# NTSB MIA91IA091: British Aerospace BAE-146-200, Jacksonville, FL, March 2, 1991

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: March 2, 1991, 14:45 local (19:45 UTC)
- Place: Jacksonville, FL
- Location: 30.3322° N, 81.6557° W: Placed by OpenAirDocs: center of Jacksonville, FL, within about 15 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=30.3322&lon=-81.6557&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 5 uninjured
- Status: Completed, report March 31, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 32772
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA91IA091
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/32772/pdf
- Page: https://openairdocs.org/ntsb/MIA91IA091

## Probable cause

INADEQUATE ENGINE PERFORMANCE IN THE DESIGNED AIRPLANE FLIGHT ENVELOPES.

## Sequence of events

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

- Loss of engine power(partial) - nonmechanical, cruise - normal
  - 2 engines
  - bleed air system - inadequate (cause)
  - acft/equip,inadequate design, manufacturer (cause)
  - precautionary landing - performed, pilot in command

## Analysis

THE FLIGHT CREW EXPERIENCED THE PARTIAL POWER LOSS OF THREE OF FOUR ENGINES WHILE IN CRUISE FLIGHT.  THE AIRPLANE WAS OPERATING IN ICING CONDITIONS WITH ALL AIRPLANE ANTI ICE SYSTEMS ON.  THE FLIGHT PASSED THROUGH AN AREA OF RAPIDLY WARMING AIR AND THE ENGINE BLEED BANDS WERE OPEN AND COULD NOT BE CLOSED WITH THROTTLE MOVEMENT.  THE CREW SHUT DOWN TWO ENGINES TO PREVENT OVERTEMP CONDITIONS AND REDUCED ONE TO IDLE.  THEY DECLARED AN EMERGENCY AND DIVERTED TO AN AIRPORT NEARBY.  SUBSEQUENT TESTING OF A LIKE AIRPLANE REVEALED THAT THE ENGINE DESIGN WAS SUCH THAT WHEN OPERATING AT HIGH ALTITUDE WITH ALL ANTI ICE SYSTEMS 'ON' THE BLEED AIR VALVES COULD NOT BE CLOSED WITH NORMAL PROCEDURES. THE MANUFACTURER SUBSEQUENTLY DEVELOPED A MODIFIED CHECKLIST TO CORRECT FOR THIS SITUATION.

## Aircraft

- Registration: CGRNU (not matched to a registry record)
- Reported make and model: BRITISH AEROSPACE BAE-146-200 (BAE-146-20)
- Category: Airplane
- Serial number: 205
- Engines: LYCOMING ALF-502-R turbo fan
- Damage: Minor damage
- Flight: Part 129
- Operator: Air Nova
- Airworthiness certificate: Standard, Transport
- Departed: KMIA, MIAMI, FL
- Destination: LYHZ, HALIFAX, OF
- Flight plan: IFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 30; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: unknown, unknown

## Weather

- Conditions: Instrument (IMC), Day
- Wind: 130° at 4 knots
- Visibility: 2 statute miles
- Lowest ceiling: 3,000 ft overcast
- Temperature: 57 °F, dew point 57 °F
- Altimeter: 29.00 inHg
- Observed at: JAX, 15 nm away

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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