CHI01IA102

NTSB incident investigation · Fokker F28 MK 0100 · Montreal, Canada · March 6, 2001

Incident · No injuriesIncident investigationFinal report
Date
March 6, 2001, 06:40 local (11:40 UTC)
Place
Montreal, Canada
Injuries
44 uninjured
Damage
Minor damage
Phase of flight
Standing
Aircraft
N1426AFokker F28 MK 0100
Weather
Visual (VMC) · Day
Status
Completed · report November 1, 2001
Report
Approved by Office Director
Parties
Federal Aviation Administration AAI 100
Case key
53247

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 inaccurate aircraft deicing service the ground personnel performed alowing fluid injestion and the auxiliary power unit's turbine failure while standing. A factor was the auxiliary power unit's overspeed.

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/malfunctionStanding - engine(s) operating
Aircraft service - inaccurateGround personnelCause
Auxiliary power unit - ingested
Auxiliary power unit - overspeedFactor
Auxiliary power unit - failureCause
Fuselage,bulkhead - punctured

Analysis

The auxiliary power unit (APU) ingested deicing fluid and snow and sustained an uncontained turbine failure. The pressure bulkhead sustained minor damage. The airplane was being deiced. Four crew and 40 passengers were uninjured. The YUL weather was: Wind 050 degrees at 25 knots gusting to 33 knots; visibility 15 statute miles; present weather drifting snow; sky condition broken 2,800 feet overcast 7,600 feet; temperature -1 degree C; dew point -5 degrees C; altimeter 29.57 inches of mercury. Honeywell's APU teardown inspection stated, "Evidence of an engine overspeed event with a commanded auto-shutdown was present in the Electronic Control Unit (ECU) non-volatile memory." The report further stated, "In February 2001 American Airlines issued a 'Winterization Bulletin' for the F-100 advising that de-ice spray should not be sprayed into the APU inlet. Additionally, the Fokker 100 maintenance manual section 12-31-00, page 301specifically advises 'Do not let de-icing and/or anti-icing fluid/water mixture go into the APU inlet. Injury to persons and/or damage to equipment can occur.'"

Factual narrative

On March 6, 2001, about 0640 eastern standard time, a Fokker F28 MK 0100, N1426A, operated as American Airlines flight #581 from Montreal/Dorval International (YUL), near Montreal, Quebec, Canada to Chicago O'Hare International Airport (ORD), Chicago, Illinois, piloted by an airline transport rated captain and copilot, sustained minor bulkhead damage while standing for deicing at YUL. The auxiliary power unit (APU) ingested deicing fluid and snow and sustained an uncontained turbine failure. The scheduled international 14 CFR Part 121 passenger flight was operating on an IFR flight plan. Visual meteorological conditions prevailed. The 2 flight crewmembers, 2 cabin crewmembers, and 40 passengers were uninjured. The flight was being deiced in preparation for departure to ORD at the time of the incident.

The operator stated, "On March 6, 2001, N2BE suffered a APU failure during deicing at Montreal/Dorval International Airport. The weather was cold with the temperature at -2C, and blowing snow. The APU sustained a uncontained turbine failure after ingesting snow, ice, and deicing fluid. The aircraft also sustained damage to the pressure bulkhead after the APU failure."

At 0700, the YUL weather was: Wind 050 degrees at 25 knots gusting to 33 knots; visibility 15 statute miles; present weather drifting snow; sky condition broken 2,800 feet overcast 7,600 feet; temperature -1 degree C; dew point -5 degrees C; altimeter 29.57 inches of mercury.

The APU was removed from the airplane, shipped to, and stored in a bonding room at the Honeywell Services Repair and Overhaul Facility, Phoenix, Arizona. On April 10, 2001, Federal Aviation Administration inspectors oversaw the teardown and inspection of the APU. Excerpts of Honeywell’s inspection report stated the following:

"In February 2001 American Airlines issued a 'Winterization Bulletin' for the F-100 advising that de-ice spray should not be sprayed into the APU inlet. Additionally, the Fokker 100 maintenance manual section 12-31-00, page 301specifically advises 'Do not let de-icing and/or anti-icing fluid/water mixture go into the APU inlet. Injury to persons and/or damage to equipment can occur.' ...

Evidence of an engine overspeed event with a commanded auto-shutdown was present in the Electronic Control Unit (ECU) non-volatile memory.

An engine overspeed condition is a known phenomenon when de-ice fluid is ingested. Since de-ice fluid is flammable when compressed, it will add to the combustion process of the engine. If enough is ingested, it will sustain combustion even though there is no metered fuel flow from the engine fuel control. Because the engine fuel control no longer has command of the engine speed, it cannot limit the preset maximum speed to its 107 percent limit. With the de-ice fluid maintaining combustion, the engine speed will be uncontrolled and can accelerate to the burst limit of the rotating components. This acceleration can occur extremely quickly because of the low inertia of the APU rotating components."

Aircraft

Registration
N1426A
Reported as
Fokker F28 MK 0100
Category
Airplane
Serial number
11411
Airframe hours
20,553
Engine
Rolls-Royce TAY 650-15, 15,100 lbs thrust, turbo jet
Damage
Minor damage
Flight
Part 121
Registered owner
American Airlines Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · March 4, 2001 · 2 hours before
Departed
YUL · Montreal
Destination
ORD · Chicago, IL
Flight plan
IFR
Airport
YUL · Dorval Intl

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Unknown
Seat
Left
Flight hours
292 in this make and model
Role
Co-pilot
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Unknown, Unknown
Seat
Right
Flight hours
343 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 25 knots, gusting 33
Visibility
15 statute miles
Lowest ceiling
2,800 ft broken
Temperature
30 °F, dew point 23 °F
Altimeter
29.56 inHg
Observed at
YUL