

3.4 Engine Interior

3.4.1 Left Engine Interior
As described in 2.12.1 (1) and 2.12.1 (3), the hot section suffered the interior damage
ranging from the HP nozzle guide vane to the exhaust diffuser. Among the rotating parts,
turbine blades were fractured in full circumference, while other parts were heat-damaged
toward the Upper Structure. Six of the 10 fuel manifold injectors were clogged or having
insufficient fuel flow. The unclogged injectors accounted for those placed in the upper part
of the combustion chamber, corresponding to the area of interior damage behind the
combustion chamber.
It is highly probable that the interior damage developed as follows:
The accumulated material clogged six lower injectors allowing upper injectors to
operate leading to overheated conditions in the upper interior, damaging the upper
structure between the HP nozzle guide vanes and exhaust diffuser; this destruction
resulted in fractures of downstream rotating parts – HP turbine blades and power turbine
blades.

3.4.2 Right Engine Interior

As described in 2.12.1 (2) and 2.12.1 (4), the interior damage of the right engine was
limited to a partial fracture of the HP nozzle guide vanes, but sediments were found in the
fuel filters and several injectors. Like the left engine, the unclogged injectors were those
placed in the upper area of the combustion chamber. As described in 2.7.1 and 2.7.2, both
engines remained installed on the helicopter since its production. As the records of
inspection and maintenance for the helicopter at the Academic Corporate Body and its
operational history are consistent, it is probable that the condition of the right engine was
in a process leading to the same kind of damage observed in the left engine.

3.5 Reason Why the Fungicide Permeated Through the Pump Filter
The fungicide in the fuel precipitated on the bottom of the container as transparent
material not completely dissolving into the fuel when left as it was, and a detailed
examination of the fuel drums made at Yomitan Heliport found foreign substances derived
from the fuel drums and the precipitated fungicide on the bottom, which was added when

15
 refueling. (The fungicide was added to the fuel drums even before the serious incident, but
not to all the drums at the Heliport, with fluctuating amount of dosage.)
On the other hand, the pump filter is permeable to the fungicide-added fuel, and the
fungicide-dosed fuel was fed into the tank immediately after putting fungicide into the fuel
drum and stirring at the Heliport The examination of the pump filter demonstrated that
many metallic pieces and other substances derived from the fuel drums were trapped on
the filter surface, but not the ingredients of the fungicide.
Given these facts, it is highly probable that the fungicide went through the fuel filter
into the fuel tank.

3.6 Accumulated Substance on Fuel Filters and Injectors

(1), (2), (3) and (4) mentioned below probably explain that the sediment on the fuel
filters is sea salt, while the accumulated substances in the injectors are the fungicide and
sea salt.
(1) As described in 2.12.2 (1) and (2), the sediments in the fuel filters and the
injectors were accumulated salt.
(2) As described in 2.12.9 (1), the salt content of the fuel filter sediments is consistent
with that of the sea salt.
(3) As described in 2.12.8, the viscosity of the fungicide increases when heated. (The
temperature of fuel near injectors increases not exceeding 150℃. The fungicide
does not solidify but its viscosity was increased to a higher extent.)
(4) As described in 2.12.9 (1), sulfur was detected from the sediment of the heated
fungicide while viscous sulfur was detected from the injector residue.
As described in 2.13, both engines were replaced with new ones after the occurrence of
this serious incident, and then, the Academic Corporate Body resumed EMHS. The
helicopter operation and the circumstances remained unchanged between pre- and
post-serious incident, except for the terminated use of the fungicide additive. As described
in 2.13, the fuel system checks after the termination of the fungicide use revealed no
sediments in the fuel filters and the injectors.

3.7 The Route of Sea Salt Contamination

As described in 3.6, the sediments found in the fuel filters and the injectors were sea
salt. As described in 2.14.1, the fuel filters are filled with fuel from the fuel tank regardless
of fuel pump operation, while the fuel which goes through the fuel filters jets out from the
injectors. Therefore, it is probable that sea salt which had got into the fuel tank was driven
with the fuel and accumulated in the fuel filters and the injectors.
However, as described in 2.12.2 and 2.12.3, sea salt was not detected in the liquid
taken from the fuel tank when it was examined in France and Japan. As described in 2.13,
sea salt was not found in the follow-up observation, either. With these facts the JTSB could
not determine the sea salt penetration route into the fuel tank.
On the other hand as described in 2.8 and 2.9, Yomitan Heliport, where the helicopter
had been parked, is in an environment of floating sea salt particles. In addition, the
helicopter flew close to the sea surface where salt particles float, with frequent engine
shutdowns and restarts per day. As described in 2.14, at engine shutdown compressed air
in the combustion chamber pushes fuel back to the tank to prevent fuel inside the injectors

16
 from being discharged into the atmosphere. These facts suggest some possibility that some
of sea salt particles in the outside air in the combustion chamber accumulated on the
injectors.

3.8 Process of Injector Clogging

As stated in 2.14.1, the fuel line is designed to push back remaining fuel in injectors to
fuel tank when engine main switch is turned off. The design prevents excessive fuel from
remaining in the fuel line. In case of fuel line contamination, fuel contamination and
degraded injector decreases the push-back capability.
It is probable that fuel remaining in the fuel line (the one not being pushed back to the
fuel tank) flowed into the lower injectors as the air pressure in the combustion chamber
decreased, and as described in 2.12.8, sea salt accumulated on the fungicide whose
viscosity was increased by being exposed to the heat from fuel injectors and surrounding
parts.
Salt did not accumulate equally regardless of injector’s location; the lower the injectors
are, the more salt accumulation observed. This unequal accumulation was probably caused
by gravity. There is also a possibility that differential pressures for fuel push-back were not
necessarily equal due to clogged injectors

3.9 Detection of Signs for Engine Interior Damage

As described in 2.7.1, the engines received an inspection and maintenance at the
Academic Corporate Body in accordance with the engine manufacturer EMM. Both
engines had not reached the TBO.
As described in 2.7.2, the sediment-affected injectors found in the engine teardown
had been replaced about seven months before (September 13, 2008) the serious incident.
Further, follow-on daily checks and 100 hr engine power checks recorded normal values.
Therefore, it is probable that the fuel nozzles were completely or partially clogged after the
use of the fungicide (December 1, 2008 or later). But, as described 2.9.1, the engine
condition checks and engine performance showed no abnormalities until the serious
incident. Therefore, it was probably difficult to detect signs of engine interior damage.

3.10 Inappropriate Use of Fungicide

As described in 2.11, the RFM carried no descriptions about fungicide in the clause
about fuel additives. But, as described in 2.10 and 2.11, the use of the fungicide involved
had been authorized in the EMM for the helicopter. Therefore, it is highly probable that
the Academic Corporate Body had started to use the fungicide. But no clear in-house
instructions about the fungicide use as described in 2.10 suggests that the amount of use
as prescribed in the EMM had not been observed and been used in a higher density than
authorized.
These findings suggest that if the Academic Corporate Body had added prescribed
amount of fungicide into the fuel drums as per the EMM, stirred the mixture, and refueled
the helicopter after a lapse of sufficient time as described in 2.10, the fungicide had not
acquired viscosity for sea salt accumulation leading to clogging of the fuel nozzles.

17
4. PROBABLE CAUSES

It is very likely that in this serious incident, the clogged injectors located relatively
lower part of the left engine combustion chamber caused uneven fuel injection and
combustion limited in the upper part, lead to a heat concentration to the Upper Structure
resulting in engine interior damage.
Sea salt accumulation on fungicide with increased viscosity by heat probably clogged
the fuel nozzles. Improper use of fungicide is probable. The JTSB could not determine the
route of the sea salt penetration.

18
5. PREVENTIVE ACTIONS

5.1 Preventive Actions Taken after the Occurrence of the Incident

5.1.1 Measures Taken by the Corporate Academic Body
1. Fungicide use was terminated.
2. Engine air inlets and exhaust pipes are plugged with covers when the helicopter is
housed in the hanger.
3. Engine compressors are cleaned by cranking the engines (with the starter on
without ignition) with cleaning water dosed with a cleaning agent authorized in
the EMM. In case of post-flight EET exceeding 70 °C, another compressor
cleaning is required next morning.
4. In-flight engine conditions are monitored.
5. Fuel filters and engine interiors are inspected with an endoscope at shorter
intervals than prescribed in the EMM.

5.2 Preventive Actions to be Taken

The use of fungicide for the same type of rotorcraft has not yet been described in the
RFM and the AMM, but there are pertinent descriptions in the helicopter EMM. Therefore,
when the helicopter and engine designer/manufacturer examine the use of the fungicide,
both parties should, based on the findings of this investigation, cooperatively study the
helicopter operational environment and the effects of fungicide to inform helicopter
customers of the proper dosing instructions and precautions.

19
6. SAFETY RECOMMENDATIONS

In this serious incident a Eurocopter EC135T2, registered JA135E, operated by

academic corporate body HIRATAGAKUEN, diverted to an aerodrome after the left engine
shutdown during an emergency patient airlift.
Highly probable cause of the engine shutdown is that the clogging of injectors in the
relatively lower part of the left engine combustion chamber left the fuel injection restricted
to upper part, developing into a heat concentration in the Upper Structure damaging the
engine interior.
Increased viscosity of the fungicide near the fuel nozzle clogged the injectors with sea
salt.
Possible contributing factor is: a larger amount of the fungicide than authorized in the
EMM (engine maintenance manual) for the same type of rotorcraft had been added to fuel
drums, stirred, and the mixture was immediately supplied to the helicopter．The RFM
(rotorcraft flight manual) for the same type of helicopter carries no descriptions about the
use of fungicide in its authorized fuel additives.
In view of this serious incident investigation, the Japan Transport Safety Board
recommends that the EASA should take the following measures:

It is recommended that the European Safety Agency directs Eurocopter and

Turbomeca to cooperatively study the helicopter operational environment and the
effects of fungicide to inform helicopter customers of the proper dosing instructions
and precautions.

20
 Figure 1: Estimated Flight Route

Yomitan Helipad
09:12 Takeoff
Kumejima Helipad
09:40 Landing
10:07 Take off
(PIC’S statement)
Emergency Declared at
22nm W of Naha Airport
(Controller’s statement)
21

Naha Airport
10:46 Landing

10:20 Left Engine

Shutdown
(PIC’s statement)

Kerama Airport Shuri Heliport

0 50km

Topographical map generated by the Geospatial Information Authority of Japan

 Figure 2: Three angle view of Eurocopter EC135T2

Unit：m

３.５１
3.15

２.６５
2.65

１２.１６

10.20
１０.２０

10.20
１０.２０

22
 Figure 3 The Structure of the Engine and Main
Sections Damaged in the Left Engine Inside
Injector
Cold Section Hot Section
PT Nozzle guide vane
Air intake
：Air
：Burnt gas
Power turbine
FWD

Exhaust diffuser
Centrifugal compressor
(Rotating part)
HP Turbine
(Rotating part)
HP Nozzle guide vane

Preferred injector

Combustion chamber

Fuel manifold
（Include Injector）

12 o’clock
(Upper)
3 o’clock

Exhaust diffuser
9 o’clock
6 o’clock Power turbine
(Lower) (Rotating part)

PT Nozzle guide vane

Rear bearing support

Rear bearing

：Damaged section
Turbine ring
：Injectors which were closed or
Inappropriate in the fuel flow

23
 Photo 1: Serious Incident Aircraft

Photo 2: Display Example of ENG Instrument

Torque

Turbine Outlet
Temperature

FLI

※ This picture’s information of engine instrument isn’t a Data of Serious Incident

25
 Photo 3: Left Engine Interior Damage
Exhaust Diffuser view from above Engine Engine injector viewed from aft
Diffuser struts are fractured and broken Damaged section of Power Turbine
sections are melted Nozzle Guide Vane

After

All power turbine blades

Fwd
were damaged

Exhaust Diffuser was damaged Exposed Power Turbine Nozzle Guide Vane

Engine interior viewed through a scope

Fractured HP Turbine

Fractured HP Nozzle Guide Vane

26
 Photo 4: Left Engine Interior Damage

Indicates the Upper structure

Combustion HP Nozzle Guide Vane

Upper interior wall is discolored black Upper structure is discolored by over-heating

indicating being over-heated and trailing edges of vanes are damaged

Rear Bearing
HP Turbine (rotating parts） Rear Bearing Support

All blades are fractured

at mid length
Burnt Gas rote
Segment of damaged PT Nozzle Guide vane

Fractured Rear Bearing

Damage rear bearing support and
Exposed rear bearing

27
 Photo 5：Contaminated Fuel System Components
《Injector for Both Engines》
Injector head
Preference Injector （New）

Fuel Manifold (left)

No.1 No.1

No.10
No.10
No.2
No.2 No.9
No.9
No.3
No.3 RH Engine Two nozzles
LH Engine No.8
（In-flight shutdown） Nominal diameter:
No.8 0.55mm
No.4
No.4 No.7
：closed
No.7 No.6
No.5 ：less fuel flow
No.6
No.5 Fuel Manifold (right)
《Accumulated material on injector heads and clogged fuel nozzles for the left Engine which experienced in-flight
shutdown ( clogged）》
No. 1 No. 2 No. 3 No. 4 No. 5

No.6 No.7 No.8 No.9 No.10

Injector heads are discolored in brown covered with accumulated with material
(Analyzed to be NaCl)
Contaminated fuel filter
New fuel filter LH Engine fuel filter RH Engine fuel filter

The fuel filter inlet was covered with accumulated materials. Analysis proved them to be NaCl

※ The fuel filter inlet is two layered. The outlet layer is fine metal grid. The inner
layer glass fiber 20 ㎛ grid.

28
 Photo 6: Bird’s-eye View of Yomitan Heliport

Office Hange

Fuel Storage Facility

About 50m

Helipad

Photo 7: Transparent Liquid Taken from a Fuel Drain in Use

Transparent Liquid

《IR absorption spectrum for the fungicide》

[ ％ ]

【O-H】

【C-H】 【CH3】 【Ether link】

[ ㎝-1 ]
【O-H】 ：Fungicide
：Transparent Liquid from fuel dram

29
 Photo 8: Fungicide Dissolution in the Fuel
《① The fuel make an addition to fungicide and stirred》

When being left stationary, the

fungicide deposited

《② Seven days later》

※ The mixture was stirred once a day

The fungicide remains deposited

30
Photo 9: Permeation of the Fungicide Through the Pump Filter
《1. The fuel filter stops the fungicide》
The pump filter
The fungicide doesn’t permeate
through the filter to trickle into the
flask

Fungicide
Temp:20.2℃
Humid:40％
The filter support

《2. The mixture of fungicide and fuel permeates through the filter》

Mixture of fuel and fungicide

The mixture permeated though

the filter into the flask

The fungicide deposited on the bottom

31
 Photo 10: Transformation of the Heated Fungicide

Being heated to 100℃

When heated, the viscosity of the

fungicide in creased

Fungicide

Heater

At more than 200℃

At more than 200℃, the fungicide was

discolored to dark brown and left on
the bottom

32