CEN11IA649

NTSB incident investigation · Airbus Industrie A320-211 · Chicago, IL · September 17, 2011

Incident · No injuriesIncident investigationFinal report
Date
September 17, 2011, 10:45 local (15:45 UTC)
Place
Chicago, IL
Injuries
140 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
C-FGYLAirbus Industrie A320-211
Defining event
Enroute-cruise: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report November 7, 2012
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, French Bureau d' Enquetes et d'Analyses (BEA), PPG Industries, Inc., Transportation Safety Board of Canada
Case key
81818

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

On this page

Probable cause

The infiltration of moisture into the windshield heating layer that induced arcing in the heating system that subsequently cracked the windshield.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Windows-windshield system: flight compartment windowsAircraft › Aircraft structures · FailureAll aircraft: 42 casesProbable cause
Windows-windshield system: flight compartment windowsAircraft › Aircraft structures · DesignAll aircraft: 42 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The first officer's (FO) windshield cracked during cruise flight. The crack subsequently progressed into multiple multidirectional cracks that obscured the FO’s view through the window. The flight crew was unable to determine the severity of the cracks and diverted without further incident. A postincident examination of the windshield revealed an area of arcing located along the electrical bus bar at the lower edge of the windshield, near the forward corner. This location coincided with the area in which the power and sensing element wires were routed around the structural glass plies. The area of arcing was surrounded by a cloudy and degraded interlayer, which was consistent with the presence of moisture. A section of the moisture seal was worn and appeared to have been repaired, resulting in moisture ingress. The moisture degraded the interlayer and electrical system resulting in a discontinuity that led to electrical arcing and failure of the heating system causing the windshield cracking. The latest windshield revisions, with part numbers NP-165331-1/-2, are available and include enhancements that reduce the potential for moisture ingress and its subsequent effects on the electrical system.

Factual narrative

On September 17, 2011, about 1045 central daylight time, an Airbus Industrie A320, C-FGYL, sustained minor damage when the copilot’s window cracked during cruise at flight level 340 northwest of Chicago, Illinois. The flight crew declared an emergency, and diverted to the Chicago O'Hare International Airport (ORD), Chicago, Illinois, landing about 1113 without further incident. There were no injuries to the 2 flight crewmembers, 4 cabin crewmembers, and 134 passengers. The airplane was registered to GECAS and the flight was operated by Air Canada as flight 791, under the provisions of 14 Code of Federal Regulations Part 129 as a scheduled international passenger flight. Day visual flight rules conditions prevailed for the flight, which operated on an activated instrument flight rules flight plan. The flight originated from the Toronto Pearson International Airport, near Toronto, Ontario, Canada, about 0940, and was destined for the Los Angeles International Airport, near Los Angeles, California. The operator’s incident report stated an 18-inch long crack developed in the first officer’s (FO) windshield, extending from the left bottom corner to the top right corner, during cruise flight. The crack subsequently progressed into multiple multi directional cracks that obscured the FO’s view through the window. The flight crew was unable to determine the severity of the cracks and how many plies were affected. The flight crew complied with the quick reference handbook guidance and diverted to ORD. The flight crew performed an overweight landing and taxied the airplane to the gate. The incident windshield, part number NP-165311-8 with serial number 07169H9453; CA122417, was made from laminated glass. The layers, from the outboard surface to the inboard surface; included a Herculite II glass layer coated with a Nesatron anti-ice system and its associated conductive bus bar, a urethane interlayer, a vinyl interlayer, a urethane interlayer, a Herculite II glass layer, a vinyl interlayer, and a Herculite II glass layer. A NTSB aircraft structures and maintenance specialist oversaw a postincident examination of the windshield at PPG Industries, Inc., near Huntsville, Alabama, on March 9, 2012. The examination revealed that the fracture origin was located at the center of the windshield. An area of arcing was located along the electrical bus bar at the lower edge of the windshield, near the forward corner. This location coincided with the area in which the power and sensing element wires were routed around the structural glass plies. This area of arcing was surrounded by a cloudy and degraded interlayer, which was consistent with the presence of moisture. The moisture seal was worn and the moisture seal upper edge had been repaired. Appearance of the moisture seal’s forward and lower edges was consistent with a factory condition. The latest windshield revisions produced by PPG Aerospace, with part numbers NP-165331-1/-2, are now available and includeenhancements that reduce moisture ingress and its subsequent effects on the electrical system. According the Accredited Representative from the Bureau d’Enquêtes et d’Analyses (BEA), Airbus had issued a Flight Operation Telex (FOT) on May 25, 2011, to inform operators about the issuance of a revised Cockpit Windshield/ Window Cracked operational procedure in case of a cockpit window cracking. The new procedure asked the crew to check if the inner ply is affected by the crack by using either a pen or finger nail. If the inner ply is not cracked, based on the fail safe design, the flight crew can continue the flight, without other restriction.

Aircraft

Registration
C-FGYL
Reported as
Airbus Industrie A320-211
Category
Airplane
Serial number
MSN 254
Airframe hours
49,660
Engines
CFM 56-5A, turbo fanCFM 56-5A, turbo fan
Damage
Minor damage
Flight
Part 129
Operator
Air Canada
Registered owner
Gecas
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · September 16, 2011
Departed
CYYZ · Toronto
Destination
LAX · Los Angeles, CA
Flight plan
IFR
Airport
ORD · Chicago O'Hare IAP, runway 14R, 9,685 × 200 ft, asphalt

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
50
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
May 17, 2011
Seat
Left
Flight hours
10,809 total
Role
Co-pilot
Age
38
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
August 7, 2011
Seat
Right
Flight hours
5,419 total

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 43 °F
Altimeter
30.30 inHg
Observed at
ORD, 93 nm away

Docket · 6

The files NTSB released with the investigation on September 21, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.4 MB in all.