SEA96IA074

NTSB incident investigation · Dornier DO 328-100 · Eugene, OR · March 31, 1996

Incident · No injuriesIncident investigationFinal report
Date
March 31, 1996, 06:30 local (14:30 UTC)
Place
Eugene, OR
Injuries
27 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N334PHDornier DO 328-100
Weather
Visual (VMC) · Day
Status
Completed · report February 28, 1997
Report
Approved by Office Director
FAA report
19960331044229I
Case key
42293

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

On this page

Probable cause

delamination of the wing de-icing boot, due to the boot reaching its life limit.

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
Anti-ice/deice system,wing - life expiredCause
Anti-ice/deice system,wing - delaminationCause

Analysis

The flight crew reported that as the airplane was climbing between 14,000 feet and 16,000 feet in light icing conditions, they felt a moderate shudder. The autopilot disconnected, and the airplane immediately rolled 15 degrees to the left. An emergency was declared, and the flight was diverted with no further incident. After landing, examination revealed that a section of the left wing de-icing boot had delaminated. When pressure was applied to the system, a bubble was created. When pressure was off, the delaminated plies were stretched beyond their elastic limits and would not return to the normal shape, thus creating wrinkles. Examination of the plies revealed that there was no evidence of contamination. The separation occurred between the adhesion coat and the knit fabric. The manufacturer of the boot reported that this mode of failure was consistent with an elastromeric construction that had reached the end of its useful life. The outer delaminated plies were found to be unusually durable, which resulted in a large bubble instead of the normally expected 'burst' of the outer plies.

Factual narrative

On March 31, 1996, at 0630 Pacific standard time, a Dornier Luftfahrt GMBH DO 328-100, N334PH, flight number 2620, registered to First Security Bank of Utah, operated by Horizon Air as a 14 CFR Part 121 passenger flight, diverted to Portland, Oregon, after the flight crew felt a shudder and an immediate roll to the left. The flight crew declared an emergency and landed at Portland without further incident. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The airplane received minor damage and there were no injuries to the 24 passengers, one flight attendant, and the two airline transport pilots. The flight originated from Eugene, Oregon, about 30 minutes before the incident.

The flight crew reported that as the airplane was climbing between 14,000 feet and 16,000 feet, at 200 KIAS in light icing conditions, they felt a moderate shudder. The auto pilot disconnected and the airplane immediately rolled 15 degrees to the left. An emergency was declared and the flight was diverted to Portland. After landing, it was found that a portion of the left wing leading edge de-icing boot was loose. When air pressure was applied to the boot, a 12 inch diameter "bubble" formed six inches in from the outboard section of the middle boot. When air pressure was removed, that portion of the boot remained loose.

The boot was removed from the wing and transported to Daimler-Benz Aerospace, Germany. The boot was installed on a test airplane and wind tunnel tested. The test revealed that the airplane was controllable even with the delamination in front of the aileron.

The boot was removed and transported to BFGoodrich Ice Protection Systems, Uniontown, Ohio to determine the reason for the delamination. Preliminary inspection determined that the delaminated plies had stretched beyond their elastic limits and would not return to the normal shape upon deflation. The result was permanent wrinkles in the affected area. Samples of the affected area were taken and examined under optical microscopy and scanning electron microscopy. The result of the examination revealed no evidence of contamination. Peel adhesion samples were then constructed and found that the separation occurred between the adhesion coat and the knit fabric. BFGoodrich reports that this mode of failure is consistent with an elastromeric construction de-icer that has reached the end of its useful life. The outer delaminated plies were found to be unusually durable which resulted in a large bubble instead of the normally expected "burst" of the outer plies.

Aircraft

Registration
N334PH
Reported as
Dornier DO 328-100
Category
Airplane
Serial number
3012
Airframe hours
4,331
Engine
P&W 119B, 2,180 horsepower, turbo prop
Damage
Minor damage
Flight
Part 121
Operator
Horizon Air
Registered owner
First Security Bank Of Utah
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · March 28, 1996
Departed
EUG · OR
Destination
SEA · Seattle, WA
Flight plan
IFR

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
32
Certificates
Flight instructor, Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
5,266 total · 1,897 as pilot in command · 178 in the last 90 days · 59 in the last 30 days · 7 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.