CHI06IA011

NTSB incident investigation · Bombardier CL-600-2B19 · West Grove, PA · October 17, 2005

Incident · No injuriesIncident investigationFinal report
Date
October 17, 2005, 00:25 local (04:25 UTC)
Place
West Grove, PA
Injuries
51 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N244PSBombardier CL-600-2B19
Weather
Visual (VMC) · Night
Status
Completed · report August 29, 2006
Report
Approved by Office Director
Parties
Federal Aviation Administration - Cincinnati FSDO
FAA report
20051017032629I
Case key
62748

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 separation of the left engine exhaust nozzle during cruise climb due to inadequately designed attachment hardware.

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/malfunctionClimb - to cruise
Exhaust system,exhaust cone/tailpipe(jet engine) - separationCause
Miscellaneous,bolt/nut/fastener/clamp/spring - failure,totalCause
Aircraft/equipment inadequateManufacturerCause

Analysis

The left engine exhaust nozzle and fairing departed the airplane during cruise climb. The flight crew reported hearing a "small thud" while climbing through 15,000 feet msl. The flight crew stated that they monitored the aircraft engines and no anomalies were noted. The flight crew attributed the event to possible wake turbulence and elected to continue to their scheduled destination. During a post-flight inspection the flight crew noticed the left engine exhaust nozzle and fairing were missing. The left engine exhaust nozzle was found about 26.5 nm west-southwest of the departure airport. The nozzle was examined and its attachment hardware was missing. The bolt holes used to install the exhaust nozzle to the engine were elongated and had evidence of fretting. The exhaust nozzle manufacturer issued Service Bulletin CF34-NAC-78-024 on January 24, 2003, to address "exhaust nozzle bolt attachment failures." The service bulletin called for the removal of the existing hardware and replacement with "new, improved hardware." This maintenance was to be completed at the "operator's earliest convenience or within a maximum of 4,000 hours." At the time of the incident, the airplane had accumulated 3,440 hours since new. The service bulletin had not been complied with, according to the maintenance records. The operator immediately inspected their entire fleet of Bombardier CL-600-2B19 regional jets and found three additional aircraft with either missing or loose attachment exhaust nozzle hardware. The operator ordered replacement kits for the entire fleet and will comply with Service Bulletin CF34-NAC-78-024 upon delivery of the replacement parts.

Factual narrative

On October 17, 2005, at 0025 eastern daylight time, a Bombardier CL-600-2B19 regional jet, N244PS, sustained minor damage when the left engine exhaust nozzle and fairing departed the airplane during cruise climb near West Grove, Pennsylvania. Night visual meteorological conditions prevailed at the time of the incident. The flight was being operated by PSA Airlines, Inc., as a scheduled revenue flight under the provisions of 14 Code of Federal Regulations Part 121. The flight crew and 48 passengers on-board were not injured. Flight 2319 departed Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, at 0004 and was en route to Dayton International Airport (DAY), Dayton, Ohio.

The flight crew reported hearing a "small thud" while climbing through 15,000 feet msl. The flight crew stated that they monitored the aircraft engines and no anomalies were noted. The flight crew attributed the event to possible wake turbulence and elected to continue on to DAY. The airplane continued without further incident and during a post-flight inspection the flight crew noticed the left engine exhaust nozzle and fairing were missing.

The left engine exhaust nozzle was found in West Grove, Pennsylvania, about 26.5 nm west-southwest of the departure airport. The nozzle was examined and its attachment hardware was missing. The bolt holes used to install the exhaust nozzle to the engine were elongated and had evidence of fretting.

The exhaust nozzle manufacturer, Bombardier-Shorts, issued Service Bulletin CF34-NAC-78-024 on January 24, 2003, to address "exhaust nozzle bolt attachment failures." The most current service bulletin revision was dated April 1, 2004. The service bulletin called for the removal of the existing hardware and replacement with "new, improved hardware." This maintenance was to be completed at the "operator's earliest convenience or within a maximum of 4,000 hours."

The incident airplane, serial number 7912, was issued an airworthiness certificate on April 16, 2004, and at the time of the incident had accumulated 3,440 hours since new. Service Bulletin CF34-NAC-78-024 had not been complied with, according to the maintenance records.

Subsequent to the accident, the operator immediately inspected their entire fleet of Bombardier CL-600-2B19 regional jets and found three additional aircraft with either missing or loose attachment exhaust nozzle hardware. The operator ordered replacement kits for the entire fleet and will comply with Service Bulletin CF34-NAC-78-024 upon delivery of the replacement parts.

Aircraft

Registration
N244PS
Reported as
Bombardier CL-600-2B19
Category
Airplane
Serial number
7912
Airframe hours
3,440
Engine
General Electric C-34-3B1, 8,729 lbs thrust, turbo jet
Damage
Minor damage
Flight
Part 121
Operator
PSA Airlines, Inc., doing business as US Airways Express
Registered owner
US Airways, Inc.
Airworthiness certificate
Standard, Transport
Departed
PHL · Philadelphia, PA
Destination
DAY · Dayton, OH
Flight plan
IFR

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
Age
43
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
June 1, 2005
Seat
Left
Flight hours
1,222 in this make and model
Role
Co-pilot
Age
32
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Seat
Right
Flight hours
534 in this make and model

Weather

Conditions
Visual (VMC) · Night
Wind
290° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
55 °F, dew point 41 °F
Altimeter
29.77 inHg
Observed at
PHL, 25 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.