ATL91IA134

NTSB incident investigation · de Havilland DHC-8-102 · Savannah, GA · July 17, 1991

Incident · No injuriesIncident investigationFinal report
Date
July 16, 1991, 20:25 local (Jul 17, 1991, 00:25 UTC)
Place
Savannah, GA
Injuries
5 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N922HAde Havilland DHC-8-102
Weather
Visual (VMC) · Dusk
Status
Completed · report March 9, 1993
Report
Approved by Office Director
FAA report
19910716033829I
Case key
8346

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The inadequate inspection procedures which allowed the loss of torque on the top retraction fitting attachment bolt which subsequently failed in fatigue. Factors were the loss of hydraulic fluid through a severed line, and the corrosion of a hydraulic quantity limiting valve.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionClimb - to cruise
Landing gear,normal retraction/extension assembly - looseCause
Maintenance,inspection - inadequateCause
Procedure inadequateManufacturer
Landing gear,normal retraction/extension assembly - fatigueCause
Hydraulic system,line - sheared
Fluid,hydraulic - loss,totalFactor
Hydraulic system,shutoff valve - failure,totalFactor
Hydraulic system,shutoff valve - corrodedFactor
Landing gear,normal retraction/extension assembly - fractured
Miscellaneous equipment - inadequateManufacturer
Inadequate quality controlManufacturer

Analysis

After flt 4317 took off, the main lndg gear did not retract. The flt crew accomplished the emerg checklist, extdd the lndg gear & made an uneventful lndg. An exam of the acft disclosed that the rgt lndg gear retraction fitting had failed & a hydraulic line was severed. Also, the quantity limiting valve(s) were corroded & the respective piston movement was restricted. Subsequently, both hydraulic systems were drain of fluid. An exam of the fitting attachment bolts revealed the top bolt lost torque & the bolt failed in fatigue; the bottom bolts failed in overload. Adnly, the fitting spigot failed due to hydrogen embrittlement; an improved fitting has been produced to correct hydrogen embrittlement problems. The oper conducted a fleet campaign & fnd 13 loose bolts in other 100 series acft. Svrl airworthiness directives were issued to correct the loss of torque on attachment bolts, which included checking the torque at the 300 hr lndg gear inspn.

Aircraft

Registration
N922HA
Reported as
de Havilland DHC-8-102
Category
Airplane
Serial number
094
Airframe hours
9,081
Engine
P&W 120A, 2,000 horsepower, turbo prop
Damage
Minor damage
Flight
Part 121
Operator
Henson Airlines
Registered owner
Westinghouse Credit Corp
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · July 12, 1991 · 25 hours before
Departed
49J · Hilton Head Isl, SC
Destination
JAX · Jacksonville, FL
Flight plan
IFR
Airport
SAV · Savannah, runway 27, 9,003 × 150 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
32
Certificates
Commercial, Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
8,671 total · 2,359 in this make and model · 5,375 as pilot in command · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dusk
Wind
270° at 6 knots
Visibility
8 statute miles
Lowest ceiling
1,100 ft broken
Temperature
77 °F, dew point 75 °F
Altimeter
29.00 inHg
Observed at
SAV, 1 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.