MIA94FA001

NTSB accident investigation · Mcdonnell Douglas MD-83 · Miami, FL · October 3, 1993

Accident · Serious injuriesField investigationFinal report
Date
October 3, 1993, 15:55 local (19:55 UTC)
Place
Miami, FL
Injuries
1 serious, 1 minor, 80 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
9YTHRMcdonnell Douglas MD-83
Weather
Visual (VMC) · Day
Status
Completed · report November 1, 1994
Report
Approved by Office Director
Case key
37403

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The failure of the water heater relay and the overpressure relief valve to operate properly. In addition, the design of the relief valve was inadequate in that it allowed the o-ring to migrate from its normal position preventing the valve from opening.

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/malfunctionClimb - to cruise
Misc eqpt/furnishings,galley - life expiredCause
Misc eqpt/furnishings,galley - inoperativeCause
Acft/equip,inadequate designManufacturerCause
Misc eqpt/furnishings,galley - pressure excessiveCause
ExplosionClimb - to cruise
Misc eqpt/furnishings,galley - exploded

Analysis

The water heater in the forward galley exploded. Examination revealed that the contacts of the water heater relay, which, when energized, provides electrical power to the 3 heater elements, were rough, ragged, discolored, and showed excessive erosion. According to the manufacturer, when a relay exceeds its lifetime, it is possible for erosion and wear on the surface to cause the contacts to stick in the closed position. In addition, the pressure relief valve, which is designed to crack at 65 PSI, was tested to 300 PSI without cracking. Upon disassembly, the o-ring was found to have migrated from its normal location into the lower valve body where it lodged between the inside diameter and the head of the poppet. In this condition, the o-ring presented a completed flow blockage and prevented the pressure relief valve from opening.

Factual narrative

History of flight

On October 3, 1993, about 1555 eastern daylight time, 9Y-THR, a McDonnell Douglas MD-83, experienced an explosion in the forward galley during climb to cruise altitude. The airplane was registered to and operating as British West Indies Airlines [BWIA] flight No. 431, scheduled, international, passenger service from Miami, Florida, to Barbados. The airplane was substantially damaged, 1 flight attendant received serious injuries, 1 flight attendant received minor injuries, 82 persons were not injured. Visual meteorological conditions prevailed at the time and an IFR flight plan was filed. The flight had originated from Miami, Florida, about 1525 and landed back at Miami, Florida, around 1625 the same day.

Examination of the airplane revealed that a water heater, Nordskog model, had over pressurized and exploded. The entire forward galley and the cabin wall to the cockpit was destroyed. The water heater was removed and examined at the NTSB laboratory. All failures noted were consistent with overload. The over pressure valve was examined and the "O" ring had migrated blocking the valve "Pop Off" function. The electrical contacts to the heater element were found failed in a way that allowed constant power to the element. Details of these examinations are included in this report as attachments.

Aircraft

Registration
9YTHR
Reported as
Mcdonnell Douglas MD-83
Category
Airplane
Serial number
49568
Airframe hours
14,657
Engine
P&W JT8D-219, 20,000 lbs thrust, turbo jet
Damage
Substantial damage
Flight
Part 129
Operator
British West Indies
Registered owner
British West Indies
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · September 12, 1993 · 162 hours before
Destination
TBPB · Barbados, OF
Flight plan
IFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
39
Certificate
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
8,500 total · 4,200 in this make and model · 220 as pilot in command · 200 in the last 90 days · 65 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 5 knots
Visibility
7 statute miles
Lowest ceiling
14,000 ft overcast
Temperature
79 °F, dew point 73 °F
Altimeter
30.00 inHg
Observed at
MIA, 100 nm away