CHI93IA312

NTSB incident investigation · British Aerospace 146-300A · Chicago, IL · July 21, 1993

Incident · No injuriesIncident investigationFinal report
Date
July 20, 1993, 19:54 local (Jul 21, 1993, 00:54 UTC)
Place
Chicago, IL
Injuries
8 uninjured
Damage
Minor damage
Phase of flight
Initial climb
Aircraft
N611AWBritish Aerospace 146-300A
Weather
Visual (VMC) · Dusk
Status
Completed · report October 20, 1994
Report
Approved by Office Director
Case key
9196

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

was a crack in the fuel system fuel flow distribution manifold which resulted from an inadequate design by the manufacturer.

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 flow divider/distributor - crackedCause
Acft/equip,inadequate designManufacturerCause
FireTakeoff - initial climb

Analysis

During the initial climbout the flight attendant observed the tailcone of the airplane's number four engine glowing. As the power was reduced the glow ceased. The airplane returned to the departure airport. The engine was inspected and its fuel manifold was found cracked at the scallop radius. The manufacturer modified the fuel manifold so that its wall would be thicker at the radius. The modified manifold was not installed on the incident airplane.

Factual narrative

On July 19, 1993, at 2242 central daylight time (cdt), a British Aerospace 146-300A, N611AW, operated by Air Wisconsin, Incorporated, of Appleton, Wisconsin, as flight number 5140, and piloted by an airline transport certificated crew, experienced a fire on the number four engine during initial climb following takeoff from O'Hare International Airport, Chicago, Illinois. Visual meteorological conditions prevailed at the time of the incident. The 14 CFR Part 121 air carrier flight was operating on an IFR flight plan. The pilots, two flight attendants, and 4 passengers reported no injuries. The flight originated from Chicago, Illinois, at 2239 cdt.

The captain said that during initial climb following takeoff a flight attendant observed a glow near the end of number four engine jet pipe. He stated that a fire warning light was not observed in the cockpit when the glow was observed by the flight attendant. The glow was no longer observed when the takeoff power setting was reduced to the climb power setting. He stated the difference between takeoff power and climb power settings is a two percent rollback. The airplane continued to its destination.

The jet pipe area is not part of the fire/overheat detection and warning system. The detection and warning system is associated with the engine's fan casing bay and core engine assembly.

An examination of the number four engine revealed a crack in the right-hand fuel manifold assembly (manifold) and a small hole burned through the engine fairing reinforcement ribs. Damage, similar to flame damage, was observed on the engine fairing skin next to the jet pipe. The manifold has cutouts (scallops) between its mounting bolt holes. The crack was located next to the number nine fuel nozzle, on the radius of the scallop. The metal thickness between the inner wall of the manifold's fuel channel and scallop surface was .042 inch. Company maintenance records showed the manifold had a total time of 7,581 hours and 11,185 cycles on it. The last inspection on the manifold was conducted 1,742 hours and 2,597 cycles before the failure.

The engine manufacturer redesigned the manifold with an approximate .085 inch thickness about one year before this incident. Installation of the revised manifold was optional. According to the engine's manufacturer, the fuel manifold was an older design that had thinner metal near the crack.

Aircraft

Registration
N611AW
Reported as
British Aerospace 146-300A
Category
Airplane
Serial number
E3120
Airframe hours
9,468
Engine
Lycoming ALF 502R, 6,970 lbs thrust, turbo fan
Damage
Minor damage
Fire
In-Flight
Flight
Part 121
Operator
Air Wisconsin, Inc., doing business as United Express
Registered owner
Air Wisconsin, Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Annual · July 15, 1993 · 28 hours before
Destination
ATW · Appleton, WI
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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Unknown, Unknown
Seat
Left

Weather

Conditions
Visual (VMC) · Dusk

Other investigations on N611AW · 1

Matched to the same aircraft by N-number and date.