# NTSB BFO92IA017: de Havilland DHC-8-102, N923HA, Baltimore, MD, January 12, 1992

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: January 12, 1992, 14:18 local (19:18 UTC)
- Place: Baltimore, MD
- Coordinates: 39.170269, -76.670745 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=39.1703&lon=-76.6707&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 33 uninjured
- Status: Completed, report April 7, 1995
- Report: Approved by Office Director
- NTSB case key (mKey): 11741
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO92IA017
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/11741/pdf
- Page: https://openairdocs.org/ntsb/BFO92IA017

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Airframe/component/system failure/malfunction, takeoff - initial climb
  - fuel system,fuel quantity float/sensor - fatigue (cause)
  - maintenance,installation - improper, other maintenance personnel (cause)
  - fluid,fuel - leak (cause)
- Fire/explosion, takeoff - initial climb
  - 1 engine
  - engine shutdown - intentional, pilot in command
- Fire/explosion, takeoff - initial climb
  - fuselage,firewall - inadequate (contributing factor)
  - aircraft/equipment inadequate, manufacturer (contributing factor)
  - engine compartment - fire (cause)
  - 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/water, landing - 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 (not matched to a registry record)
- Reported make and model: de Havilland DHC-8-102
- Category: Airplane
- Serial number: 99
- Airframe hours: 9965
- Engines: P&W PW120A 2100 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.

- Pilot; age 37; 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 (OpenAirDocs).

- [Incident 19920112004129I](https://openairdocs.org/incident/19920112004129I), Jan 12, 1992: Dhav DHC8102, Baltimore, MD, Minor damage. NR1 engine fire on climb. Returned. Lost hydraulic pressure. Departed runway on landing. Had leaking fuel.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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