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NTSB · Safety Recommendation

Safety Recommendation A-04-069

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Require Rolls Royce to modify the Model 250 series IV engine control system so that backup engine control is available immediately following loss of primary full authority digital electronic control function and such that the backup system does not impose undue workload on the pilot.

Safety Issue and Context

On May 11, 2003, approximately 1533 central daylight time, a Bell 407 helicopter, N491PH, registered to and operated by Petroleum Helicopters, Inc. (PHI), of Lafayette, Louisiana, was substantially damaged during an autorotative water landing in the Gulf of Mexico, following a loss of engine power while in cruise flight. The airline transport pilot and his three revenue passengers were not injured. Visual meteorological conditions prevailed and a company flight plan was filed for the flight. PHI was operating the accident flight under the provisions of 14 Code of Federal Regulations Part 135 as an on-demand air taxi flight.

The flight originated from an offshore platform about 1453 and was en route to Morgan City, Louisiana.

Response History

January 22, 2008 · NTSB Correspondence · FAA

Rolls-Royce announced on February 26, 2006, that it had obtained FAA certification for a modification of the Model 250 series IV engine control system that would enable backup engine control to be available immediately following loss of the primary FADEC, so that the backup system does not impose an undue workload on the pilot. The announcement also indicates that this modification will be provided without cost to all owners of the affected engines. With the certification of this revision, the FAA has met the intent of Safety Recommendation A-04-69, which is classified Closed Acceptable Action.

September 11, 2007 · Recipient Response · FAA

Letter Mail Controlled 9/25/2007 8:18:55 AM MC# 20705181: FAA Comment. The Board’s response letter, dated October 7,2005, indicates that Rolls Royce Corporation’s (RRC) introduction of a product improvement to the Model 250 Series IV Full Authority Digital Electronic Control (FADEC) engine control system is responsive to this safety recommendation. The Board also indicated that an Airworthiness Directive (AD) mandating the incorporation of the improved Electronic Control Unit (ECU) is needed.

The Federal Aviation Administration considers the addition of the Reversionary Governor to the ECU to be a FADEC control system product improvement that will reduce the frequency of reversions to manual mode. The reversionary governor function allows the ECU to continue to provide uninterrupted automatic fuel flow control if the ECU primary governor cannot function.

Rolls-Royce Corporation published Commercial Service Letter CSL-6 1 13R1, New Configuration Electronic Control Unit, dated September 2 1, 2005, notifying operators of the Model 250-C47 Series IV FADEC engine control system product improvement for single engine installations. This commercial service letter notified operators that RRC was offering a new configuration of the ECU with a reversionary governor function without cost to all operators who registered before December 31, 2005.

To support this effort, the FAA’s Aircraft Certification Service issued Special Airworthiness Information Bulletin (SAIB) NE-06- 12, dated December 2, 2005, strongly recommending operators to take advantage of the no cost product improvement being offered by RRC. Ninety percent of the eligible owner-operators have registered for the ECU control upgrade. As a result of the FAA and the RRC activities, RRC has a pool of units ready for retrofit, and expect to complete an upgrade of the fleet by December 3 1,2008. This implementation plan is acceptable to the FAA.

While the Model 250 series IV control system complies with FAA certification requirements without the incorporation of the ECU reversionary governor upgrade, the engine’s control system’s electronic components have undergone product improvements over the years continuously improving reliability. A review of RRC’s FADEC control system’s loss-of-thrust control (LOTC) service history for the previous 5 years has revealed that the LOTC rate has remained below the certification basis of 10 LOTC failures per million engine hours (as established under Advisory Circular, Compliance Criteria for 14 CFR Part 33

February 26, 2006 · Recipient Response · FAA

Letter Mail Controlled 2/26/2006 8:18:55 AM MC# 2070434: Rolls Royce Press Release 2/26/06 Rolls-Royce has achieved FAA certification of an enhanced full-authority digital engine control (FADEC) system for the Model 250-C47B turboshaft. This enhanced FADEC will benefit operators of the Bell 407 helicopter. The new EMC-35R FADEC system is identical to the original EMC-35A with the exception of the Electronic Control Unit (ECU). The major difference between the two units is that, while the original EMC-35A ECU utilizes a single electronic channel unit, the new EMC-35R ECU features a dual electronic channel unit.

The EMC-35R’s Primary Governor (PG) channel is functionally similar to the EMC-35A’s single channel, while the use of a Reversionary Governor (RG) channel introduces a back-up electronic control. When fitted with the new EMC-35R ECU, the Model 250 FADEC system still retains its manual hydraulic back-up control system. The effort to certify this new Model 250-C47B FADEC results from an extensive and detailed engineering test program, during which Rolls-Royce was able to demonstrate that the probability of a ‘reversion to manual’ scenario is reduced by 60 percent.

This improvement will provide an increased operational benefit to the pilot, allowing continued flight in an automatic governed mode. To assist with the introduction of the new FADEC system, Rolls-Royce has issued two Customer Supportters (CSLs 6113 and 6117) which provide further details, and which request that affected operators register in order to allow all affected operators to be identified. The new EMC-35R ECU will be provided to operators at no cost, provided that they have registered in accordance with these CSLs and that the existing core ECU is returned. The new ECUs will be supplied with a new 24-month / 1,000-hour (whichever comes first) warranty.

This new FADEC system will also be certified on the Model 250-C47M turboshaft later in 2006, extending the same benefits to operators of the MD Helicopter Inc. MD 600N.

October 7, 2005 · NTSB Correspondence · FAA

The FAA's March 24, 2005, letter provided a detailed analysis of this recommendation. In that letter, the FAA indicates that it could not find in advisory circular (AC) 27-1B the requirement, referenced in the Safety Board's December 15, 2004, letter that transmitted this recommendation to the FAA, that the backup system "be available immediately following loss of the primary system." Page MG 4-6 of AC 27-1B, paragraph (iii) provides the information that the Board referenced. That paragraph is shown below, with relevant portions emphasized.

(iii) Capability of back-up system: Section 27.1143 requires that each power control provide a positive and immediately responsive means of controlling its engine. Additionally, § 27.903 requires that the powerplant systems associated with engine control systems are designed to give reasonable assurance that the engine operating limitations will not be exceeded in service. Although back-up control may be somewhat degraded, the system should allow for control of the engine and the aircraft within their operating limits.

It should be demonstrated that upon failure of the primary control the aircraft can continue to be operated safely and execute a controlled power-on landing without creating an undue pilot workload. This includes demonstration of the ability to maintain rotor speed within acceptable limits while transitioning to the backup mode and while using the backup control.

The FAA referenced other portions of the AC (on pages MG 4-6 and MG 4-9) that indicate that it should be confirmed during the flight test program that is part of the aircraft's certification that any time delays and power variations associated with transfers between the primary and backup modes are acceptable. The FAA stated that during the Bell 407 flight test program, Transport Canada pilots evaluated transfers from the primary to the backup mode and found that these transfers can be successfully made and the rotorcraft can be operated in the backup mode without an undue increase in flight crew workload. The FAA stated that it has validated Transport Canada's helicopter certification.

March 24, 2005 · Recipient Response · FAA

Letter Mail Controlled 3/30/2005 10:51:13 AM MC# 2050138: The FAA has reviewed this safety recommendation and other information contained in the Board's letter dated December 15, 2004. On page 4, the Board states: "According to FAA Advisory Circular (AC) 27-1B, Chapter 3 Airworthiness Standards Normal Category Rotorcraft, Miscellaneous Guidance (MG), modified or new backup systems for FADEC-equipped engines should be available immediately following loss of the primary system, be independent such that failure in the primary portion of the system will not propagate to the backup portion, and provide the pilot with a means to verify its availability at will.

The Board is concerned that the manual mode of the FADEC system in Rolls-Royce Model 250 series IV engines does not meet these guidelines. Therefore, the Board believes that the FAA should require Rolls Royce to modify the Model 250 series IV engine control system so that backup engine control is available immediately following loss of primary full authority digital electronic control (FADEC) function and such that the backup system does not impose undue workload on the pilot." The FAA could not find the referenced requirement that the backup system "be available immediately following loss of the primary system...." However, AC 27-1B does contain the following relevant information:

On page MG 4-6: (v) Transfer to backup: The transfer to the back-up mode from the primary control mode or an intermediate mode (fixed position) should occur without excessive time delay or variation in power. Time delays and power variations experienced during the transfer should be evaluated during flight test for acceptability. A means should be provided to alert the pilot that transfer to the back-up mode has occurred. On page MG 4-9: (B) Manual Backup: Additional aircraft operational testing is required to specifically evaluate the manual backup system for compliance with the FAR requirements.

The acceptability of the manual backup system depends substantially on its installation and interface with the airframe. The following items need to be demonstrated in accordance with 14 CFR 27.927 and 14 CFR 27.939

January 28, 2005 · Recipient Response · FAA

Letter Mail Controlled 2/1/2005 3:15:53 PM MC# 2050036. *This letter is NOT from the FAA, but from Rolls-Royce, and is directly pertinent to implementation of the recommendations*: On December 15,2004, your office released a five-page letter regarding Safety Recommendations A-04-68 and A-04-69, These recommendations and the associated information within your letter pertain to an incident involving the Rolls-Royce Model 250-C47B engine installed in a Bell 407 helicopter (N491 PH) operated by Petroleum Helicopters, Inc. (PHI). This incident was initiated by a capacitor short in the Electronic Control Unit (ECU) -15 volt power supply, which rendered the ECU inoperative.

The inoperative ECU transferred control of the engine to the backup hydromechanical system. This system requires the pilot to manually control the engine speed, torque and temperature. In this particular incident, the pilot did not believe that the engine was properly responding to his control inputs and consequently elected to perform an autorotation into the Gulf of Mexico. The autorotation was successful and the pilot and passengers were subsequently retrieved. The purpose of this letter is to clarify some information contained in your December 15, 2004 letter and provide additional context regarding some of the conclusions.

In addition, Rolls-Royce would like to acknowledge some of your concerns, which are contained within A-04.68 and A-04-69. Lastly, Rolls-Royce would like to raise concern over recent trends regarding NTSB recommendations associated with the Rolls-Royce Model 250 engine and request improvement in coordination between the NTSB, FAA and industry. On December 15,2004, your office released a five-page letter regarding Safety Recommendations A-04-68 and A-04-69, These recommendations and the associated information within your letter pertain to an incident involving the Rolls-Royce Model 250-C47B engine installed in a Bell 407 helicopter (N491 PH) operated by Petroleum Helicopters, Inc. (PHI).

This incident was initiated by a capacitor short in the Electronic Control Unit (ECU) -15 volt power supply, which rendered the ECU inoperative. The inoperative ECU transferred control of the engine to the backup hydromechanical system. This system requires the pilot to manually control the engine speed, torque and temperature. In this particular incident, the pilot did not believe that the engine was properly responding to his control inputs and consequently elected to perform an autorotation into the Gulf of Mexico. The autorotation was successful and the pilot and passengers were subsequently retrieved.

The purpose of this letter is to clarify some information contained in your December 15, 2004 letter and provide additional context regarding some of the conclusions. In addition, Rolls-Royce would like to acknowledge some of your concerns, which are contained within A-04.68 and A-04-69. Lastly, Rolls-Royce would like to raise concern over recent trends regarding NTSB recommendations associated with the Rolls-Royce Model 250 engine and request improvement in coordination between the NTSB, FAA and industry.

Read Recommendation

Recommendation Facts

Status
Closed - Acceptable Action
Issued
December 15, 2004
Priority
CLASS II
Recipient
FAA
Adopted
December 3, 2004
Closed
January 22, 2008
Related Investigation
FTW03FA148
Related Report
None
.28- 1, Aircraft Engines, Electrical and Electronic Engine Control Systems.)

As a result of the ECU upgrade, the LOTC rate is expected to further improve as the upgrade becomes prevalent in the field. Based on the already acceptable service record, and the plan for field upgrades, the FAA does not believe an AD to mandate the improved ECU configuration is warranted. The FAA will continue to work with Rolls-Royce to monitor the in-service performance of the overall fleet as part of the Continued Airworthiness program. I believe that the FAA has satisfactorily responded to this recommendation, and I look forward to your response.

In addition, the FAA reviewed the current service history with Rolls-Royce and believes that the FADEC system reliability is consistent with the certification basis. The FAA continues to believe that this basis is reasonable and acceptable.

The FAA's response noted, however, that because pilots will have more difficulty flying in the manual mode than in the electronic automatic mode, Rolls-Royce has created a product modification design to reduce the rate of FADEC faults resulting in transitions to manual mode. The FAA stated that when this modification - called reversionary control - has been finalized and approved by the FAA, Rolls-Royce will establish a retrofit program for upgrading the fleet, at no charge to the users. Despite the reversionary control improvements the FAA believes that the current FADEC failure rate is acceptable and consistent with the requirements of the original engine certification basis.

Consequently, the FAA will not issue an airworthiness directive (AD) to mandate the reversionary control modification. The FAA expects, however, that since the modification is being made available to operators at no cost, the fleet will quickly be retrofitted.

Although the Safety Board believes that the reversionary control modifications are responsive to this recommendation, the Board believes that the modification should be required. In its December 15, 2004, letter, the Board stated:

A search of the Safety Board's and the Federal Aviation Administration's (FAA) accident and incident databases revealed seven cases, including the PHI accident, in which failure of the FADEC system was indicated as an initiating event to a Bell 407 accident or incident. Recent accidents involving Bell 407 helicopters also show that failure of a single component (for example, a capacitor device) can result in complete loss of the FADEC system...

A review of the circumstances in the cases cited above, however, suggests that the manual mode of the FADEC system in Rolls-Royce Model 250 series IV engines, which is intended to provide backup redundancy when the primary FADEC function fails, is not effective. For example, in all but one of the seven cases, the pilots were uncertain of the nature of the emergency and chose to autorotate or forcefully landed the helicopter rather than manually fly it to a more suitable landing location following transition to the manual mode.

The Safety Board notes that many operations with these helicopters are at low altitude and frequently over open water, such as the Gulf of Mexico. In addition, the Board believes that although the flight tests may not have revealed a problem with transition to manual backup when the FADEC fails, actual operations have. Therefore, the Board continues to believe that an AD or other similar action to mandate the Rolls-Royce ECU modifications is needed.

Pending an AD to mandate Rolls-Royce's reversionary control modification, Safety Recommendation A-04-69 is classified "Open--Unacceptable Response."

or accomplished on each application prior to the acceptance of the manual backup system: (1) It should be demonstrated by flight test with the failure of the primary engine control, that the aircraft can be flown, and a safe and controlled power-on landing executed, without creating an undue pilot workload.

(2) It should be demonstrated by flight test that switching between control modes will not create an unsafe condition during any phase of operation within the aircraft operating envelope.

(3) The pilot action required as a result of a failure of the primary control, and used as an assumption in the functional hazard analysis and the failure mode and effect analysis, should be validated during flight tests and listed in the emergency procedures section of the flight manual. Both the MG 4-6 and MG 4-9 language indicate that it should be confirmed during the flight test program that any time delays and power variations associated with transfers between the primary and backup modes should be evaluated for acceptability and this is consistent with the coordinated Engine and Propeller Directorate/Rotorcraft Directorate Policy letter of March 30, 1998.

During the Bell 407 flight test program, Transport Canada pilots evaluated transfers from the primary to the backup mode and indicated that these transfers can be successfully made and the rotorcraft can be operated in the backup mode without an undue increase in flightcrew workload. They have further clarified that transitions to the backup mode when the power demand is stable, such as in hover or cruise phases of flight, is a low workload. The FAA validated Transport Canada's helicopter certification.

A review of current service history with Rolls-Royce shows that the FADEC system reliability is consistent with the certification basis, which we still consider to be reasonable and acceptable. Successful transitions to the manual mode are not a loss-of-thrust control. Considering all transitions to manual mode and any other control system failures, the control system's loss-of-thrust control rate for the last 5 years satisfies the certification basis agreed for the FADEC system and is below the 10 events per million flight hour guidance established under 14 CFR 33.28 for electronic engine control systems.

Nonetheless, realizing that pilots are more apt to have difficulty flying in the manual mode than in the electronic automatic mode, Rolls-Royce previously initiated a product improvement to significantly reduce the rate of FADEC faults resulting in transitions to manual mode. The FAA has been working with Rolls-Royce to approve the Reversionary Control, which is mainly a modified Electronic Control Unit (ECU) that includes the existing primary electronic control plus a new independent backup reversionary electronic control.

The addition of this electronic reversionary control channel will reduce the number of transitions from automatic rotor speed control to the hydromechanical manual backup control. Note that the electronic reversionary control provides automatic rotor speed governing as well. The rate of transitions to manual mode is anticipated to be reduced by approximately 35 percent when the fleet is retrofitted with the new ECU. There will still be some FADEC failure modes that will result in transition to the hydromechanical manual mode.

Hence, the flightcrews will still need to be familiar, knowledgeable, and capable of applying the procedures associated with the transition to manual mode, as well as operating the aircraft in the backup mode. With the added ECU electronic reversionary control feature, the flightcrews will operate in the hydromechanical manual backup mode less often. The modified ECU configuration with the added electronic reversionary control is expected to be approved by August 2005.

The modified ECU will have no impact on the hydromechanical manual backup mode, which will not be modified from its current design and will continue to provide "failed fixed" fuel flow during transition to manual mode. Switching to the reversionary backup control mode is automatic and is not considered to impose an undue workload on the pilot. Upon FAA approval of the modified ECU configuration, new units having the Reversionary Control will be immediately available to the fleet. Rolls-Royce will establish a retrofit campaign, at no charge to the users, for upgrading the fleet to the modified ECU. The FAA will track the Rolls-Royce retrofit campaign.

Although the Reversionary Control will reduce the number of transitions from automatic rotor speed control to the hydromechanical manual backup control, it should be emphasized that the current FADEC failure rate is acceptable and consistent with the requirements of the original engine certification basis as discussed above. Consequently, AD action to mandate the Reversionary Control is not planned at this time. However, since the modified ECU is being made available to operators at no cost, it is expected that the fleet will quickly be retrofitted with the modified ECU. I will keep the Board informed of the FAA's progress on this safety recommendation.

On December 15,2004, your office released a five-page letter regarding Safety Recommendations A-04-68 and A-04-69, These recommendations and the associated information within your letter pertain to an incident involving the Rolls-Royce Model 250-C47B engine installed in a Bell 407 helicopter (N491 PH) operated by Petroleum Helicopters, Inc. (PHI). This incident was initiated by a capacitor short in the Electronic Control Unit (ECU) -15 volt power supply, which rendered the ECU inoperative. The inoperative ECU transferred control of the engine to the backup hydromechanical system. This system requires the pilot to manually control the engine speed, torque and temperature.

In this particular incident, the pilot did not believe that the engine was properly responding to his control inputs and consequently elected to perform an autorotation into the Gulf of Mexico. The autorotation was successful and the pilot and passengers were subsequently retrieved. The purpose of this letter is to clarify some information contained in your December 15, 2004 letter and provide additional context regarding some of the conclusions. In addition, Rolls-Royce would like to acknowledge some of your concerns, which are contained within A-04.68 and A-04-69.

Lastly, Rolls-Royce would like to raise concern over recent trends regarding NTSB recommendations associated with the Rolls-Royce Model 250 engine and request improvement in coordination between the NTSB, FAA and industry. Throughout the December ljth letter, references to Rolls-Royce 250 series IV engines and those engines, which are FADEC controlled, are used interchangeably (e.g. footnote 1 and A-04-69). It should be noted, however, that not all Model 250 series IV engines are FADEC controlled. Out of thirteen certified Series IV models, only five (25O-C30W3,250-C30R/3M, 250-C40B, 250-C47B, 250-C47M) are FADEC controlled engines.

Within the discussion section it is stated that it was unclear to the investigators whether the pilot acted too quickly in his attempts to switch to manual control, or whether the system did not respond appropriately by automatically switching to manual mode. It should be clarified that pilot response time or attempts to switch to manual control is immaterial within this context because the failure mode involved in this incident (loss of the ECU power supply) automatically places the engine into manual control. There is no other option besides manual control in this instance.

The control system did respond appropriately by transitioning to manual control and this is evidenced in your report by the statements concerning multiple right yaws consistent with the pilots throttle inputs to increase power. It is stated that the pilot was fully trained and had completed Bell 407 emergency recurrent training and it is implied subsequently that the pilot’s response was intuitive and normal. What is not stated is any measure of the pilot’s comprehension of the system function from his training and awareness of the proper response to this particular failure situation.

Based on the Rolls-Royce obtained deposition given by the pilot, it is clear that he did not understand the system function or how to properly respond in this instance. Additionally, the pilot admitted that he failed to monitor his flight instruments and fly the aircraft after noting the FADEC FAIL light and was unaware of existing Bell instructions (such as Operator Safety Notice 407-96-1) cautioning pilots to exercise care when lowering collective during a FADEC FAIL condition in order to avoid tripping the engine overspeed protection system.

Several of the statements and conclusions expressed within the NTSB letter center around the engine control system delay during the transition from automatic to manual control and the pilot’s ability to cope with that transition. Changeover from electromechanical control to hydromechanical control requires movement of two pistons to capture and control the fuel metering valve. The delay time is variable and dependent on fuel flow and flight condition when transition is initiated. The delay varies between 2.3 and 5.8 seconds and has been optimized for cruise flight conditions.

The multiple references to a delay of 6 seconds are based on a worst-case interpretation of the system and are not indicative of the circumstances in this incident. Declaring the current system of transition to manual as unmanageable and counterintuitive is an investigator opinion based on observations during simulator training at PHI’S facility. Rolls-Royce has no knowledge regarding the analytical modeling contained within the simulator or the simulator’s accuracy and Rolls-Royce questions the NTSB declaration that the "simulator was realistic and provided accurate responses to all control inputs". This would require corroboration from Bell Hel