NYC00IA116

NTSB incident investigation · Israel Aircraft Industries 1125 · Pine Knot, KY · April 3, 2000

Incident · No injuriesIncident investigationFinal report
Date
April 2, 2000, 20:30 local (Apr 3, 2000, 00:30 UTC)
Place
Pine Knot, KY
Injuries
4 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N511WAIsrael Aircraft Industries 1125
Weather
Visual (VMC) · Night/dark
Status
Completed · report May 1, 2003
Report
Approved by Office Director
FAA report
20000402022779I
Case key
48988

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 partial failure of an inverter and the inadequate design of the electrical circuit breaker system.

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/malfunctionCruise
Electrical system,inverter - failure,partialCause
Acft/equip,inadequate designManufacturerCause
Electrical system,electric relay - inadequate
Electrical system,circuit breaker - inadequate
Warning system(other) - inadequate

Analysis

While in cruise flight, the flightcrew selected "GPS" on the pilot's Electronic Horizontal Situation Indicator (EHSI). The number one inverter then began to malfunction and produce lower than normal voltage. As the voltage decreased, the vertical gyroscopes began to slow down and the displays on the Electronic Attitude Display Indicators (EADI) "blacked out," without any warning from the master caution panel. Shortly thereafter, heading warning flags appeared and the compass cards locked in position on both EHSI's. Due to the decreased voltage, the motors of the directional gyroscopes drew higher-than-normal amperage, and blew their respective internal 0.75-amp fuses. When the fuses blew, the load was decreased on the number one inverter, and the voltage output increased back to normal levels; however, because of their inaccessibility, the flightcrew could not reset the fuses. Additionally, a sensing relay, pre-set to de-energize at about 40-volts AC, did not activate to illuminate an "AC FAIL" light on the master caution annunciator panel. With the normal voltage levels restored, the vertical gyroscopes began to accelerate, and approximately 8 to 10 minutes later, the EADI displays returned. The flight landed uneventfully. After the incident, the airplane manufacturer issued an Alert Service Bulletin providing instructions to replace existing low voltage sensing relays with higher accuracy relays capable of providing a warning at higher voltages and to replace the 3-amp Directional Gyros circuit breakers on the overhead circuit breaker panel, with 0.5-amp circuit breakers, enabling disconnection of power to the EHSI's prior to their internal 0.75-amp blowing.

Factual narrative

On April 2, 2000, about 2030 eastern daylight time, an Israel Aircraft Industries 1125, N511WA, experienced a total loss of it's gyroscopic reference system while in cruise flight over Pine Knot, Kentucky. The certificated airline transport crew and two passengers were not injured. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the executive/corporate flight conducted under 14 CFR Part 91.

According to the operator of the airplane, while at 41,000 feet in level flight, the crew selected "GPS" on the pilot's Electronic Horizontal Situation Indicator (EHSI). The number one inverter then began to malfunction and produce lower than normal voltage. As the voltage decreased, the vertical gyroscopes began to slow down and the displays on the Electronic Attitude Display Indicators (EADI) "blacked out." Shortly thereafter, heading warning flags appeared and the compass cards locked in position on both EHSI's. Due to the decreased voltage, the motors of the directional gyroscopes for the EHSI's drew higher-than-normal amperage, and blew their respective internal 0.75-amp fuses. When the fuses blew, the load was decreased on the number one inverter, and the voltage output increased back to normal levels. With the normal voltage levels restored, the vertical gyroscopes began to accelerate, and approximately 8 to 10 minutes later, the EADI displays returned. The master caution panel did not alert the crew of the low voltage condition. Additionally, when the internal fuses for the EHSI's blew, the flightcrew was unable to reset them.

The flight landed at the Cincinnati Municipal Airport Lunken Field, Cincinnati, Ohio, without incident.

According to the airplane's manufacturer, the airplane was equipped with two 1,000-amp inverters, each capable of providing 400 cycle 115-volts AC, and 26-volts AC power to the entire airplane, with reserve. The inverters also had an internal "fault" mode that detected conditions to include thermal and over/under current conditions.

The "AC FAIL" warning annunciator system, installed on both the number 1 and number 2 electrical systems, consisted of a circuit breaker connected to a 115-volts AC bus, and an AC coil relay. With a respective AC bus normally powered, the AC coil relay would also be powered. If power was removed from the AC bus, or lowered to about 40-volts AC, the AC coil relay would then de-energize, and provide a ground signal to the opposite-powered AC bus, simultaneously an "AC FAIL" light would illuminate on the master caution annunciator panel.

The electrical system also included transfer relays. If the EHSI were selected to a long-range navigation source, the number 2 transfer relay would have activated and transferred the number 2 electrical bus consumers to the number 1 bus, requiring the number 1 inverter to supply all power to the airplane.

The airplane manufacturer issued an Alert Service Bulletin, number 1125-24A-246, which provided instructions to replace existing low voltage sensing relays with higher accuracy relays capable of providing a warning at approximately 97.5-volts AC, and to replace the 3-amp Directional Gyros circuit breakers on the overhead circuit breaker panel, with 0.5-amp circuit breakers, enabling disconnection of power to the EHSI's prior to their internal 0.75-amp blowing.

Aircraft

Registration
N511WA
Reported as
Israel Aircraft Industries 1125
Category
Airplane
Serial number
034
Airframe hours
3,755
Engine
Airesearch TFE-731-3A, 3,600 lbs thrust, turbo jet
Damage
No damage
Flight
Executive/Corporate · Part 91
Registered owner
Ssw Jet Limited
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · March 9, 2000 · 55 hours before
Departed
APF · Naples, FL
Destination
LUK · Cincinnati, OH
Flight plan
IFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
40
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
5,815 total · 155 in this make and model · 4,330 as pilot in command · 145 in the last 90 days · 35 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
10° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
115 °F, dew point 82 °F
Altimeter
30.00 inHg
Observed at
SME, 25 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.