NTSB CAROL · Event
Event ERA23LA319
Aircraft involved
Probable cause & findings
A failure of the tail rotor pitch change lever assembly due to incorrectly installed bolts and maintenance personnel’s inadequate inspection of the tail rotor control system.
Factual narrative
On August 1, 2023, about 1530 eastern daylight time, a Bell Helicopter Textron Canada 407, N31PB, was substantially damaged when it was involved in an accident near North Charleston, South Carolina. The commercial pilot sustained minor injuries. The helicopter was operated as a public aircraft. The helicopter, operated by the Charleston County Sheriff’s Office, was on a positioning flight from Sumter Airport (SMS), Sumter, South Carolina, to Charleston AFB International Airport (CHS), North Charleston, South Carolina. The pilot reported that, after about 35 minutes of flight, the helicopter started to yaw slowly to the right. The pilot applied left pedal with no response. The pilot stated, “It felt as if the pedals were not attached.” He contacted CHS tower and declared an emergency. He set up for a straight-in approach to runway 15. While crossing the runway threshold, about 20 ft above ground level, the helicopter started to yaw to the right. He lowered the collective, but the helicopter continued to yaw right. He then reduced the throttle and attempted to maintain a level attitude. The helicopter struck the ground adjacent to runway 15 at a high rate of descent, coming to rest in the grass. The tail rotor boom severed during the impact sequence. Inspectors with the Federal Aviation Administration (FAA) responded to the accident site and examined the wreckage. They confirmed substantial damage to the fuselage, main rotor system, and tail rotor system. They found 1 of the 2 bolts that secured the tail rotor pitch change lever assembly was missing (Photo 1). The lever assembly was disconnected from the trunnion. The other bolt that connected the levers to the rod assembly was in place, but loose; the cotter pin for its attachment nut was missing (Photo 2). Photo 1: Tail rotor Pitch Change Lever Assembly. Red arrow points to area of missing bolt. Photo 2: Pitch Change Lever Assembly. Red arrow points to loose nut on bolt; cotter pin was missing. A review of the maintenance records by FAA inspectors revealed that a 300 hour/3 month inspection was performed on the helicopter on June 28, 2023. The helicopter had been flown about 15.4 hours since this inspection. According to Bell Helicopter technical support personnel, the inspection/lubrication procedure that was accomplished on June 28 would not require removal of the lever assembly bolts; however, the nuts and bolts should have been clearly visible during the inspection of the area. The mechanic who performed the inspection stated that he must have overlooked them. The pilot reported that, about 35 minutes into the flight, he noticed that the helicopter began to yaw to the right and his pedal inputs did not correct the situation. He contacted the tower at his destination and declared an emergency. As he approached the runway for a straight-in landing, the helicopter yawed again. He lowered the collective, but the helicopter continued to yaw right. He then reduced the throttle and attempted to maintain a level attitude. The helicopter struck the ground at a high rate of descent, coming to rest in the grass adjacent to runway. The helicopter sustained substantial damage to the fuselage, main rotor system, and tail rotor system. A postaccident examination of the helicotper found one of the two bolts that secured the tail rotor pitch change lever assembly was missing. The lever assembly was disconnected from the trunnion, resulting in the loss of tail rotor control. The other bolt that connected the levers to the rod assembly was in place, but loose; the cotter pin for its attachment nut was missing. A review of the maintenance records revealed that a 300 hour/3 month inspection was performed on the helicopter about 15.4 flight hours before the accident. According to the helicopter manufacturer, that recent inspection would not have required removal of the lever assembly bolts; however, the nuts and bolts should have been clearly visible during the inspection of the area. The mechanic who performed the inspection stated that he must have overlooked them. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- — Aircraft-Aircraft systems-Flight control system-(general)-Inadequate inspection
- — Personnel issues-Task performance-Inspection-Scheduled/routine inspection-Maintenance personnel
- — Personnel issues-Task performance-Maintenance-(general)-Maintenance personnel
Verbatim from NTSB's published report. Source file
NTSB_2023_ERA23LA319.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
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- Embry-Riddle Scholarly Commons 2023 · Conference paper
The Value of Strong Partnerships to Build a Successful Aviation Maintenance Career Pathway Program for Transitioning Military Service Members
The aerospace industry is competing with other industries for a qualified workforce, and many of those competing industries are investing heavily in creating workforce development pipelines.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- NASA NTRS 2026 · Conference Paper
Computational Analysis of Steady State Aerodynamics of Transonic Truss-Braced Wing Configuration in Deep Stall
This study presents a computational investigation of steady state aerodynamics of the Subsonic Ultra-Green Aircraft Research (SUGAR) Transonic Truss-Braced Wing (TTBW) configuration over a wide range …
- Semantic Scholar 2025 · Article (Applied Sciences)
Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…
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