NYC93IA113

NTSB incident investigation · Short Brothers SD3-60-200 · Atlantic City, NJ · June 14, 1993

Incident · No injuriesIncident investigationFinal report
Date
June 14, 1993, 17:02 local (21:02 UTC)
Place
Atlantic City, NJ
Injuries
21 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N711HJShort Brothers SD3-60-200
Weather
Visual (VMC) · Day
Status
Completed · report September 13, 1994
Report
Approved by Office Director
FAA report
19930614026129I
Case key
38597

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

A malfunction of the cargo fire warning system which resulted in a false alarm.

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 - normal
Fire warning system,cargo - false indicationCause

Analysis

The airplane was cruising at 6000 feet when the aft baggage compartment fire light illuminated in the cockpit. Extinguishing agent was directed to the aft baggage compartment by the flight attendant placing the nozzle of a hand held fire extinguisher through a receptacle with a sealing 'o' ring, located on the aft cabin bulkhead. The flight attendant said the extinguishing agent blew back onto her hands. She then tried two other extinguishers with the same results. After landing, examination of the baggage compartment found no evidence of a fire. The fire warning was attributed to a false indication from the smoke detector in the aft baggage compartment. Post incident testing by the FAA and the operator found that when the fire extinguisher nozzle did not fit thorugh the sealing 'o' ring, extinguishing agent would spray back on the person holding the fire extinguisher. When the sealing 'o' ring was lubricated, and the nozzle was chamfered in accordance with the manufacturers service bulletin, the extinguisher nozzle fit through the sealing 'o' ring easily and no leakage occurred.

Factual narrative

On Monday, June 14, 1993, at 1702 eastern daylight time, a Short Brothers SD3-60-200, N711HJ, operating as Allegheny Commuter Flight 3575, made a precautionary landing at Atlantic City, New Jersey, due to a fire warning in the aft baggage compartment. There was no damage to the airplane or injuries to the crew and 18 passengers. Visual meteorological conditions prevailed and flight 3575 was operating on an instrument flight plan under 14 CFR 121.

Flight 3575 was a scheduled flight operating between Philadelphia, Pennsylvania, and New Haven, Connecticut. While cruising at 6000 feet, the aft baggage compartment fire light illuminated in the cockpit. Fire extinguishing agent is directed to the aft baggage compartment by placing the nozzle of a hand held fire extinguisher through a receptacle with a sealing "O" ring on the aft cabin bulkhead. The fire extinguisher is then actuated and the extinguishing agent travels through a line to the baggage compartment.

In a written report, the captain stated:

...the smoke aft light illuminated...Jim Town, my first officer, pulled out the Emergency checklist. He notified Donna Smith, the fight attendant, to empty two fire extinguisher bottles into the back bay port...A few minutes later Jim informed me that Donna had trouble with the extinguishers blowing back when used. I gave her the flight compartment extinguisher to use. She came back later, she said she used about half a bottle and had the same problem. She informed us that no smoke was coming from the back and no heat was detected at the aft wall....

The flight attendant stated:

...I did as I was told, the fire ex.[extinguishing agent]

blew back into my face. I reread the instructions to make sure I was operating it correctly and tried again. Went to the second one with the same result. Called the Captain & asked if my actions had any effect. Told the FO[First Officer] I'd need his fire extinguisher & told Captain that there was no smoke or heat...I forced the third extinguisher mostly in & wrapped the fire extinguisher handle with paper towels to try to force more in. It was blowing back so much that it was frostbiting my hand through the paper towel. I stowed extinguishers....

After landing, the pilot stopped the airplane on the runway and deplaned the passengers through the passenger entry door. No evidence of a fire was found. The source of the false fire warning was found to be a failure of the Aft Baggage Bin Smoke Detector.

In a telephone interview, Mr. Bob Walling, of Short Brothers (USA), said other operators had reported difficulty in getting a good seal with the extinguisher nozzle in the "O" ring. The fix was to lubricate the "O" ring with Dow Corning compound # 33, (DC-33). In addition, he said the fire extinguisher manufacturer had issued a service bulletin to modify the nozzles for easier entry. This was Service Bulletin 26-107, Revision 1, dated November 2, 1992, and issued by Fire Fighting Enterprises (U.K.) Ltd. A check with the operator revealed that neither of these had been accomplished.

On June 25, 1993, the FAA conducted testing at the operator's facility, using a fire extinguisher with the nozzle modified in accordance with the service bulletin. In addition, the "O" ring the nozzle was placed through, had been lubricated with Dow Corning compound # 33. According to their report:

...Testing using a nozzle modified in accordance [with] the FFE Service Bulletin did not require excessive force and fully engaged the fire extinguisher with minimal effort, with no damage to the "O" Ring Seal.

The use of lubricant with the modified nozzle did not appreciably change the force to engage the nozzle in the fire extinguisher system port....

Aircraft

Registration
N711HJ
Reported as
Short Brothers SD3-60-200
Category
Airplane
Serial number
SH3697
Airframe hours
15,829
Engine
P&W PT6A-65AR, 1,220 horsepower, turbo prop
Damage
No damage
Flight
Part 121
Operator
Pennsylvania Commuter, doing business as Allegheny Commuter/Usair Exp
Registered owner
US West Financial Services
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · May 28, 1993 · 115 hours before
Departed
PHL · Philadelphia, PA
Destination
HVN · New Haven, CT
Flight plan
IFR
Airport
ACY · Atlantic City, runway 22, 6,144 × 150 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
45
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
6,609 total · 1,206 in this make and model · 2,276 as pilot in command · 210 in the last 90 days · 71 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
12 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 50 °F
Altimeter
30.00 inHg
Observed at
ACY, 42 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.