BFO92IA017

NTSB incident investigation · de Havilland DHC-8-102 · Baltimore, MD · January 12, 1992

Incident · No injuriesIncident investigationFinal report
Date
January 12, 1992, 14:18 local (19:18 UTC)
Place
Baltimore, MD
Injuries
33 uninjured
Damage
Minor damage
Phase of flight
Initial climb
Aircraft
N923HAde Havilland DHC-8-102
Weather
Visual (VMC) · Day
Status
Completed · report April 7, 1995
Report
Approved by Office Director
FAA report
19920112004129I
Case key
11741

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

Improper installation of the low fuel pressure warning switch snubber on the #1 engine, resulting in fatigue failure of the snubber, a fuel leak (spray), and subsequent explosion/fire damage. A factor related to the incident was: inadequate design of the firewall, which allowed fuel vapors to migrate to the hot section of the engine.

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/malfunctionTakeoff - initial climb
Fuel system,fuel quantity float/sensor - fatigueCause
Maintenance,installation - improperOther maintenance personnelCause
Fluid,fuel - leakCause
Fire/explosionTakeoff - initial climb
1 engine
Engine shutdown - intentionalPilot in command
Fire/explosionTakeoff - initial climb
Fuselage,firewall - inadequateFactor
Aircraft/equipment inadequateManufacturerFactor
Engine compartment - fireCause
Electrical system,electric wiring - burned
Hydraulic system,line - ruptured
Hydraulic system - inoperative
Landing gear,steering system - inoperative
Landing gear,normal brake system - inoperative
Loss of control - on ground/waterLanding - roll
Directional control - not possible

Analysis

As the gear & flaps were retracted after takeoff, the #1 engine low fuel pressure warning light illuminated. At about 400' AGL, a "loud bang" was heard followed by a #1 engine fire warning indication. The engine was shut down & both fire extinguishing bottles were discharged. The flightcrew extended the landing gear by using the alternate system & made a no-flap emergency landing. They used emergency brakes, but directional control was lost & the aircraft exited the side of the runway & stopped with the fire extinguished. An exam of the #1 engine area revealed a failed low fuel pressure warning switch snubber & fire damage to the engine, nacelle & wheelwell. There was evidence that during installation, the low fuel pressure warning switch snubber was torsionally deformed, then fatigue & subsequent failure occurred. Gaps in the firewall allowed leaking fuel (spray) to enter the hot section & ignite. This resulted in an explosion & fire. Fire propagation resulted in burned wires to the #1 standby hydraulic pump & a ruptered #2 system hydraulic line.

Aircraft

Registration
N923HA
Reported as
de Havilland DHC-8-102
Category
Airplane
Serial number
99
Airframe hours
9,965
Engine
P&W PW120A, 2,100 horsepower, turbo prop
Damage
Minor damage
Fire
In-Flight
Flight
Part 121
Operator
Usair Express, doing business as Henson Aviation
Registered owner
Westinghouse Credit Corp
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 9, 1992 · 96 hours before
Destination
CHO · Charlottesville, VA
Flight plan
IFR
Airport
BWI · Baltimore-Washington Intl, runway 22, 6,005 × 150 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
37
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
8,890 total · 3,120 in this make and model · 159 in the last 90 days · 64 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 9 knots
Visibility
15 statute miles
Lowest ceiling
None
Temperature
122 °F, dew point 84 °F
Altimeter
30.00 inHg
Observed at
BWI, 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.