CHI96IA173

NTSB incident investigation · British Aerospace BAE 146 · Des Moines, IA · May 27, 1996

Incident · No injuriesIncident investigationFinal report
Date
May 26, 1996, 21:20 local (May 27, 1996, 02:20 UTC)
Place
Des Moines, IA
Injuries
58 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N608AWBritish Aerospace BAE 146
Weather
Instrument (IMC) · Night/dark
Status
Completed · report February 28, 1997
Report
Approved by Office Director
FAA report
19960526017539I
Case key
10121

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

failure of the flight crew to follow proper procedures, which resulted in an accumulation of ice and subsequent loss of engine power. Factors relating to the incident were: thunderstorms, turbulence, icing conditions, and the inaccurate method that was provided by the manufacturer for determining 'in cloud' air temperature and icing conditions.

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.

In flight encounter with weatherCruise
Weather condition - thunderstormFactor
Weather condition - turbulence(thunderstorms)Factor
Weather condition - icing conditionsFactor
Loss of engine power(total) - nonmechanicalCruise
All engines
Miscellaneous,engine - iceCause
Procedures/directives - not followedFlightcrewCause
Procedure inadequateManufacturerFactor
Airframe/component/system failure/malfunctionDescent
Flt control syst,elevator control - ice
Flt control syst,elevator control - vibration

Analysis

While operating in clouds at flight level 290, in an area with thunderstorms and turbulence, the airplane experienced a loss of power in all four engines. Information from the flight data recorder indicated that during descent from flight level 290, an elevator oscillation occurred. The #1 and #2 engines were shut down due to high turbine gas temperatures. The #2 engine was restarted before making an emergency landing at the Des Moines Airport. The captain reported that the airplane had been flown into severe icing conditions. The aircraft flight manual (AFM) prohibited flight in icing conditions above 26,000 feet (except when necessary for descent). Also, the AFM stipulated the minimum engine speeds which needed to be maintained while operating in icing conditions; it also required that the thrust management system (TMS) be disconnected in icing conditions. There were indications that the TMS was disconnected about 230 seconds after engine roll-back began. Additionally, the AFM did not provide accurate information concerning 'in cloud' correction factor for the outside temperature thermometer.

Factual narrative

History of flight

On May 26, 1996, at 2120 central daylight time (cdt), a British Aerospace, BAe 146, N608AW, operating as Air Wisconsin flight 5558, experienced a loss of power on all four engines. The airplane departed from the Denver International Airport, with an intended destination of Quad City Airport, Moline, Illinois. The airplane was operating at flight level 290, when the loss of power began. Radar showed that at 2109 cdt, the approximate time of the descent from flight level 290, flight 5558's position was North 40 degrees 51 minutes 42 seconds, and West 94 degrees 20 minutes and 22 seconds. The pilot shut down the number one, and the number two engines, due to high turbine gas temperatures. The pilots also reported that the aircraft was experiencing an uncommanded pitch oscillation, but did not report this event until the day after the incident. The crew restarted the number two engine before making an emergency landing at the Des Moines, Iowa, Airport. The four flight crew members, and 54 passengers were uninjured in the incident. The 14 CFR Part 121 flight was operating on an IFR flight plan, and instrument meteorological conditions prevailed at the time of the incident.

Meteorological information

A weather package was obtained by the investigator in charge (IIC) for the time period of approximately one half hour before until one half hour after 0209 universal time coordinate (UTC). This information displays the cloud base reflectivity, wind profile and the cloud tops, around the approximate location of N608AW, when it began its descent from 29,000 feet. This weather data is included as a supplement to this report.

Communications

The en route communications for the flight of N608AW were obtained by the investigator in charge from both Minneapolis Center and Chicago Center. The company dispatch tape for the flight was also obtained by the IIC.

Flight recorders

The aircraft was equipped with both a cockpit voice recorder (CVR) and a flight data recorder (FDR). No usable data was available from the CVR. Most of the data from the incident flight was retrieved from the FDR. Some gaps existed on the FDR data, which would be consistent with the flight crews reports of power interruptions occurring during the flight.

Tests and research

The FDR read out was preformed by the NTSB and the Air Accidents Investigations Bureau (AAIB) with the assistance of AVRO. The complete textual description of the flight as prepared by the AAIB in conjunction with AVRO is included as a supplement to this document.

The FDR data showed that when the aircraft was at 29,000 feet the static air temperature varied from -28.8 degrees celsius to -30.4 degrees celsius. The FDR data also showed that while at 29,000 feet the N1's split apart from each other, similar to what would happen if the thrust management system (TMS) was disconnected while in an N1 sync mode. Before the descent was begun from 29,000 feet the FDR showed signs which appear consistent with the beginning of the loss of power on all four engines. The FDR data indicated that during the descent from 29,000 feet the elevator transducers showed movement of the elevators, similar in nature to what has previously been seen before on this aircraft, and referred to as a pitch oscillation. The investigators who looked at this data classified this pitch oscillation as the mildest pitch oscillation ever recorded.

During the captain's radio transmissions with Minneapolis Center he requests a lower altitude from flight level 290. Minneapolis Center responded by clearing flight 5558 down to flight level 240. Control of flight 5558 was transferred to Chicago Center after the descent to flight level 240.

During radio transmission with Chicago Center the captain of flight 5558 said "Chicago Wisconsin 558, 240, we need lower." Chicago Center replied "Wisconsin 558 roger, stand by." The captain replied "Wisconsin 558 we're descending we need lower altitude at this time." Chicago Center told the pilot that they were unable to approve a descent at that time, at which time the captain stated "Wisconsin 558 we are descending, we are descending." After this transmission Chicago Center cleared the flight to descend to flight level 190, and further cleared the flight down to 12,000 feet. The captain declared an emergency with Chicago Center at 18,000 feet, and reported "lost all power at this time, were descending, 558." The Chicago Center controller then gave flight 5558 a direct heading of 350 degrees, for the Des Moines Airport, Des Moines, Iowa.

The pilots of the aircraft were interviewed by the IIC in Denver, Colorado on June 27, 1996.

The captain remembered being clear of clouds at 24,000 feet, at which time the decision was made to climb to 29,000 feet. The captain thought that the airplane was at least 50 miles from any thunderstorm cells. The captain said the airplane was traveling through green on the radar at the time of the incident. The captain recalled having the engine and tail anti ice systems on while at 29,000 feet. He said that the converted SAT temperature was -40 degrees celsius. The captain did not recall any heavy moisture, or any indications of ice while cruising at 29,000 feet. He said that the pitch oscillation began before the engine rollback occurred. The captain thought that the airplane had been in the clouds for approximately 10 minutes before the pitch oscillation occurred. He did not remember any TMS arrows or the engine power settings while operating the airplane at 29,000 feet.

The copilot on the flight also remembered being clear of clouds before climbing the airplane to 29,000 feet. He reported that he disconnected the autopilot while at 29,000 feet. The copilot reported that the pitch oscillation lasted approximately 15 seconds, and that the maximum amplitude and frequency occurred at approximately 10 seconds. He reported that the pitch oscillation occurred before the descent from flight level 290 was begun. The copilot did not remember any ice detection light being on until the airplane began descending from 29,000 feet. He believed that the airplane was in the clouds between five and 10 minutes before the pitch oscillation occurred. He said he would have been the one to disengage the TMS at 29,000 feet, but did not recall disconnecting the TMS. The copilot did not remember the power setting while at 29,000 feet.

During the captain's conversation with dispatch immediately following the flight he reported to the company dispatcher that "We got in some severe icing, and we lost power to all four engines." He also stated that "we had a lot of ice all the way down." When company personnel asked the pilot if he would classify the in flight conditions as severe icing with moderate turbulence the captain agreed. When the company personnel asked the captain if they had reduced the power on the engines, the captain was unsure, but thought they might have reduced the power on the engines due to turbulence. The aircraft flight manual (AFM) stipulates minimum engine speeds which need to be maintained while operating in icing conditions, and requires that the TMS be disconnected. The AFM also prohibits flight in icing conditions above 26,000 feet, except when it is necessary for descent. During this conversation there was no mention made by the captain about a pitch oscillation. When the company personal told the captain that they were not going to find any problems with the airplane, and this incident sounded like a classic case of engine rollback, the captain did not disagree.

The IIC obtained both the AFM correction to outside air thermometer, and the Air Wisconsin Operating Handbook Correction To Outside Air Thermometer. The AFM states "In cloud the value of the correction factor is reduced, that is the instrument reads more closely to the true temperature." The AFM does not say how much the te

Aircraft

Registration
N608AW
Reported as
British Aerospace BAE 146
Category
Airplane
Serial number
E2049
Airframe hours
18,978
Engine
Lycoming ALF-502R-5, 6,970 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Air Wisconsin, doing business as United Express
Registered owner
Northern Leasing Company Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · May 26, 1996 · 10 hours before
Departed
DIA · Denver, CO
Destination
MLI · Moline, IL
Flight plan
IFR
Airport
DSM · Des Moines, runway 13L, 9,001 × 150 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
46
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
12,000 total · 7,500 in this make and model · 11,000 as pilot in command · 164 in the last 90 days · 60 in the last 30 days · 11 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
80° at 13 knots, gusting 19
Visibility
3.5 statute miles
Lowest ceiling
1,200 ft overcast
Temperature
52 °F, dew point 50 °F
Altimeter
29.00 inHg
Observed at
DSM, 50 nm away

Docket · 32

The files NTSB released with the investigation on January 6, 1997, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.1 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 354 KBSupplement EItem 2 · .PDF · 143 KBSupplement SItem 3 · .PDF · 64 KBAttachment Sup S - Passenger ListItem 4 · .PDF · 180 KBFlight Attendant StatementsItem 5 · .PDF · 248 KBWeather Package Photo 1Item 6 · .PDF · 53 KBWeather Package Photo 2Item 7 · .PDF · 53 KBWeather Package Photo 3Item 8 · .PDF · 54 KBWeather Package Photo 4Item 9 · .PDF · 55 KBWeather Package Photo 5Item 10 · .PDF · 53 KBWeather Package Photo 6Item 11 · .PDF · 54 KBWeather Package Photo 7Item 12 · .PDF · 52 KBWeather Package Photo 8Item 13 · .PDF · 52 KBWeather Package Photo 9Item 14 · .PDF · 53 KBWeather Package Photo 10Item 15 · .PDF · 54 KBWeather Package Photo 11Item 16 · .PDF · 55 KBWeather Package Photo 12Item 17 · .PDF · 55 KBWeather Package Photo 13Item 18 · .PDF · 58 KBWeather Package Photo 14Item 19 · .PDF · 59 KBWeather Package Photo 15Item 20 · .PDF · 60 KBWeather Package Photo 16Item 21 · .PDF · 59 KBWeather Package Photo 17Item 22 · .PDF · 60 KBWeather Package Photo 18Item 23 · .PDF · 60 KBWeather Package Photo 19Item 24 · .PDF · 45 KBWeather Package Photo 20Item 25 · .PDF · 45 KBWeather Package Photo 21Item 26 · .PDF · 48 KBWeather Package Photo 22Item 27 · .PDF · 48 KBWeather Package Photo 23Item 28 · .PDF · 50 KBWeather Package Photo 24Item 29 · .PDF · 49 KBWeather Package Photo 25Item 30 · .PDF · 49 KBFDR HistoryItem 31 · .PDF · 450 KBStatement of Party Representatives to NTSB InvestigationItem 32 · .PDF · 342 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.