Aircraft Accident/Incident Report

Wichita, Kansas 67277
Tuesady, February 4, 2003 18:00 CST

NTSB Narrative Summary Released at Completion of Accident

The experimental airplane returned from a test flight with evidence of an in-flight inverter fire discovered during a post flight inspection. The test flight was part of a new airplane certification test program and was to evaluate the airplane's audio design/flight deck audio system. The flight crew did not receive any fire warning indications in-flight and neither they or the test crew members noted any smoke or odors associated with burning during the flight. The inverter was located in the aft equipment bay, aft of the rear pressure bulkhead. The area within which the inverter was located was equipped with fire detection and an airplane circuit breaker for the system. The airplane circuit breaker for the inverter was not tripped. Subsequent testing demonstrated that the circuit breaker operated within specification limits. Inspection of the airplane revealed the presence of hydraulic fluid below and in the inverter tray. Examination of the inverter and fluid susceptibility testing confirmed the presence of Skydrol hydraulic fluid within the inverter. The inverter manufacturer reported that Skydrol intrusion, internal power circuit high voltages, operation at altitude, and drastic changes in temperature may have contributed to material degradation or deterioration or even possible dielectic breakdown, which resulted in the failure mode observed. Following this incident, the manufacturer reported that the inverter design was tested and confirmed that it met the fluid susceptibility requirements of DO-160C for Skydrol. A second examination of the inverter, performed by the United States Air Force Research Laboratory, was documented in a laboratory evaluation report. The failure analysis section of this report states that no root cause of failure could be found and noted that the majority of the thermal damage to the inverter was attributed to Joule heating from a sustained current overload. The examination also revealed the existence of numerous manufacturing deficiencies that would be classified as defects per Joint Industry Standard requirements for soldered electrical and electronic assemblies. The majority of these defects violated cleanliness, conformal coating, and soldering. The inverter manufacturer's FAA approved manufacturing requirements differ from those noted by the Air Force Research Laboratory and are based on its own internal design standards and practices as well as in-house workmanship standards derived from good industry practice and requirements contained in IPC-A-610C, "Acceptability of Electronic Assemblies". The inverter was part of a cabin outlet system considered non-essential under 14 CFR Part 25, Subpart F. Information contained in Advisory circular 25-10 regarding guidance for installation of miscellaneous, non-required equipment states. that circuit protective devices should be provided such that a fault in the nonrequired system does not cause a failure of a required system. Supplementing this guidance, AC 25-16, "Electrical Fault and Fire Prevention and Protection," states that in cases where internally faulted components will not cause automatic disconnection of their circuit protective devices before causing excess temperatures potentially resulting in fire, these electrical equipment should be provided with adequate backup protection (beyond the aircraft circuit breakers). In addition, the AC states that each installation of an electrical device should be assessed for its potential to generate fire or smoke under failure conditions. The inverter specified for this installation was a TSO-C73 certified article. The applicable TSO addresses short circuit and overload conditions to the extent that inverters continue producing power through these conditions, but it does not require circuit protection when these conditions are encountered. A design analysis of the inverter as installed in the cabin outlet system to consider failure conditions and corresponding hazards such as fire/smoke generation, in accordance with the related provisions of 14 CFR Part 25.1309, had not been performed by the aircraft manufacturer prior to this incident. As a result, additional requirements to address internal inverter circuit protection for this installation were not mandated by the aircraft manufacturer. Subsequent to this incident, a design analysis was performed by the airplane manufacturer. Correspondingly, the inverter manufacturer modified the inverter design to incorporate fuses on the power input lines to interrupt electrical power in the event a short circuit or overload failure condition develops inside the inverter.

NTSB Probable Cause Narrative

The uninterrupted current overload of the cabin outlet system static inverter leading to ignition and sustained fire. The cause of the initiating overload condition could not be determined. Contributing factors were the lack of adequate current overload protection for the static inverter due to a failure to adequately assess fire/smoke hazards of the inverter in this installation and the absence of timely fire annunciation to the flight crew.

Event Information

Type of Event Incident
Event Date 2/4/2003
Event Day of the Week Tuesday
Time of Event 1800
Event Time Zone Central Standard Time
Event City Wichita
Event State KANSAS
Event Country --
Zipcode of the event site 67277
Event Date Year 2003
Event Date Month 2
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 --
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 1556 Central Standard Time
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID ICT
Elevation of weather observation facility 1338
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation CST
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 3
Dew Point at event time (in degress fahrenheit) -6
Wind Direction (degrees magnetic) 110
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 7
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.14
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 4
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 20082
NTSB Notification Source BOMBARDIER AEROSPACE
NTSB Notification Date Feb 5 2003 12:00AM
NTSB Notification Time 1405
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record May 30 2006 1:54PM
User who most recently changed record NTSB\JOHB
Basic weather conditions Visual Meteorological Cond
FAA District Office Wichita MIDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number C-GJCV
NTSB Number CHI03IA066
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed VFR
Flight plan Was Activated? Yes
Damage None
Aircraft Fire In-flight
Aircraft Explosion None
Aircraft Manufacturer's Full Name Bombardier
Aircraft Model BD 100-1A10
Aircraft Series Identifier --
Aircraft Serial Number 20004
Certified Max Gross Weight --
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft --
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Unknown
Date of Last Inspection --
Airframe hours since last inspection --
Airframe Hours --
ELT Installed Unknown
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name Bombardier Aerospace
Aircraft Owner Street Address PO Box 6087, Station Centre-ville
Aircraft Owner City Montreal, Quebec
Aircraft Owner State UN
Aircraft Owner Country USA
Aircraft Owner Zipcode H3C 3G9
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country --
Operator Zip code --
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Flight Test
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code ICT
Departure City Wichita
Departure State KS
Departure Country USA
Departure Time 1600
Departure Time Zone CST
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code ICT
Destination City --
Destination State --
Destination Country --
Specific Phase of Flight Takeoff
Report sent to ICAO? Yes
Evacuation occurred No
Date of most recent change to record Feb 24 2004 4:54PM
User who most recently changed record SULP
Since inspection or accident --
Event Location Runway Number and Location --
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --