# NTSB LAX87FA128: British Aerospace BA146-200A, N356PS, Fresno, CA, February 28, 1987

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Field investigation · Final report
- Date: February 27, 1987, 20:00 local (Feb 28, 1987, 04:00 UTC)
- Place: Fresno, CA
- Coordinates: 36.640201, -119.910476 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=36.6402&lon=-119.9105&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 87 uninjured
- Status: Completed, report November 15, 1989
- Report: Approved by Office Director
- NTSB case key (mKey): 25384
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX87FA128
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/25384/pdf
- Page: https://openairdocs.org/ntsb/LAX87FA128

## Probable cause

FAILURE OF COMPANY MAINTENANCE PERSONNEL TO ADEQUATELY EXAMINE THE ENGINE LUBRICATION SYSTEM WHEN CONTAMINATION WAS DETECTED.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(total) - mech failure/malf, cruise - normal
  - turboshaft engine,free(power) turbine
  - lubricating system,oil magnetic plug - contamination
  - lubricating system - contamination (cause)
  - fluid,oil - contamination (cause)
  - maintenance - inadequate, company maintenance personnel (cause)
  - turbine assembly,shaft bearing - failure,total (cause)
  - turbine assembly,turbine blade - failure,total
- Airframe/component/system failure/malfunction, cruise - normal
  - fuselage,fairing - penetrated
  - fuselage,skin - penetrated

## Analysis

THE FLIGHT WAS UNEVENTFUL DURING TAKEOFF AND CLIMB TO AN ASSIGNED CRUISE ALTITUDE OF FL260. APPROXIMATELY 40 MINUTES AFTER TAKEOFF THE NUMBER 3 ENGINE EXPERIENCED AN UNCONTAINED FAILURE OF THE TURBINE BLADES ON THE NUMBER 4 POWER TURBINE WHEEL. ALTHOUGH DEBRIS FROM THE ENGINE PENETRATED THE PRESSURE VESSEL, THE PILOT MADE AN UNSCHEDULED LANDING AT AN AIRPORT WITHOUT FURTHER INCIDENT. EXAMINATION OF THE ENGINE REVEALED THAT FERROUS CHIPS WERE CONTAMINATING, AND OIL WAS BYPASSING THE ENGINE OIL FILTER FOR AT LEAST 40 DAYS. HOWEVER, NO CORRECTIVE ACTION WAS TAKEN BY COMPANY MAINTENANCE PERSONNEL. THE OIL AND FILTER WERE CHANGED THREE TIMES IN THE THREE MONTHS PREVIOUS TO THE ACCIDENT. THE EXAM REVEALED THAT THE CONTAMINATED OIL CONTRIBUTED TO THE FAILURE OF THE NUMBER FOUR TURBINE BEARING SUBSEQUENTLY LEADING TO OVERHEATING AND DAMAGE TO THE OVERSPEED SENSORS. THE TURBINE OVERSPED AND THE TURBINE BLADES DEPARTED THE TURBINE DISC.

## Aircraft

- Registration: N356PS (not matched to a registry record)
- Reported make and model: BRITISH AEROSPACE BA146-200A
- Category: Airplane
- Serial number: E2039
- Airframe hours: 4662
- Engines: LYCOMING ALF502R-5 6970 lbs thrust turbo fan
- Damage: Substantial damage
- Flight: Part 121
- Operator: Pacific Southwest Airlines
- Registered owner: Connecticut Nat'L Bank
- Airworthiness certificate: Standard, Transport
- Last inspection: Continuous airworthiness, February 21, 1987
- Departed: LAX, LOS ANGELES, CA
- Destination: RNO, RENO, NV
- Flight plan: IFR
- Airport: FAT, Fresno Air Terminal, runway 11L, 9,218 × 150 ft, concrete

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 42; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 19,592 total, 1,579 in this make and model, 18,000 as pilot in command, 128 in the last 90 days

## Weather

- Conditions: Visual (VMC), Night/bright
- Wind: 10° at 5 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 52 °F, dew point 34 °F
- Altimeter: 30.00 inHg
- Observed at: FAT, 50 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 (OpenAirDocs).

- [Accident 19870227008069A](https://openairdocs.org/incident/19870227008069A), Feb 27, 1987: Bac 146200A, Fresno, CA, Substantial damage. Uncontained explosion of NR3 engine at cruise. Turbine blade failure sent debris into cabin, damaged lines controls

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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