CHI94IA095

NTSB incident investigation · British Aerospace ATP · Mosinee, WI · February 26, 1994

Incident · Minor injuriesIncident investigationFinal report
Date
February 25, 1994, 22:23 local (Feb 26, 1994, 04:23 UTC)
Place
Mosinee, WI
Injuries
2 minor, 16 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N854AWBritish Aerospace ATP
Weather
Visual (VMC) · Night/bright
Status
Completed · report January 26, 1995
Report
Approved by Office Director
Case key
9400

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 inadequate design of the PBSI electrical switch(es), and the operator's failure to expeditiously implement corrective Service Bulletins.

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.

Miscellaneous/otherDescent - normal
Electrical system,electric switch - melted
Electrical system,electric wiring - burned
Maintenance,service bulletin/letter - not performedCompany/operator managementCause
Acft/equip,inadequate designManufacturerCause

Analysis

The flight crew saw smoke in the cockpit while descending from cruise and declared an emergency. The copilot discovered the source of the smoke to be a red-hot push button selector indicator (pbsi) switch for the flight idle baulk test. He discharged a portable fire extinguisher on the switch and the smoke stopped. The switch was subsequently removed by maintenance personnel and found to scorched and melted. Adjacent wiring was also heat damaged. The manufacturer had previously issued two service bulletins which dealt with pbsi switch malfunctions associated with water ingress to the cockpit in the vicinity of the switches. The operator had not complied with the voluntary service bulletins at the time of the incident.

Factual narrative

On February 25, 1994, about 2223 central standard time, a British Aerospace ATP airplane, N854AW, operating as scheduled passenger flight 5033 under 14 CFR Part 121 by United Express, Inc., experienced in-flight smoke in the cockpit as it approached Mosinee, Wisconsin. The flight landed successfully at Central Wisconsin Airport (Mosinee), and the fourteen passengers were evacuated by use of the left side cabin door slides. Two of the passengers reported minor scrapes and bruises. None of the two flight crew members or two cabin attendants were injured. The flight departed Chicago's O'Hare International Airport at 2045 and operated in visual meteorological conditions. An instrument flight plan was filed for the flight.

The flight crew reported the airplane was descending through 12,000' to 8,000' msl when they smelled smoke in the cockpit. Shortly thereafter, the cabin attendants informed the flight crew that they also smelled smoke. The flight crew initiated and completed the emergency check list for fuselage smoke, and then discovered a red-hot, push button selector indicator (PBSI) switch located on the copilot's right side panel. The copilot discharged a fire extinguisher on the switch, and the smoke stopped.

United Express maintenance personnel removed the flight idle baulk test PBSI switch and found that adjacent wiring was heat damaged, and that the switch body was burned and partially melted. The switch was sent to the NTSB for examination.

Conversations with representatives from the manufacturer disclosed that failures of like PBSI switches in the cockpit had been reported, and that the switch failures had been attributed to water entering the switches from the side cockpit sliding windows which were left open in inclement weather during ground operations. The manufacturer has issued Service Bulletins SB 56- 3, dated October 30, 1992, and SB 24-53, dated March 22, 1993, which call for the operator to modify the side trim panel consoles to divert water from the switches, and for an application of a silicone sealing gel to the switches.

The incident airplane had not complied with the above Service Bulletins at the time of the incident.

Aircraft

Registration
N854AW
Reported as
British Aerospace ATP
Category
Airplane
Serial number
2028
Engine
P&W PW126A, 2,600 horsepower, turbo prop
Damage
Minor damage
Fire
Unknown
Flight
Part 121
Operator
United Feeder Service, doing business as United Express
Registered owner
Wilmington Trust Co.
Airworthiness certificate
Standard, Transport
Departed
ORD · Chicago, IL
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
Age
31
Certificate
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
4,300 total · 300 in this make and model

Weather

Conditions
Visual (VMC) · Night/bright
Wind
360° at 10 knots
Visibility
20 statute miles
Lowest ceiling
None
Observed at
CWA