DEN99IA038

NTSB incident investigation · British Aerospace BAE 146-200A · Aspen, CO · February 12, 1999

Incident · No injuriesIncident investigationFinal report
Date
February 11, 1999, 18:50 local (Feb 12, 1999, 01:50 UTC)
Place
Aspen, CO
Injuries
88 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N608AWBritish Aerospace BAE 146-200A
Weather
Visual (VMC) · Dusk
Status
Completed · report June 22, 2000
Report
Approved by Office Director
FAA report
19990212012999I
Case key
45760

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 inadequate maintenance overhaul of the number four turbine disc by the manufacturer. A factor was the turbine blade's failure due to high cycle fatigue fracture.

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.

Loss of engine power(total) - mech failure/malfClimb - to cruise
Maintenance,overhaul - inadequateManufacturerCause
Turbine assembly,turbine blade - fatigueFactor
Turbine assembly,turbine blade - fracturedFactor

Analysis

The airplane experienced an uncontained number 4 engine failure during climb to cruise altitude. Examination of the engine revealed that the number 4 turbine disc had all its blades separated just above the blade platform except 1, which separated just below the blade platform. According to maintenance records, the number 4 turbine disc assembly was installed 22.5 hours or 22 cycles prior to this event. The manufacturer of the turbine disc said that the wheel was new; however, all 60 of the blades had seen previous use. A high-cycle fatigue crack was found in the one blade which had separated below the blade platform. The metallurgist noted that the fatigue crack originated from a fretting damage mark located at the fir-tree portion. The manufacturer reported that 9 blade retention pins, which were used to prevent blade radial movement, did not meet the requirement of no more than 0.005 inch clearance between pen head and wheel. They further reported that blade stress concentration was induced by the wheel broach slots sharp edges.

Factual narrative

On February 11, 1999, approximately 1850 mountain standard time, a British Aerospace BAe 146-200A, N608AW, received minor damage when the number 4 engine experienced an uncontained failure during climb to cruise near Aspen, Colorado. The 2 airline transport pilots, 2 flight attendants, and 84 passengers were not injured. The airplane was being operated by Air Wisconsin under Title 14 CFR Part 121. Visual meteorological conditions prevailed for this scheduled domestic passenger flight which originated from Aspen, Colorado, 13 minutes before the incident. An IFR flight plan had been filed with a destination of Denver, Colorado.

The captain said that they were climbing through 14,700 feet msl when they heard a loud noise and strong vibration from the number 4 engine. He shut down the engine, and pulled the fire handle. A passenger reported seeing flames come out the tailpipe. The pilot reported that they received no indications of an engine fire in the cockpit. He discharged a second fire bottle in the number 4 engine, and then declared an emergency. The captain reported completing all the check list items, and that the remaining flight to Denver was uneventful.

Postincident examination of the engine revealed that the number 4 turbine disc had all its blades separated just above the blade platform except 1, which separated just below the blade platform. According to Air Wisconsin maintenance records, the number 4 turbine disc assembly was installed 22.5 hours or 22 cycles prior to this event. The manufacturer of the turbine disc said that the wheel was new; however, all 60 of the blades had seen previous use.

Metallurgical evaluation by the National Transportation Safety Board's (NTSB) Materials Laboratory found a fatigue crack in the blade that separated below the blade platform. The laboratory further noted that the fatigue crack originated from a fretting [relative movement between metals] damage mark, located at the fir-tree portion (see attached metallurgical reports). The laboratory said that "fretting damage areas reduce the fatigue properties of a material, and are sources of fatigue cracking."

The manufacturer performed an additional examination of the number 4 turbine wheel and blade root. They reported that 9 blade retention pins, which were used to prevent blade radial movement, did not meet the requirement of no more than 0.005 inch clearance between pen head and wheel. They further reported that blade stress concentration was induced by the wheel broach slots sharp edges. Their engineering staff determined that the failure was due to subsequent "high-cycle fatigue."

Aircraft

Registration
N608AW
Reported as
British Aerospace BAE 146-200A (BAE 146-20)
Category
Airplane
Serial number
E2049
Airframe hours
24,544
Engine
Lycoming ALF502R-5, 6,996 lbs thrust, turbo jet
Damage
Minor damage
Flight
Part 121
Registered owner
Wilmington Trust Company
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · February 9, 1999 · 23 hours before
Departed
ASE
Destination
DEN · Denver, CO
Flight plan
IFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
55
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
21,500 total · 4,687 in this make and model · 216 in the last 90 days · 68 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dusk
Wind
170° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
18 °F, dew point -0 °F
Altimeter
30.00 inHg
Observed at
DEN, 90 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.