PPRuNe Forums - View Single Post - Final report on CX780 accident published
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Old 8th Sep 2013, 10:22
  #40 (permalink)  
Sqwak7700
 
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I'm surprised that there is almost no mention of the root cause of the incident and what can be done to prevent re-occurrence, i.e. fuel contamination.
There is if you read the report. From what I understood, as in most accidents, it was a chain of events. Contamination of salt water from some relief ponds in the airport managed to get into the airport's refueling system when it was being worked on during a parking ramp extension.

The contaminants blocked the filters, and the fueling company just pumped up the pressure instead of investigating the reason for reduced flow. This pressure exceeded the inner metal structure design limits of the filtering cartridge, causing it to collapse and bulge slightly, creating more restriction.

The saltwater in the system affected the integrity of the filtering material, which then released the globules into the fuel flow. These spheres where small enough to not be detected during visual inspections, and caused FCU malfunctions after prolonged operation which allowed excessive buildups to block moving components.

There were plenty of recommendations to all parties, and the filter manufacturer improved the design of their system. Overall, I think the fault lies on the airport operator for sloppy construction practices followed by sloppy inspection and flushing of the system. The fueling operator also suffered from a bit of sloppiness in not investigating the blockage causing the pressure drop.
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