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Aviation safety reports, made easier to study

NTSB Reports is an independent research and search tool for public aviation accident and incident records. It brings NTSB aviation reports, structured fields, docket files, extracted figures, photos, videos, and update history into one searchable interface.

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NTSB Report

February 26, 1994 · British Aerospace ATP · N854AW

Mosinee, WI

Overview

Report Status
Final with probable cause
Event Type
Incident
Date
February 26, 1994
Injury Outcomes
2 injuries (2 minor injuries), 16 uninjured
Location
Mosinee, WI
Aircraft
British Aerospace ATP
Tail Number
N854AW
Operator
United Feeder Service
Injuries
Minor
Aircraft Damage
Minor
NTSB Number
CHI94IA095

THE FLIGHT CREW SAW SMOKE IN THE COCKPIT WHILE DESCENDING FROM CRUISE AND DECLARED AN EMERGENCY. THE COPILOT DISCOVERED THE SOURCE OF THE SMOKE TO BE A RED-HOT PUSH BUTTON SELECTOR INDICATOR (PBSI) SWITCH FOR THE FLIGHT IDLE BAULK TEST. HE DISCHARGED A PORTABLE FIRE EXTINGUISHER ON THE SWITCH AND THE SMOKE STOPPED. THE SWITCH WAS SUBSEQUENTLY REMOVED BY MAINTENANCE PERSONNEL AND FOUND TO SCORCHED AND MELTED. ADJACENT WIRING WAS ALSO HEAT DAMAGED. THE MANUFACTURER HAD PREVIOUSLY ISSUED TWO SERVICE BULLETINS WHICH DEALT WITH PBSI SWITCH MALFUNCTIONS ASSOCIATED WITH WATER INGRESS TO THE COCKPIT IN THE VICINITY OF THE SWITCHES. THE OPERATOR HAD NOT COMPLIED WITH THE VOLUNTARY SERVICE BULLETINS AT THE TIME OF THE INCIDENT.

NTSB Probable Cause

the inadequate design of the PBSI electrical switch(es), and the operator's failure to expeditiously implement corrective Service Bulletins.

Full Narrative

On February 25, 1994, about 2223 central standard time, a British Aerospace ATP airplane, N854AW, operating as scheduled passenger flight 5033 under 14 CFR Part 121 by United Express, Inc., experienced in-flight smoke in the cockpit as it approached Mosinee, Wisconsin. The flight landed successfully at Central Wisconsin Airport (Mosinee), and the fourteen passengers were evacuated by use of the left side cabin door slides. Two of the passengers reported minor scrapes and bruises. None of the two flight crew members or two cabin attendants were injured. The flight departed Chicago's O'Hare International Airport at 2045 and operated in visual meteorological conditions. An instrument flight plan was filed for the flight. The flight crew reported the airplane was descending through 12,000' to 8,000' msl when they smelled smoke in the cockpit. Shortly thereafter, the cabin attendants informed the flight crew that they also smelled smoke. The flight crew initiated and completed the emergency check list for fuselage smoke, and then discovered a red-hot, push button selector indicator (PBSI) switch located on the copilot's right side panel. The copilot discharged a fire extinguisher on the switch, and the smoke stopped. United Express maintenance personnel removed the flight idle baulk test PBSI switch and found that adjacent wiring was heat damaged, and that the switch body was burned and partially melted. The switch was sent to the NTSB for examination. Conversations with representatives from the manufacturer disclosed that failures of like PBSI switches in the cockpit had been reported, and that the switch failures had been attributed to water entering the switches from the side cockpit sliding windows which were left open in inclement weather during ground operations. The manufacturer has issued Service Bulletins SB 56- 3, dated October 30, 1992, and SB 24-53, dated March 22, 1993, which call for the operator to modify the side trim panel consoles to divert water from the switches, and for an application of a silicone sealing gel to the switches. The incident airplane had not complied with the above Service Bulletins at the time of the incident.

Flight

Event TypeIncident
Event Time22:23 CST
Nearest Airport0nm
Runway0
Flight Plan FiledIFR
Aircraft FireUnknown
Aircraft ExplosionNo

Aircraft

AircraftBritish Aerospace ATP
Tail NumberN854AW
Aircraft CategoryAir
DamageMinor
OperatorUnited Feeder Service
Operating RulePart 121
Engines2
Engine TypeTurboprop
Engine DetailsP&W · PW126A · Turboprop · 2600
Seats68

People & Injuries

Injury Summary2 injuries (2 minor injuries), 16 uninjured
Fatal0
Serious0
Minor2
Uninjured16
Total18
Crew 1Age 31 · First Class

Conditions

ConditionsVMC
LightBright Night
Wind360° @ 10 kt
Visibility20 sm
CeilingNone
Temperature / Dew Point0 C / 0 C
Altimeter0
Observation Time03:00
Weather SourceWFAC

Appendix: Source Data