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NTSB Report

March 6, 2001 · Fokker F28 MK 0100 · N1426A

Montreal, CA

Overview

Report Status
Final with probable cause
Event Type
Incident
Date
March 6, 2001
Injury Outcomes
No injuries (44 uninjured)
Location
Montreal, CA
Aircraft
Fokker F28 MK 0100
Tail Number
N1426A
Injuries
None
Aircraft Damage
Minor
NTSB Number
CHI01IA102

The auxiliary power unit (APU) ingested deicing fluid and snow and sustained an uncontained turbine failure. The pressure bulkhead sustained minor damage. The airplane was being deiced. Four crew and 40 passengers were uninjured. The YUL weather was: Wind 050 degrees at 25 knots gusting to 33 knots; visibility 15 statute miles; present weather drifting snow; sky condition broken 2,800 feet overcast 7,600 feet; temperature -1 degree C; dew point -5 degrees C; altimeter 29.57 inches of mercury. Honeywell's APU teardown inspection stated, "Evidence of an engine overspeed event with a commanded auto-shutdown was present in the Electronic Control Unit (ECU) non-volatile memory." The report further stated, "In February 2001 American Airlines issued a 'Winterization Bulletin' for the F-100 advising that de-ice spray should not be sprayed into the APU inlet. Additionally, the Fokker 100 maintenance manual section 12-31-00, page 301 specifically advises 'Do not let de-icing and/or anti-icing fluid/water mixture go into the APU inlet. Injury to persons and/or damage to equipment can occur.'"

NTSB Probable Cause

the inaccurate aircraft deicing service the ground personnel performed alowing fluid injestion and the auxiliary power unit's turbine failure while standing. A factor was the auxiliary power unit's overspeed.

Full Narrative

On March 6, 2001, about 0640 eastern standard time, a Fokker F28 MK 0100, N1426A, operated as American Airlines flight #581 from Montreal/Dorval International (YUL), near Montreal, Quebec, Canada to Chicago O'Hare International Airport (ORD), Chicago, Illinois, piloted by an airline transport rated captain and copilot, sustained minor bulkhead damage while standing for deicing at YUL. The auxiliary power unit (APU) ingested deicing fluid and snow and sustained an uncontained turbine failure. The scheduled international 14 CFR Part 121 passenger flight was operating on an IFR flight plan. Visual meteorological conditions prevailed. The 2 flight crewmembers, 2 cabin crewmembers, and 40 passengers were uninjured. The flight was being deiced in preparation for departure to ORD at the time of the incident. The operator stated, "On March 6, 2001, N2BE suffered a APU failure during deicing at Montreal/Dorval International Airport. The weather was cold with the temperature at -2C, and blowing snow. The APU sustained a uncontained turbine failure after ingesting snow, ice, and deicing fluid. The aircraft also sustained damage to the pressure bulkhead after the APU failure." At 0700, the YUL weather was: Wind 050 degrees at 25 knots gusting to 33 knots; visibility 15 statute miles; present weather drifting snow; sky condition broken 2,800 feet overcast 7,600 feet; temperature -1 degree C; dew point -5 degrees C; altimeter 29.57 inches of mercury. The APU was removed from the airplane, shipped to, and stored in a bonding room at the Honeywell Services Repair and Overhaul Facility, Phoenix, Arizona. On April 10, 2001, Federal Aviation Administration inspectors oversaw the teardown and inspection of the APU. Excerpts of Honeywell’s inspection report stated the following: "In February 2001 American Airlines issued a 'Winterization Bulletin' for the F-100 advising that de-ice spray should not be sprayed into the APU inlet. Additionally, the Fokker 100 maintenance manual section 12-31-00, page 301specifically advises 'Do not let de-icing and/or anti-icing fluid/water mixture go into the APU inlet. Injury to persons and/or damage to equipment can occur.' ... Evidence of an engine overspeed event with a commanded auto-shutdown was present in the Electronic Control Unit (ECU) non-volatile memory. An engine overspeed condition is a known phenomenon when de-ice fluid is ingested. Since de-ice fluid is flammable when compressed, it will add to the combustion process of the engine. If enough is ingested, it will sustain combustion even though there is no metered fuel flow from the engine fuel control. Because the engine fuel control no longer has command of the engine speed, it cannot limit the preset maximum speed to its 107 percent limit. With the de-ice fluid maintaining combustion, the engine speed will be uncontrolled and can accelerate to the burst limit of the rotating components. This acceleration can occur extremely quickly because of the low inertia of the APU rotating components."

Flight

Event TypeIncident
Event Time11:40 UTC
Nearest AirportDorval Intl (0nm N)
Flight Plan FiledIFR
Flight Plan ActivatedNo
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftFokker F28 MK 0100
Tail NumberN1426A
Aircraft CategoryAir
DamageMinor
Operating RulePart 121
Engines2
Engine TypeTurbojet
Engine DetailsRolls-Royce · TAY 650-15 · Turbojet · 15100
Seats40

People & Injuries

Injury SummaryNo injuries (44 uninjured)
Fatal0
Serious0
Minor0
Uninjured44
Total44
Crew 1First Class · None
Crew 2Unknown · None

Conditions

ConditionsVMC
LightDaylight
Wind50° @ 25 kt, gusting 33 kt
Visibility15 sm
CeilingBroken clouds 2800 ft
Temperature / Dew Point30 C / 23 C
Altimeter29.56 inHg
Observation Time17:00
Weather SourceWFAC

Appendix: Source Data