Aircraft Accident/Incident Report

Jacksonville, Florida 32229
Saturday, March 2, 1991 14:45 EST

NTSB Narrative Summary Released at Completion of Accident

THE FLIGHT CREW EXPERIENCED THE PARTIAL POWER LOSS OF THREE OF FOUR ENGINES WHILE IN CRUISE FLIGHT. THE AIRPLANE WAS OPERATING IN ICING CONDITIONS WITH ALL AIRPLANE ANTI ICE SYSTEMS ON. THE FLIGHT PASSED THROUGH AN AREA OF RAPIDLY WARMING AIR AND THE ENGINE BLEED BANDS WERE OPEN AND COULD NOT BE CLOSED WITH THROTTLE MOVEMENT. THE CREW SHUT DOWN TWO ENGINES TO PREVENT OVERTEMP CONDITIONS AND REDUCED ONE TO IDLE. THEY DECLARED AN EMERGENCY AND DIVERTED TO AN AIRPORT NEARBY. SUBSEQUENT TESTING OF A LIKE AIRPLANE REVEALED THAT THE ENGINE DESIGN WAS SUCH THAT WHEN OPERATING AT HIGH ALTITUDE WITH ALL ANTI ICE SYSTEMS 'ON' THE BLEED AIR VALVES COULD NOT BE CLOSED WITH NORMAL PROCEDURES. THE MANUFACTURER SUBSEQUENTLY DEVELOPED A MODIFIED CHECKLIST TO CORRECT FOR THIS SITUATION.

NTSB Probable Cause Narrative

INADEQUATE ENGINE PERFORMANCE IN THE DESIGNED AIRPLANE FLIGHT ENVELOPES.

Event Information

Type of Event Incident
Event Date 3/2/1991
Event Day of the Week Saturday
Time of Event 1445
Event Time Zone Eastern Standard Time
Event City JACKSONVILLE
Event State FLORIDA
Event Country --
Zipcode of the event site 32229
Event Date Year 1991
Event Date Month 3
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude
Event Location Longitude
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 0
Degrees magnetic from airport 0
Airport Elevation 0
Weather Briefing Completeness Full
Investigator's weather source Weather Observation Facility
Time of the weather observation 1450 Eastern Standard Time
Direction of event from weather observation facility (degrees) 355
Weather Observation Facility ID JAX
Elevation of weather observation facility 30
Distance of event from weather observation facility (units?) 15
Time Zone of the weather observation EST
Lighting Conditions Day
Lowest Ceiling Height 3000
Lowest Non-Ceiling Height 1700
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 2
Air Temperature at event time (in degrees celsius) 14
Dew Point at event time (in degress fahrenheit) 14
Wind Direction (degrees magnetic) 130
Variable Wind Indicator Unknown
Wind Speed (knots) 4
Wind Velocity Indicator Unknown
Wind Gust Indicator Unknown
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 29
Density Altitude (feet) 0
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal --
Injury Total Minor --
Injury Total None 5
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 5001
NTSB Notification Source --
NTSB Notification Date --
NTSB Notification Time 0
Fiche Number and/or location -used to find docket information 43455
Date of most recent change to record Dec 12 2000 9:33AM
User who most recently changed record dbo
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number CGRNU
NTSB Number MIA91IA091
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 129: Foreign
Type of Flight Plan filed IFR
Flight plan Was Activated? --
Damage Minor
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name BRITISH AEROSPACE
Aircraft Model BAE-146-200
Aircraft Series Identifier BAE-146-20
Aircraft Serial Number 205
Certified Max Gross Weight 93000
Aircraft Category Airplane
Aircraft Registration Class Foreign Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 74
Number of Engines 4
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Unknown
Date of Last Inspection --
Airframe hours since last inspection 0
Airframe Hours --
ELT Installed Unknown
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name
Aircraft Owner Street Address
Aircraft Owner City
Aircraft Owner State
Aircraft Owner Country
Aircraft Owner Zipcode
Operator is an individual? --
Operator Name AIR NOVA
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 1550 BEDFORD HWY
Operator City BEDFORD
Operator State OF
Operator Country
Operator Zip code
Operator Code
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not Non-scheduled
Indicates Domestic or International Flight International
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) Unknown
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code KMIA
Departure City MIAMI
Departure State FL
Departure Country
Departure Time 1405
Departure Time Zone EST
Destination Same as Local Flt --
Destination Airport Code LYHZ
Destination City HALIFAX
Destination State OF
Destination Country
Specific Phase of Flight Cruise
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:30AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length 0
Runway Width 0
Sight Seeing flight No
Air Medical Flight No
Medical Flight --