BFO88FA036

NTSB accident investigation · Fokker F28 MK 4000 · Charleston, WV · April 14, 1988

Accident · Minor injuriesField investigationFinal report
Date
April 14, 1988, 09:45 local (13:45 UTC)
Place
Charleston, WV
Injuries
8 minor, 54 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N110URFokker F28 MK 4000
Weather
Visual (VMC) · Day
Status
Completed · report October 1, 1991
Report
Approved by Office Director
FAA report
19880414009269A
Case key
11364

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

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Probable cause

Engine and airframe failure were caused by the the separation of the first stage low pressure turbine disk. The disc interstage seal was installed inadequately, resulting in rubbing between the seal and disk, causing failure of the disk. Inadequate procedure by maintenance personnel are a contributing factor.

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.

Loss of engine power(total) - mech failure/malfCruise - normal
Turbine assembly,seal - movement restrictedCause
Maintenance,installation - improperOther maintenance personnelCause
Turbine assembly,turbine wheel - chafedFactor
Procedures/directives - not followedOther maintenance personnelFactor
Turbine assembly,turbine wheel - failure,totalFactor
DecompressionCruise - normal
Turbine assembly,turbine wheel - separationFactor
Fuselage,cabin - penetratedFactor
Oxygen system,mask,passenger - jammed

Analysis

The acft was at flight level 310, when the no. 2 engine first stage turbine disc separated, causing an uncontained engine failure. Turbine debris penetrated the fuselage structure & caused depressurization. The plt made an emergency descent & landed at Charleston, WV, which was about 50 miles away. The investigation revealed severe rubbing & melting of the low pressure turbine interstage seal & separation of the drive flanges connecting the LP1 & LP2 turbine discs. Rolls-royce repair scheme xrs 3505 describes a procedure for repair of the interstage seals. However, in replacing the seals, the repair facility used machining reference surfaces which differed from those in the repair scheme. Rolls-roycesubsequently amended xrs 3505 to make it more tolerable to rubbing or misassembly of the low pressure turbine seal. All of the first class section & two cabin section passenger oxygen masks failed to deploy.

Aircraft

Registration
N110UR
Reported as
Fokker F28 MK 4000 (F28 MK 400)
Category
Airplane
Serial number
11182
Airframe hours
14,441
Engine
Rolls-Royce 555-15P, 9,850 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Registered owner
Piedmont Aviation
Airworthiness certificate
Standard, Transport
Departed
CLT · Charlotte, NC
Flight plan
IFR
Airport
CRW · Yeager, runway 5, 6,302 × 150 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
45
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
11,009 total · 325 in this make and model · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 4 knots
Visibility
7 statute miles
Lowest ceiling
25,000 ft overcast
Temperature
57 °F, dew point 39 °F
Altimeter
29.00 inHg
Observed at
CRW, 50 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.