Driveshaft failure and hard

landing involving Overseas

Aircraft Support UH-1H
helicopter, VH-OXI
near Crawford River, New South Wales, on 7 December 2019

ATSB Transport Safety Report

Aviation Occurrence Investigation
AO-2019-070
Final – 16 July 2020
Addendum – 28 January 2021
Released in accordance with section 25 of the Transport Safety Investigation Act 2003

Publishing information

Published by: Australian Transport Safety Bureau

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Addendum
Page Change Date
Safety Last sentence of ‘What the ATSB found’ removed. 28 Jan 2021
Summary
6 Last paragraph of ‘KAflex® driveshaft overhaul and inspection’ removed. 28 Jan 2021
7 New section ‘Discovery of broken washer’ added. 28 Jan 2021
8 Safety analysis section ‘Missing washers’ removed. 28 Jan 2021
8 Finding section ‘Other factors that increased risk’ removed. 28 Jan 2021
9 New section ‘Maintenance organisation’ under ‘Safety action’ added. 28 Jan 2021
Safety summary
What happened
On 7 December 2019, at about 1034 Eastern Daylight-saving Time, the pilot of an Overseas
Aircraft Support UH-1H helicopter (formally known as Bell UH-1H or ‘Huey’ helicopter), registered
VH-OXI, experienced a main driveshaft failure and hard landing near Crawford River, New South
Wales, while engaged in fire control aerial work. The pilot was not injured, and the helicopter was
substantially damaged.

What the ATSB found

The ATSB found that the pilot elected to abort the fire control aerial work and conduct a
precautionary landing as a result of the failure of the driveshaft. While attempting to land, the pilot
experienced an uncontrollable yaw to the right, resulting in a hard landing and substantial damage
to the helicopter when the main rotor blades struck the ground and forcibly ejected the main
gearbox, mast, rotors and KAflex® driveshaft from the airframe.
The helicopter’s KAflex® driveshaft, which transmits power from the engine to the main gearbox,
failed due to a fatigue crack prior to the hard landing.

What's been done as a result

Following the accident, the Civil Aviation Safety Authority emailed Australian operators of UH-1
helicopters a brief on the accident, which included a copy of a previously issued (2007)
airworthiness bulletin on the subject of pre-flight inspection requirements for the KAflex®
driveshaft. The requirements included checking the condition of all driveshaft hardware in addition
to the pre-existing inspection requirements.
As a result of this occurrence, the helicopter operator replaced the KAflex® driveshaft on their
other UH-1H helicopter with a new driveshaft. For the new driveshaft, they implemented a
maintenance routine to monitor the hours flown and time-in-service and included a scheduled
retirement time of 5,000 hours.

Safety message
In 2018, the driveshaft manufacturer provided a position paper to the United States Federal
Aviation Administration, which recommended that driveshafts with the same part number as the
accident helicopter should be replaced at 5,000-hours service, or, if the time-in-service could not
be determined, removed and replaced. Any legacy driveshafts of the accident part number
SKCP2281-103 can be sent to the manufacturer for modification to a new ‘safety of flight’ part
number SKCP3303-1.
This accident highlighted the importance of pilots operating helicopters in the low-level
environment to respond to the early symptoms of a problem immediately, and to be prepared to
commit to a precautionary landing before the condition deteriorates to the point of a forced
landing. In this case, the pilot responded without delay and was able to reach a safe landing site
before a catastrophic failure of the driveshaft occurred.
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The investigation
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are
based on many factors, including the level of safety benefit likely to be obtained from an
investigation. For this occurrence, a limited-scope, fact-gathering investigation was conducted in
order to produce a short summary report, and allow for greater industry awareness of findings that
affect safety and possible safety actions.

The occurrence
On 7 December 2019, at about 0918 Eastern Daylight-saving Time (EDT), 1 the pilot of an
Overseas Aircraft Support (OAS) 2 UH-1H helicopter, registered VH-OXI, departed the town of
Wauchope, New South Wales for fire control aerial work 128 km to the south-west. The tasking
was for firefighting, which involved the helicopter using a 150 ft long-line and a 1,200 L bucket to
drop water on the fire grounds under the direction of the ‘air attack’ crew. 3
On arrival at the fire ground at about 1028, the pilot of VH-OXI made contact with the air attack
crew, and was directed to the water source (Crawford River) for the uplifts, and the fire grounds for
the drops. The pilot made an approach to the river where the operation of the bucket was tested,
and the first water drop on the fire ground was conducted.
On return to the Crawford River for the second uplift, and immediately prior to filling the bucket,
the pilot heard a momentary ‘burring’ noise with a ‘buzzing’ vibration through the airframe. The
pilot aborted the uplift and started to transition away from the hover when the noise and vibrations
resumed. The pilot noted the intensity increased when the collective lever was raised. 4
The pilot radioed the air attack crew the intention to land, released the bucket, and initially tracked
towards a clear area that was not a confined area. 5 However, the continuing noise indicated to the
pilot that the condition of the helicopter was deteriorating and the pilot elected to divert to a small
clearing, which required an approach to the hover prior to landing. The air attack crew broadcast
an emergency radio call for the pilot while the helicopter was tracking to the clearing.
On approach to the hover, at a height of about 10 ft, the helicopter started to yaw to the right,
which the pilot was unable to stop with the left pedal. At about 90° rotation to the right, the pilot
closed the throttle to idle, which did not appear to slow down the rotation, and then ‘dumped’ the
collective lever. The helicopter rotated about 180° from the approach heading before landing hard.
The main rotor blades struck the ground in the forward left position (reference to the pilot’s seat),
which resulted in the failure of the main gearbox mounts and the ejection of the main gearbox,
mast, rotors and driveshaft from the airframe.
Rural Fire Service and National Parks personnel responded immediately and arrived at the
accident site shortly after the pilot had exited from the wreckage (Figure 1). They extinguished a
small grass fire that had been started by the helicopter. The pilot was transported to hospital by
ambulance for observation and then released with nil injuries. The helicopter was substantially
damaged.

1 Eastern Daylight-saving Time (EDT): Coordinated Universal Time (UTC) +11 hours.
2 Formerly Bell UH-1H (‘Huey’ helicopter).
3 The ground-based air attack (helicopter) crew provide the airborne supervision for the fire control air assets.
4 Collective: a primary helicopter flight control that simultaneously affects the pitch of all blades of a lifting rotor. Collective
input is the main control for vertical velocity.
5 A confined area is an area where the departure or approach flight path is limited in some direction by terrain or the
presence of obstructions, natural or manmade.

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Figure 1: Main wreckage site

Source: Operator

Context
Airframe inspection
The ATSB inspected the airframe at one of the operator’s hangar facilities on 20 December 2019.
Due to the damage and disassembly for transport, the flight controls and transmission could not
be inspected for mechanical continuity and correct operation. The engine could not be rotated and
there was evidence of fine metallic particles present on the exhaust and combustion side of the
power turbine, which indicated metal debris passed through the engine during the accident
sequence.
The KAflex® driveshaft (part number: SKCP2281-103), which transmits the drive power from the
engine output to the main gearbox input, was found to have fractured into multiple pieces. The
driveshaft uses flexible plates (Figure 2) to accommodate relative movement between the engine
and gearbox, and was designed with an integral failsafe feature for continued flight in the event of
a single flex frame fracture. It will permit a limited continued power operation (20 minutes
demonstrated during qualification), enabling pilots to safely land the helicopter.

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 ATSB – AO-2019-070

Figure 2: KAflex® driveshaft – key parts identified with the number of each part fitted
annotated in brackets

Source: Kamatics Corporation, annotated by the ATSB

The visual inspection of the driveshaft noted a failure of one of the outer flex plate bolt holes,
where the plate was bolted to the main gearbox-end fitting. In addition, there were five recessed
washers missing from various fasteners. The rear transmission mount support assembly exhibited
scoring below the location of the driveshaft gearbox-end fitting (Figure 3). Discoloration of a
section of the failed outer flex plate was consistent with the scoring to the support assembly. The
ATSB retained the helicopter’s KAflex® driveshaft (serial number 2136) for materials examination.
Figure 3: Scoring to the rear transmission mount support assembly

Source: ATSB

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Materials examination
The flex plates from the driveshaft had fractured into multiple segments. The outer flex plate at the
main gearbox-end fitting had fractured through the bolt hole, with a small section remaining
attached at the join (Figure 4). Examination of the flex plate fracture surfaces revealed evidence of
beachmarks, consistent with fatigue crack progression. The fatigue crack had propagated across
about 90 per cent of the fractured surface. The surfaces surrounding the fatigue fracture exhibited
evidence of surface corrosion and pitting (Figure 5).
Figure 4: Fractured bolt hole (left) and small section remaining attached (right)

Source: ATSB

Figure 5: Fatigue failure of flex plate

Source: ATSB

The five missing washers were from four fasteners, and in each of these locations the fasteners
were loose and the flex plates free to move with respect to each other. Damage to the fasteners at
these locations precluded any useful information with regard to torque values. A witness mark,
consistent with a washer, was observed in all the locations. While some marks were more distinct
than others, it was considered very likely that a washer had been present at each location at some
stage in the life of the component. Figure 6 depicts the location of one of the missing washers.

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 ATSB – AO-2019-070

Figure 6: Missing washer

Source: ATSB

KAflex® driveshaft overhaul and inspection

The manufacturer (Kamatics Corporation) reported that driveshaft SKCP2281-103, serial number
2136, was purchased in 1980 by the then owner, the United States (US) Army, as part of the
UH-1H driveshaft retrofit program. There was no time-between-overhaul (TBO) or retirement life
for the driveshaft. There was a period in which the US Army implemented an overhaul program,
but this was discontinued, and the driveshaft TBO/retirement became ‘on condition’. This was the
accepted practice when the UH-1H helicopters were transferred to the civilian register in the
restricted category. 6
As the UH-1H was the driveshaft manufacturer’s only program without a TBO or retirement life,
they worked with the US Army to develop a new safety of flight part number (SKCP3303-1).
These driveshafts have a formal TBO of 5,000-hours, which is in accordance with the
manufacturer’s other driveshaft programs. Any legacy driveshafts of part number SKCP2281-103
can be sent to the manufacturer for modification to part number SKCP3303-1.
In 2018, the manufacturer provided a position paper to the US Federal Aviation Administration
with their concerns and recommendations for driveshafts in civilian UH-1H helicopters. 7 Their
paper identified several different legacy part number driveshafts for the UH-1H. Part number
SKCP2281-103 was identified as the only legacy part number that should be remaining in the
field, and those with a serial number below 635 should be removed from service. In addition to
recommending a ‘thorough Out of Aircraft inspection’, the manufacturer recommended to the FAA
a removal from service for part number SKCP2281-103 driveshafts at 5,000-hours, or, if the time
cannot be determined from historical records, ‘removal and replacement with a serviceable unit’.
The manufacturer reported that the Federal Aviation Administration has assigned a case number
to review the issue of the UH-1H driveshaft in response to the manufacturer’s position paper.

6 Restricted category indicated that additional limitations on operations were required as the design did not comply with
the normal category.
7 Kamatics Corporation (KER-2355A): Current State Conditions of Concern, Army Surplus KAflex Driveshafts Fielded in
UH-1H Civil Rotorcraft, dated 8 March 2018. The paper included reports on four non-fatal UH-1H driveshaft failure
accidents.

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 ATSB – AO-2019-070

The KAflex® driveshaft should not be disassembled outside of the factory. The manufacturer’s
position paper and instructions for continued airworthiness for part number 3303 (Revision B),
stated that all inspections should include checking for missing hardware (bolts, nuts, and
washers), and a warning not to ‘disturb or tighten flex frame nuts or bolts. Evidence of turning
fasteners by wrench or other means is cause for rejection.’
The maintenance organisation reported that the driveshaft was not being tracked as it did not
have a service life and was an ‘on condition’ component. It was removed for an engine change
about 74.5 hours prior to the accident and received a general visual inspection prior to installation.
They reported that disassembly of the KAflex® driveshafts was not permitted and therefore there
was no disassembly of it during the engine change.

Maintenance organisation comments

The maintenance organisation reported that they could not explain how the washers came to be
missing, but were confident that they were all installed prior to the accident for the following
reasons:
• Quality pictures of the KAflex® bolts securing the end fittings were taken post-installation after
the engine change. As the pictures were focused on the bolt securing the two clamps together,
some of the KAflex® fasteners were not visible. However, the fasteners that were visible were
all correctly assembled.
• During the engine change, the licenced aircraft maintenance engineer, with more than
15 years of experience on the ‘Huey’, was doing some training with another engineer. They
focused on the KAflex® and how to inspect the driveshaft correctly, especially when it was
removed from the helicopter. During that training, they attempted to turn each fastener by hand
to check if any were loose. In addition, they inspected for any evidence of fretting or cracks. No
defects were found, and the driveshaft was installed.
• The organisation used an unserviceable KAflex® driveshaft to check if it was possible to have
one or two washers missing and the nut not be ‘shank bound’. 8 They found that a fastener with
one washer removed could be tightened up enough that it could not be turned by hand.
However, a fastener with two washers removed was shank bound with about a 10 thousandth
of an inch gap between the nut and the flex plate.
• In the case of the fastener missing two washers, they considered that the damage caused by a
driveshaft having a shank bound bolt would cause a large amount of fretting. That damage
would have been easily visible over the past 1,000 hours they had maintained it. In addition,
they considered that the flex plate bolt hole would have elongated or caused large amounts of
damage to the bolt. This damage was not evident.

Airworthiness bulletin
In 2007, the Civil Aviation Safety Authority released an Airworthiness Bulletin (AWB 63-004:
Kamatics Corporation KAflex Drive Shafts – Bell 407) for the purpose of alerting industry to an
‘inadequacy in a detail in the pre-flight check requirements of the approved Bell 407 Flight Manual
with regard to checking the KAflex© drive shaft’. They recommended that pre-flight checks include
the specific condition of all hardware and included the warning not to ‘disturb or tighten flex frame
nuts or bolts. Evidence of turning fasteners by wrench or other means is cause for rejection’.

Discovery of broken washer

On 14 November 2020, following publication of the ATSB’s investigation report, an aircraft
maintenance engineer found a broken washer in the wreckage while removing salvageable parts.
The maintenance organisation notified the ATSB of the discovery and the broken washer was

8 Shank bound describes the condition when the nut is inhibited by the shank (grip or unthreaded portion of the bolt)
before clamping torque is achieved.

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sent to the ATSB facilities in Canberra for analysis. In addition, the maintenance organisation
provided further details, including photographs, about the maintenance history of the driveshaft.
Based on a photographic review of the broken washer, Kamatics reported the washer was
consistent with those used on the KAflex® driveshaft. Analysis conducted by the ATSB revealed a
high aluminium content, which was consistent with the SermeTel® coating used on these
washers. 9 The dimensions were consistent with those for the KAflex® driveshaft recessed washer
part number, the surface exhibited signs of fretting and there was no evidence of fatigue on the
fracture surfaces. Kamatics reported that fretting is the usual type of wear found on the washers
for driveshafts that have accumulated 4,500-6,000 hours operation, but they have never recorded
cracked or broken washers during overhaul. Figure 7 below provides a comparison of the broken
washer with a KAflex® driveshaft recessed washer.
The additional maintenance information and analysis of the broken washer suggested the most
plausible scenario was that the missing washers failed as a result of the break-up of the driveshaft
when the main gearbox was forcibly ejected from the airframe.
Figure 7: Comparison of washers

Source: Maintenance organisation, annotated by the ATSB

Safety analysis
Precautionary landing
As the helicopter approached a high hover over the Crawford River for a water uplift, the pilot
experienced a ‘buzzing’ airframe vibration and ‘burring’ noise. The pilot immediately aborted the
uplift, released the water bucket, and tracked to a nearby clearing for a precautionary landing.
When in a hover position, just prior to landing, the helicopter started to yaw right. Despite the
pilot’s attempt to stop the yaw, directional control could not be regained, which resulted in a hard
landing. During the landing, the main rotor blades struck the ground, resulting in the failure of the
main gearbox mounts and the forced ejection of the main gearbox, mast, rotors and KAflex®
driveshaft from the airframe.

Flex plate fatigue failure

An inspection of the airframe revealed the KAflex® driveshaft exhibited a fatigue failure of the
outer flex plate at a bolt hole where the plate was fastened to the main gearbox-end fitting. The

9
SermeTel® coating is used for protection of metal components operating in severe environments at high temperatures.

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 ATSB – AO-2019-070

observed scoring marks to the rear transmission mount support assembly were consistent with the
failed driveshaft flex plate striking it during operation. This indicated that the driveshaft failure
started before the hard landing and was consistent with the symptoms of noise and vibration
reported by the pilot when overhead the Crawford River.

Findings
These findings should not be read as apportioning blame or liability to any particular organisation
or individual.
• While conducting fire control operations, the pilot detected a 'buzzing' vibration through the
airframe with an associated noise, which necessitated a precautionary landing. During the
landing directional control could not be maintained, resulting in a hard landing.
• The helicopter's KAflex® driveshaft failed as a result of a fatigue failure of the outer flex plate
attached to the main gearbox fitting.

Safety action
Whether or not the ATSB identifies safety issues in the course of an investigation, relevant
organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB
has been advised of the following proactive safety action in response to this occurrence.

Civil Aviation Safety Authority

As a result of this occurrence, the Civil Aviation Safety Authority advised the ATSB that they took
the following safety action:

Communication
The Civil Aviation Safety Authority inspected the driveshaft and then distributed an occurrence
brief to all Australian operators of the UH-1 helicopters and variants with a copy of Airworthiness
Bulletin 63-004: Kamatics Corporation KAflex Drive Shafts – Bell 407. This included the statement
that the bulletin for the Bell 407 helicopters ‘is considered equivalent information for all UH-1
rotorcraft.’

Helicopter operator
As a result of this occurrence, the operator advised the ATSB that they took the following safety
action:

Replacement part
The operator replaced the KAflex® driveshaft on their other UH-1H helicopter with a new
driveshaft. They implemented a maintenance routine to monitor the hours flown and
time-in-service of the new driveshaft and included a scheduled retirement time of 5,000 hours.

Maintenance organisation
As a result of the occurrence, the maintenance organisation advised the ATSB that they took the
following safety action:
Addition of maintenance worksheet line item for all KAflex (and similar) driveshafts over-and-above
the maintenance manual data checks. This line item covers a step to check all hardware against IPC
[illustrated parts catalogue]/data (i.e. correct quantity and part number for all bolts, washers and nuts)
and visual verification by means of applying Torque Sealant specified by KAflex OEM [original
equipment manufacturer] as well as signing off the task. Subsequent checks will require that this
torque seal is checked and reapplied if required, in order to verify a subsequent check of hardware
has been made. This checklist item references Kamatics (OEM) ICA [instructions for continued
airworthiness] 3303 Rev. B.

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 ATSB – AO-2019-070

General details
Occurrence details
Date and time: 7 December 2019 – 1035 EDT
Occurrence category: Accident
Primary occurrence type: Transmission and gearboxes – Driveshaft failure
Location: near Crawford River, New South Wales
Latitude: 32º 25.833' S Longitude: 152º 7.200' E

Aircraft details
Manufacturer and model: Overseas Aircraft Support UH-1H
Registration: VH-OXI
Operator: Touchdown Helicopters
Serial number: 64-13497
Type of operation: Aerial work – Fire control
Departure: Wauchope, New South Wales
Destination: Wauchope, New South Wales
Persons on board: Crew – 1 Passengers – 0
Injuries: Crew – 0 Passengers – 0
Aircraft damage: Substantial

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About the ATSB

The ATSB is an independent Commonwealth Government statutory agency. The ATSB is
governed by a Commission and is entirely separate from transport regulators, policy makers and
service providers. The ATSB’s function is to improve safety and public confidence in the aviation,
marine and rail modes of transport through excellence in: independent investigation of transport
accidents and other safety occurrences; safety data recording, analysis and research; fostering
safety awareness, knowledge and action.
The ATSB is responsible for investigating accidents and other transport safety matters involving
civil aviation, marine and rail operations in Australia that fall within the ATSB’s jurisdiction, as well
as participating in overseas investigations involving Australian registered aircraft and ships. A
primary concern is the safety of commercial transport, with particular regard to operations
involving the travelling public.
The ATSB performs its functions in accordance with the provisions of the Transport Safety
Investigation Act 2003 and Regulations and, where applicable, relevant international agreements.

Purpose of safety investigations

The object of a safety investigation is to identify and reduce safety-related risk. ATSB
investigations determine and communicate the factors related to the transport safety matter being
investigated.
It is not a function of the ATSB to apportion blame or determine liability. At the same time, an
investigation report must include factual material of sufficient weight to support the analysis and
findings. At all times the ATSB endeavours to balance the use of material that could imply adverse
comment with the need to properly explain what happened, and why, in a fair and unbiased
manner.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are
based on many factors, including the level of safety benefit likely to be obtained from an
investigation. For this occurrence, a limited-scope, fact-gathering investigation was conducted in
order to produce a short summary report, and allow for greater industry awareness of potential
safety issues and possible safety actions.

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