DEN04IA060

NTSB incident investigation · Canadair CL-600-2C10 · Denver, CO · April 11, 2004

Incident · No injuriesIncident investigationFinal report
Date
April 11, 2004, 14:25 local (20:25 UTC)
Place
Denver, CO
Injuries
60 uninjured
Damage
No damage
Phase of flight
Approach
Aircraft
N609QXCanadair CL-600-2C10
Weather
Visual (VMC) · Day
Status
Completed · report December 3, 2004
Report
Approved by Office Director
Parties
Horizon Air, Parker Hannifin, Abex Division, Federal Aviation Administration, Aircraft Mechanics Fraternal Association
Case key
59044

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 total failure of the airplane's number 1 system hydraulic pump.

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/malfunctionApproach
Hydraulic system,pump - failure,totalCause
Emergency procedure - performedFlightcrew
Hydraulic system,pump - seized

Analysis

The captain reported that while in cruise flight at flight level 330, the crew received a master caution light and a hydraulic system 1 low pressure along with warning lights for the outboard ground spoilers, outboard spoilerons, and the outboard spoilers. The hydraulic fluid quantity and fluid temperature readings were good, but the system pressure was dropping. The crew ran the emergency checklist and continued their flight to Denver, using the backup (1B) system. On final approach and landing, the captain reported that they lost number 1 system pressure and quantity. The crew shut off the 1B system and continued to land. After landing, the crew shut down the number one engine and taxied to the gate. A post-incident examination of the airplane's number 1 hydraulic system showed that the hydraulic pump had come apart internally and seized. Metal fragments were found in the hydraulic filters and lines. Further examination of the hydraulic pump showed that several piston shoes in the pump's hanger and piston subassembly had come apart. The resulting metal fragments subsequently caused damage to the hold-down plate, the hanger, and other internal components of the pump, resulting in its seizure.

Factual narrative

On April 11, 2004, at 1435 mountain daylight time, a Canadair (Bombardier) CL-600-2C10, N609QX, operated by Horizon Air as Horizon Flight 4339, experienced a complete failure of the airplane's number 1 system hydraulics, while on approach into the Denver International Airport (DEN), Denver, Colorado. The flight crew shut off the system and made an uneventful landing. The captain, first officer, 2 flight attendants and 56 passengers on board were not injured. The scheduled domestic passenger flight from Ontario, California, to DEN was being conducted on an instrument flight rules flight plan under the provisions of Title 14 CFR Part 121. Visual meteorological conditions prevailed at the time of the incident.

The captain reported that while in cruise flight at flight level 330, the crew received a master caution light and a hydraulic system 1 low pressure along with warning lights for the outboard ground spoilers, outboard spoilerons, and the outboard spoilers. The hydraulic fluid quantity and fluid temperature readings were good, but the system pressure was dropping. The crew ran the emergency checklist and continued their flight to Denver, using the backup (1B) system. On final approach and landing, the captain reported that they lost number 1 system pressure and quantity. The crew shut off the 1B system and continued to land. After landing, the crew shut down the number one engine and taxied to the gate.

A post-incident examination of the airplane's number 1 hydraulic system showed that the hydraulic pump had come apart internally and seized. Metal fragments were found in the hydraulic filters and lines. Company maintenance replaced the pump and filters and flushed out the lines several times to remove all debris. The number 1 system hydraulic pump, the filters, metal fragments, cockpit voice recorder, and flight data recorder were retained for further examination.

An examination of the data obtained from the flight data recorder showed that the first loss of system 1 occurred approximately 29 minutes after takeoff. The data shows that the second loss of system 1 occurs 1.5 hours after the first loss event. The data then shows the airplane touching down approximately 10 seconds after the second loss event.

The hydraulic pump was examined at Parker Hannifin Corporation's Abex Division, Kalamazoo, Michigan, on May 11, 2004. The examination showed that several piston shoes in the pump's hanger and piston subassembly had come apart. The resulting metal fragments subsequently caused damage to the hold-down plate, the hanger, and other internal components of the pump, resulting in its seizure.

An Abex Division representative reported that over the past two years, 29 other hydraulic pumps had been returned to the factory with seal leaks and piston shoes damage. The representative said that because of this, several pump improvements were developed including a return to a previously qualified design of the pump's piston shoes. At the time of the incident pump's examination, Abex was in the process of issuing retrofit engineering orders that incorporated the improvements.

Aircraft

Registration
N609QX
Reported as
Canadair CL-600-2C10
Category
Airplane
Serial number
10031
Airframe hours
5,388.8
Engines
General Electric CF34-8C1, 13,800 lbs thrust, turbo jetGeneral Electric CF34-831, 13,800 lbs thrust, turbo jet
Damage
No damage
Flight
Part 121
Operator
Horizon Air, doing business as Horizon Air
Registered owner
Wells Fargo Bank Northwest NA Trust
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · March 24, 2004
Departed
ONT · Ontario, CA
Destination
DEN · Denver, CO
Flight plan
IFR
Airport
DEN · Denver International Airport

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, Valid Medical--w/ waivers/lim
Last flight review
December 18, 2003
Seat
Left
Flight hours
5,178 total
Role
Co-pilot
Age
50
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
November 4, 2003
Seat
Right
Flight hours
8,849 total

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
45 °F, dew point 21 °F
Altimeter
30.03 inHg
Observed at
DEN, 5 nm away