SQ-368 (engine & wing on fire) final report out

[Aluminium shuffler]

Parabellum, it is you who is wrong, and bullying and name calling won't change that. It was only luck that the cabin wasn't breached like in many another incident, and it would have been over inside that cabin in seconds if it had breached. The crew were grossly negligent in their assumptions that the fire could be contained so quickly - there was nothing other than blind hope/faith that it could be contained at all.

[lomapaseo]

Parabellum, it is you who is wrong, and bullying and name calling won't change that. It was only luck that the cabin wasn't breached like in many another incident, and it would have been over inside that cabin in seconds if it had breached. The crew were grossly negligent in their assumptions that the fire could be contained so quickly - there was nothing other than blind hope/faith that it could be contained at all.

But the cabin wasn't breached !

Let's deal in facts, because that 's what immediate decisions are based on.

This should not be a paint brush discussion of what the crew did not do, based on our armchair viewing, but why did they act the way they did

[ManaAdaSystem]

So how much of the aircraft should be on fire if one wing was not enough to trigger an evacuation?

[hunbet]

I'm not sure if this picture had been posted but does anyone see any fire damage to the fuselage ?
Probe of Singapore Air Jetliner Fire Focuses on Oil Cooler - WSJ (http://www.wsj.com/articles/probe-of-singapore-air-jetliner-fire-focuses-on-oil-cooler-1467900630)
The fire was caused by the thinned out and fuel laden oil exiting the engine breather.When the A/C decelerated after landing the mist of fuel caught up with the A/C and caused the rather large fire on the wing surfaces There was no giant leak and that fire could have probably burned out on its own.
Here is a picture of a similar A/C with a breather fire.
Incident: Emirates B773 at Boston on Aug 10th 2014, engine fire after landing (http://www.avherald.com/h?article=4789f125&opt=0)

[MrSnuggles]

Some of you are falling into the clever trap of

Decision A was correct because noone died.

This is assuming that the only correct decision is the one where noone dies. This also assumes that any decision where people do suffer fatal injuries are incorrect. However you can not keep this logically consistent.

How about the recent crash of Emirates. Many people leaving with carry on luggage. Noone of the passengers died. Logical conclusion following above reasoning: Decision to bring carry on luggage was correct because noone died.

To apply some kind of logical consistency to the debate, one needs to consider the available scenarios. This includes factoring in survival possibilities and possibilities of injuries "if"/"not if".

If people stay in the cabin of a plane on fire, history tells us that the risks for injuries and/or fatalaties are very great.
If people are evacuated from the cabin of a plane on fire, history tells us that the risk for injuries and/or fatalaties greatly diminishes.

"Not if"s are: no fire chief in his/her sane mind would ever claim to know exactly how long a fire would take to extinguish: noone can accurately predict the probability, location, placement or duration of explosions when aircraft are on fire: the probability of survival for people staying in the cabin diminishes very quickly the larger the flames and the larger the affected area of the plane is engulfed in flames.

To reason that a decision is correct because noone died is logically inferior in this case.

Also, I hear many of you often say "better safe than sorry" and "if in doubt, there are no doubts". In this particular case I would say that both these statements logically contradicts the events on this particular flight.

It is very lucky that everyone got out alive. I am satisfied with that.

[lomapaseo]

If people stay in the cabin of a plane on fire, history tells us that the risks for injuries and/or fatalaties are very great.
If people are evacuated from the cabin of a plane on fire, history tells us that the risk for injuries and/or fatalaties greatly diminishes.

not so simple,

One needs to parse the data down a few clicks with other historical combinations

The same history shows that most (never all) fatalities are associated with fire that reaches into the cabin creating things like deadly smoke.


Theory :As long as the cabins stays smoke free you have time for considered decision making.

Once you open doors you create the entranceway for an external fire to enter.

As such you may notice in photos that the fire runs along the top inside (thermal effects) concentrating visible damage near open doors.

As a passenger I expect that once the doors are opened and fire starts to come in with smoke I have less than two minutes left to get out. As such I'm quite willing to listen for instructions of when that two minutes starts my personal panic clock.

[etudiant]

I'm not sure if this picture had been posted but does anyone see any fire damage to the fuselage ?
Probe of Singapore Air Jetliner Fire Focuses on Oil Cooler - WSJ (http://www.wsj.com/articles/probe-of-singapore-air-jetliner-fire-focuses-on-oil-cooler-1467900630)
The fire was caused by the thinned out and fuel laden oil exiting the engine breather.When the A/C decelerated after landing the mist of fuel caught up with the A/C and caused the rather large fire on the wing surfaces There was no giant leak and that fire could have probably burned out on its own.
Here is a picture of a similar A/C with a breather fire.
Incident: Emirates B773 at Boston on Aug 10th 2014, engine fire after landing (http://www.avherald.com/h?article=4789f125&opt=0)



The scale of the Emirates fire shown is of a different magnitude from that of the Singapore Airlines jet. So there may be doubt that the 'fire could probably have burned out on its own'.
I'll wait for the inquiry results but right now I believe the happy outcome borders on the miraculous.

[RatherBeFlying]

Theory :As long as the cabins stays smoke free you have time for considered decision making.

Question: Once fire breaches the cabin, what proportion of people still inside the cabin will succumb?

[parabellum]

Parabellum, it is you who is wrong, and bullying and name calling won't change that


I disagree with everything you say in your post Aluminium Shuffler and I am not a bully. I called deadheader a troll because I believe that is what he is, it is not an insult, it is a description.

[hunbet]

The difference is the photo I posted shows an A/C that had the engine operating within normal parameters while in flight.

The SIA A/C was operating with an engine at idle for about 2 hours.The fuel and oil was pooling in the engine exhaust tail cone and when they put it in reverse all of that fuel and oil was expelled out of there .

That A/C will probably fly again.The damage is all to flight controls and secondary structure !

I saw this A/c and the damage was far worse than SIA !



"I am surprised nobody else posted this info yet. On Tue, 27JUL04, a UPS 752 caught on fire while under going maintenance for a fuel leak. I think it was a/c 410. I have got pics but I left my camera in my tool box at work, I will load some pics when I bring it home. The fire damaged the pylon, flaps, aileron, flap track fairings. Heat damage seemed to be the fillet fairing, and the lower fuel tank structure surrounding the pylon. The airport fire department responded very quickly and saved the rest of the a/c. Currently the a/c is parked inside DL's hangar, yesterday reps from UPS and Boeing spent the day examining/evaluating the a/c. I will post more info and pics as I get them. "

It was repaired and flew away !

[tdracer]

"I am surprised nobody else posted this info yet. On Tue, 27JUL04, a UPS 752 caught on fire while under going maintenance for a fuel leak. I think it was a/c 410. I have got pics but I left my camera in my tool box at work, I will load some pics when I bring it home. The fire damaged the pylon, flaps, aileron, flap track fairings. Heat damage seemed to be the fillet fairing, and the lower fuel tank structure surrounding the pylon. The airport fire department responded very quickly and saved the rest of the a/c. Currently the a/c is parked inside DL's hangar, yesterday reps from UPS and Boeing spent the day examining/evaluating the a/c. I will post more info and pics as I get them. "


FWIW, I was involved in the investigation of that incident - in short it was the mother of all tailpipe fires.
Due to a procedural error while troubleshooting a strut fuel leak, they had managed to pool an estimated 10 to 20 gallons of fuel in the burner. They then decided to start the engine. :eek:
It doesn't take much fuel to make a good sized fire...

[Aluminium shuffler]

Lomapaseo (and parabellum),

I'm aware that the cabin didn't breach, but how could the crew have possibly known that it wouldn't? Look at how quickly the cabins have breached in most comparable situations, including Okinawa, Manchester, and the most recent case on the same type... To sit there and do nothing with a raging fire is extraordinary negligence. Had the fire penetrated, there is no way they could have evacuated everyone. It was blind luck that nobody was lost as a result of this failure to make a decision.

[lomapaseo]

I'm aware that the cabin didn't breach, but how could the crew have possibly known that it wouldn't? Look at how quickly the cabins have breached in most comparable situations, including Okinawa, Manchester, and the most recent case on the same type... To sit there and do nothing with a raging fire is extraordinary negligence. Had the fire penetrated, there is no way they could have evacuated everyone. It was blind luck that nobody was lost as a result of this failure to make a decision.

Single events are always open to variations in causes and results.

My point was a general comment on the data having to do with the significance of opening doors to evacuate and after that what you call a breach.

To me the burn through breach from a ground pool fire would look a lot different than the result pics that one sees along the top of the fuselage. I'm not saying an initiating fire breach never happens, but just that opening doors followed by a fire entrance happens more often in a time frame.

just thinking as a passenger, I like the time to think as long as I can still breathe good air. I make no judgments about the crew actions and leave that to the experts who trained them.

[hunbet]

Your comparables are not comparable.In Okinawa , a fuel tank was punctured by a slat upstop bolt and Manchester there was a fuel tank plate punctured that allowed the entire contents of the tank to pour out.The latest was a crash.
The paint on the fuselage of SIA wasn't even discolored.

[ArchieBabe]

https://www.youtube.com/watch?v=D5B8QrpudpA

Sublime !

[Julio747]

But the cabin wasn't breached !

Let's deal in facts, because that 's what immediate decisions are based on.

This should not be a paint brush discussion of what the crew did not do, based on our armchair viewing, but why did they act the way they did

Now, remind me, who is using 20/20 hindsight?

The "evacs" are saying it should have been an evac, despite the hindsight that everyone survived.

Whilst you are saying the call was good because they all survived (in hindsight).

And then we have the fence sitters, who refuse to make a decision before they have all the facts. Much like the FC perhaps?Ideal, yes. Real life, no.

The pilots did not have 5 mins to collect facts. They probably had a tail camera view, they had a cabin crew with working eyes. They could see the RFF driving past them and away from them, out of the RHS cockpit window. They could probably sense thd glow from the cockpit at that time in the morning. The RFF had not yet arrived. You don't need fence sitters in that scenario...

If the RFF were in position at wheels stop, then maybe I it is debatable. But they were still a minute plus out. That's a long time when you have a wing fire and you have no idea why or what...

[hunbet]

Do you notice that 34 seconds into that video the windows are covered with foam?

[Julio747]

Do you notice that 34 seconds into that video the windows are covered with foam?

And how long after wheels stop was that???

My guess is around 3-4 minutes. You may notice the fire is well underway at the beginning of the video!

Yeah! Really sublime! The pax got to watch the plane burning for at least 3 mins. The "we need to run" quote at the beginning of the video says it all.

It is worrying that the pax can call it better than the cc or the fc. Okay, you can't see that from the cockpit but let's not forget that the fc have legs. That's why we land with the window shades up, right? So we can eyeball the wings and engines?

The cc should have called it, but this is Asia. What does "father" (boss) say?

I have no doubt the if one of the fc had got off their arse, and seen what the pax were seeing, it would have been an immediate evac..

[PT6Driver]

To Lomapaseo and Parabellum
Firstly we as hindsight observers can see from the video a fire outside. At the time we would not have known what was burning, how effective the fire services would or wouldn't be, or how quickly the fire would burn through if at all etc. Based on that the majority here including myself would have ordered an evacuation.
The fire at Manchester breached the hull in a matter of seconds, fire did not enter through any open doors. The smoke that entered created a sense of panic in the passengers, this is all from the official report. Waiting until the fire breaches before ordering an evacuation is time wasted. Once smoke or flames enter the cabin it is almost a certainty that people will die. By 1 minute after stopping it is highly likely that pax had already died at Manchester. foam did not start in this case until after 1 minute.
Watch the video of the evacuation in Dubai, there is no sense of urgency to get out, rather pax are looking for a normal exit procedure, getting luggage etc. The aisles are blocked and initially there is very little movement towards the exits. Now imagine thick smoke or flames entering that scene. How do you think people would have reacted?
The next question is why did the Flightdeck not order the evacuation? Remember that they were not in fire mode. They had a technical problem, an engine was not shut down but at idle, a normal approach and landing was made, thrust reversers were used. All perfectly normal and non emergency. Why did they stop on the runway? Was it a fire warning or had they already decided to stop so the fire services could inspect for leaks? From the cockpit it could be that they were unaware of the fire. The engine fire warning may not have sounded. If so why look at the ctv? From an earlier post refrencing a cabin crew forum post a cc states she was very busy blocking her door dealing with anxious pax including a mother and her child. She was unable to inform the flight deck or the senior about the situation outside. What if none of the cabin crew informed the flight deck? What if the tower didn't? What if the initial fire crews didn't comunicate? All these what ifs mean that it is entirely possible that the Flightdeck were unaware of the fire or how serious it was. Given that scenario what would your decision making process be? How long would it take? However I would like to think that if they were made aware of the true situation then they would have chosen to evacuate. FWIW the Captain is the person who is responsible for initiating an evacuation not the Fire Chief.
Finally Lomapaseo (and parabellum), at Manchester how long would you have delayed opening the doors?

[gatbusdriver]

I apologise, I hadn't realised that PT6 and Julio etc are cabin crew, now I understand where you are coming from. You would have ordered the evacuation because you had a clear understanding of what was going on outside the aircraft.

As cabin crew would you make every effort to ensure the flight crew were aware of the situation unfolding or would you classify it as clearly catastrophic and innitiate the evacuation of your own accord? The only reason I ask is you need to be careful because in this situation if both engines have not been shut down prior to innitiating an evac from the cabin you could be putting peoples lives at risk.

Of course, if you are flight crew passing comment, you can assume as much as you like, but until you know what the flight crew knew on the day you cannot pass judgement (well ok, you have and will continue to do so, but to do so is foolish).

GBD

[Julio747]

To Lomapaseo and Parabellum
Firstly we as hindsight observers can see from the video a fire outside. At the time we would not have known what was burning, how effective the fire services would or wouldn't be, or how quickly the fire would burn through if at all etc. Based on that the majority here including myself would have ordered an evacuation.
The fire at Manchester breached the hull in a matter of seconds, fire did not enter through any open doors. The smoke that entered created a sense of panic in the passengers, this is all from the official report. Waiting until the fire breaches before ordering an evacuation is time wasted. Once smoke or flames enter the cabin it is almost a certainty that people will die. By 1 minute after stopping it is highly likely that pax had already died at Manchester. foam did not start in this case until after 1 minute.
Watch the video of the evacuation in Dubai, there is no sense of urgency to get out, rather pax are looking for a normal exit procedure, getting luggage etc. The aisles are blocked and initially there is very little movement towards the exits. Now imagine thick smoke or flames entering that scene. How do you think people would have reacted?
The next question is why did the Flightdeck not order the evacuation? Remember that they were not in fire mode. They had a technical problem, an engine was not shut down but at idle, a normal approach and landing was made, thrust reversers were used. All perfectly normal and non emergency. Why did they stop on the runway? Was it a fire warning or had they already decided to stop so the fire services could inspect for leaks? From the cockpit it could be that they were unaware of the fire. The engine fire warning may not have sounded. If so why look at the ctv? From an earlier post refrencing a cabin crew forum post a cc states she was very busy blocking her door dealing with anxious pax including a mother and her child. She was unable to inform the flight deck or the senior about the situation outside. What if none of the cabin crew informed the flight deck? What if the tower didn't? What if the initial fire crews didn't comunicate? All these what ifs mean that it is entirely possible that the Flightdeck were unaware of the fire or how serious it was. Given that scenario what would your decision making process be? How long would it take? However I would like to think that if they were made aware of the true situation then they would have chosen to evacuate. FWIW the Captain is the person who is responsible for initiating an evacuation not the Fire Chief.
Finally Lomapaseo (and parabellum), at Manchester how long would you have delayed opening the doors?

The only thing I would add to that is that if the fc did not order the RFF before landing (understandably, at that point they did not think they had a fire problem), then who did? It has been said that the RFF was already out (for whatever reason). Regardless, someone sent them to the SQ plane. I would imagine it was the tower that saw #2 on fire, given the response time. It was an emergency landing so attention was raised after all. And in the half light, it would be easy to see.

So the tower would have said #2 is on fire to the fc. And when the a/c is already on the ground and stopped, my first instinct would be to send the FO to eyeball the situation and report.

OK, some conjecture I know. But if the fc did not see they were ablaze, someone did, and for sure that info got to the flight deck.

So here is the bottom line. You can either call evac on the news that #2 is on fire. Or you can send the FO back to take a look, and call evac when he reports the whole wing is on fire. These are the only two acceptable options. Doing nothing is not an option in that scenario.

If the cc tells you the same news, then evac is also the same answer. But I for one would send the FO back if I don't here anything from the cc.

[PT6Driver]

Gatbus,
1 I did not say I was cabin crew and nowhere did I state that they should have initiated the evacuation on their own.
2. The main purpose of my posts has been to explicitly point out to those who say a decision to not evacuate was acceptable because the hull was not breached,is incorect
3. Nowhere in the above posts have I criticised the crew. Rather I have pointed out that we simply do not know what information the had available on which to make their decision.
4. I have highlighted above the fact that they could have been unaware of the fire and so did not consider evacuation.
5. Finally everyone here who states an evacuation would have been a good call bases that on the fact that we know the wing was on fire. There are some here who feel that the wing being on fire is insufficient evidence for an evacuation. I personally feel that if I had recieved the information thst the wing was on fire I would have evacuated.

[Needle Knocker]

And how long after wheels stop was that???

My guess is around 3-4 minutes. You may notice the fire is well underway at the beginning of the video!

Wheels stop to foam on it's way = 39 seconds by my stopwatch:

https://www.youtube.com/watch?v=Hf-QLDGgORk

[parabellum]

However I would like to think that if they were made aware of the true situation then they would have chosen to evacuate. FWIW the Captain is the person who is responsible for initiating an evacuation not the Fire Chief.


Having been made aware of the true situation they decided NOT to evacuate, the Fire Chief passes back up to date information from the scene of the fire and may add a recommendation. No one is arguing as to who makes the decision. Those that say they would have evacuated regardless of the information available are the ones who will deliver you out of the frying pan and literally, into the fire.


Finally, there is no comparison between the Manchester incident and the Singapore incident.

[lomapaseo]

PT6Driver

You appear to ascribe to me more than was written in my posts.

I did not express an opinion about what the pilot did or should have done. I only expressed an opinion based on experience for myself as a passenger to start to panic (based on breathable air) and the knowledge that anything that breaks open the cabin with a fire letting smoke in means I need to get out in less than 2 mins.

[RatherBeFlying]

anything that breaks open the cabin with a fire letting smoke in means I need to get out in less than 2 mins.Typically smoke and toxic combustion products will incapacitate in much less than 2 mins.

If you are fortunate enough to have a smoke hood in a cabin breach, all those between you and the exit will likely be prostrate in about 30 seconds.

Yesterday 13 young people were overcome in seconds before they could reach the exit:(

France Rouen fire kills 13 at birthday party - BBC News (http://www.bbc.com/news/world-europe-36995155)

Admittedly aircraft interiors are more carefully regulated, but once the cabin is breached, it will be too late for many.

[Machinbird]

In my personal opinion, this was clearly an evacuate situation at the moment the aircraft came to a stop. My past military training and actual experience in shipboard aircraft fire fighting lead me to that conclusion. This was no small fire. If the fire had proceeded unimpeded, it would be reasonable to expect the hull to be breached. The amount of fuel on the ground under the aircraft could not be known by the crew, but the scope of the fire clearly extended to one entire wing. There is no video or pictorial evidence to indicate that fire ever reached under the aircraft to the port side so it appears that an escape route was visibly available and that opening the doors on the port side of the aircraft would not have introduced fire or smoke.

Compare to:
After the airplane came to a stop, a fire initiated within the separated right engine, which came to rest adjacent to the right side of the fuselage. When one of the flight attendants became aware of the fire, he initiated an evacuation, and 98% of the passengers successfully self-evacuated. As the fire spread into the fuselage, firefighters entered the airplane and extricated five passengers (one of whom later died) who were injured and unable to evacuate. Overall, 99% of the airplane’s occupants survived
Note that in the picture below, the burning engine fire was relatively small and localized and there were exits ahead and behind the source of the fire that were not scorched and apparently usable.https://pbs.twimg.com/media/BOg6uXWCQAEHJlB.png

[DingerX]

Yes, every case is different, and this case is one where the whole thing didn't burn down. But, given the available information, they got damn lucky.
The interim report says it all; if they had anything positive to contribute to the non-evacuation debate, they would have at least said something. The decision to defer such a discussion was their way of not pouring fuel on another fire.
Asiana was a very different accident. The flight crew there, by the way, sent the F/As to stations and left them there too (except, of course, for the F/As who'd been ejected already). They waited 90 seconds in a breached, broken, and eventually burning aircraft before initiating an evacuation on their own while the boys at front fiddled with their radios.
Here, on the other hand, we have a problem that developed some time before and that the crew seems to have decided to combat largely with the power of positive thinking. At every step, their actions suggest someone seeing something anomalous and thinking: what's the best possible scenario?
An optimist's brief existence ends in absolute disappointment.

Put another way, accidents can and do happen to the most competent crews. But an accident is a powerful moment of cognitive dissonance, and you could have folks up front so far behind that they're doing everything to convince themselves there is no fire. How do you train for that?

[PT6Driver]

Lomapaseo,
My appologies if I atributed to you more than you wrote.
My main point is that a fire or other emergency situation is a very varied one where events can change extremely rapidly. The unbreached hull can appear relatively safe, however once a breach by fire or ingress of smoke occurs the situation can deteriorate extremely rapidly.
Evidence from Manchester shows that passengers were incapacitated with just 2 breaths. The second breath an uncontrollable reflex reaction by their bodies. Depending on where one is in relation to the smoke or fire, incapacitation or death can occur within seconds.
A panicing crowd with everyone fighting for their lives to get to an exit is not a good survival environment and eggress will be significantly slower than a calmer more orderly one.
It therefore makes sense to evacuate before actual fire and or smoke enters the cabin.
Your point that opening the doors will automatically cause an ingress of flames or smoke only holds true if the door is next to the flames.
However the cabin crew are trained to check for danger before opening a door. We can see this in the onboard video where a cabin crew can be seen blocking a door, outside of which there is clearly a fire.
(An exception would be a case like the rear right door at Manchester, however in this instance the main entry point for flames and smoke was the hull breach by the fire on the right hand side ).
Unless you are next to a usable exit survival time could be seconds not minutes, therefore maximum use of time by evacuating expeditiously is vital.

[ACMS]

PT6driver...... Well said....

[lomapaseo]

PT6Driver

In your last post you have added value to the discussion by clarifying your opinions on the subject :ok:

To continue with my own views, following yours, the issue facing the crew (both Captain and cabin) is what doors and when and where is the fire and its spread. No doubt there is lots of info being generate when you add in a third party like an outside fire captain.

for me as a passenger I just wait until..

As for lessons learned I still await what info was really available to the three parties on the intercoms etc. (Captain, Cabin and fireman)

[Julio747]

Wheels stop to foam on it's way = 39 seconds by my stopwatch:

https://www.youtube.com/watch?v=Hf-QLDGgORk

At 39 seconds after wheels stop, foam starts spraying, but not on the plane alas, and certainly not on the windows.

[Machinbird]

But an accident is a powerful moment of cognitive dissonance, and you could have folks up front so far behind that they're doing everything to convince themselves there is no fire. How do you train for that?
The short and simple answer is to teach aircrews tactical or combat breathing techniques. Tactical Breathing Can Stop Stress on the Spot | On Resilience (http://onresilience.com/2011/06/02/tactical-breathing-can-stop-stress-on-the-spot/)
You can use it anytime your stress begins to increase.... not just for accidents.

PT6Driver. :ok:

[OldLurker]

At 39 seconds after wheels stop, foam starts spraying, but not on the plane alas, and certainly not on the windows.Why would they spray the fuselage or the windows? The fire was affecting only the wing, not the fuselage, as demonstrated by post-incident photos of the right-hand side of the fuselage which show that the fuselage is undamaged, the paint not even scorched.

http://i.ndtvimg.com/i/2016-06/singapore-airlines-afp-650_650x400_71466999595.jpg

[Aluminium shuffler]

Hubnet, you say the examples are incomparable because of the cause? Are you kidding? It takes weeks to find that cause; how long do you want to sit in a burning aeroplane, cause unknown, before getting away? Likewise, prabellum, saying the Manchester is incomparable. Why? Aeroplane stopped on the runway, massive external fire... What is incomparable about that? Really, some people need to stop using little details to justify a bad big picture...

AS PT6 said, the crew are not at fault if they had not been made aware of the problem, but given fire crews rocking up and spraying, they must have been made aware at some point prior to the fire trucks arriving so that they didn't taxy.

[johdi]

Not seen linked earlier: https://www.youtube.com/watch?v=EUtYwY7igj4

[parabellum]

https://en.wikipedia.org/wiki/British_Airtours_Flight_28M


Aluminium shuffler, if you read this short report, (taken from the AAIB report), you will see there is no similarity between the Manchester incident and the SQ incident.

[Chu Chu]

Spraying the fuselage would cool it and help prevent a breach. I'd expect that with good boundary cooling, an intact fuselage could survive almost indefinitely even with a pretty hot fire nearby. Of course, that's not to say that the fire couldn't get too hot, or that the cooling wouldn't be interrupted, or . . . .

[Julio747]

Why would they spray the fuselage or the windows? The fire was affecting only the wing, not the fuselage, as demonstrated by post-incident photos of the right-hand side of the fuselage which show that the fuselage is undamaged, the paint not even scorched.

http://i.ndtvimg.com/i/2016-06/singapore-airlines-afp-650_650x400_71466999595.jpg

I was responding to an earlier post, regarding video from inside the a/c, where you can see foam landing on the windows. Of course, foam was going everywhere at that point. Well everywhere on the RHS that is.

[Aluminium shuffler]

Apart from the whole issue we're concerned with, Parabellum, namely the huge external fire? What planet are you on? The exact cause of the fire may differ, but the external threat to the fuselage is the same! Huge, uncontained fire!

[trickii]

We are assuming this was an engine fire on this GE UNIT. It appears to resemble a breached oil sytem again? Anyone know the cause?

[henra]

The video evidence is totally unreliable, mainly taken from iPhones.



The quality of footage is sufficient for me to get an idea of the magnitude of the fire.
And that is huuuge.



Sorry deadheader but you are quite wrong, your bull-headed actions might well cause more deaths than action based on all the information available. There was no gross negligence or dereliction of duty on anyone's part. A passenger who initiates there own evacuation, (possibly you?), are a serious danger if they don't have the full facts available to them.



Deadheader might be a little bit direct in the way he states his opinion but I think there is quite some truth to it.


I have no idea why you are so heavily favoring staying in a wildly burning aircraft.
Yes I don't want to hang the crew, in hindsight it appears (rather clearly) they haven't judged the situation well. That happens when human beings face the big unexpected. In all fairness they probably didn't have a clear full picture immediately.
However, the trick is to learn from such things rather than desperately trying to justify it.
So: No I don't want to crucify the crew. But it should be taken as a learning opportunity. Rather than denial.

[crippen]

as a SLF ! How far is it from the cabin to the nearest point of the fire? It looks a long way when you are sat in it , or waiting to board ' at remote stand ' !

[Whinging Tinny]

A few things for you all to mull over...

1. SQ SOPs forbide CC to self initate an EVAC command. Only exception is if FD crew are incapacitated.

2. FD crew were in contact with RFF chief and he reckoned they (RFF) could contain the fire without the need to EVAC.

3. There was no engine fire warning - I wouldn't expect one either due to the fire beginning internally in the powerplant itself.

Trickii - the interim report states where the failure of the sytem occurred.People have explained how the system works previously in this thread.

[hoss183]

wrong thread, editied out.

[Ian W]

Lomapaseo (and parabellum),

I'm aware that the cabin didn't breach, but how could the crew have possibly known that it wouldn't? Look at how quickly the cabins have breached in most comparable situations, including Okinawa, Manchester, and the most recent case on the same type... To sit there and do nothing with a raging fire is extraordinary negligence. Had the fire penetrated, there is no way they could have evacuated everyone. It was blind luck that nobody was lost as a result of this failure to make a decision.

The crew probably knew it wouldn't as the fire crew outside would have reported that the fire was at the engine and outboard and all smoke and fire was blowing away from the fuselage. They may even have added advice not to evacuate to give them full access to put the fire out. The examples you quote are precisely the opposite with fire being blown onto the fuselage.

[PAXboy]

Yet ... the video recording the pax leaving on the safety stairs show no sign of fuel or foam under the aircraft. The area some are talking about - was dry. The area where a chute from L1 door would have opened, was dry.

[Machinbird]

The crew probably knew it wouldn't as the fire crew outside would have reported that the fire was at the engine and outboard and all smoke and fire was blowing away from the fuselage. They may even have added advice not to evacuate to give them full access to put the fire out. The examples you quote are precisely the opposite with fire being blown onto the fuselage.
In the below picture despite the favorable cross wind from the left, the soot goes right up to the corner of the TE Flap cutout in the wing and the entire Flap appears to be trashed. That is all well inboard of the engine pylon.

Then there is the non-linearity factor that fires exhibit. One minute you are fighting a localized fire, the next instant something explodes in your face like the wing on the Emirates T7. No one can really predict exactly how a particular fire is going to behave in advance. They are as predictable as a pet rattlesnake.

[lomapaseo]

It's not the soot that worry me, it's the stuff towards the center (ala the bunsen burner effect in school labs)

Flickering flame is one thing but steady concentrated flame is what causes metal burnthrough.

Much of the visible damage in today's planes is the non-metalics losing their binders

[parabellum]

I have no idea why you are so heavily favoring staying in a wildly burning aircraft.


Henra - Please go back and read all my posts again. I have only advocated making sure the crew have made use of all the information available to them before making their decision and in this case information from the fire fighters on the scene, quickly, is likely to be valuable. I have also criticised people who would evacuate regardless of available information, as these are the people who may well turn an incident into a catastrophe. There are incidents where the decision to evacuate is obvious, Manchester and Dubai for example, Manchester the engine had blown up and Dubai was a catastrophic crash.




PAXboy - The fact that any area may look dry doesn't mean that there is no fuel present, the top surface of the runway is deliberately porous to allow rapid dispersal of moisture.

[etudiant]

As SLF, I fear this precedent will encourage crews to sit tight and wait in other burning airplanes rather than to exit asap. That is a very damaging shift imho.
Will it take a planeload of dead people for the priorities to be reset?


As is, even though all went well, I would be more reluctant to use this carrier, because the safety of the passengers does not appear to have been the primary consideration.

[armchairpilot94116]

1 + 1 = 2
2 + 2 = 4
FIRE = EVAC

Any other reasoning is illogical
and in the case of fire tempts fate.

[Julio747]

But, the right answer is staring you in the face if you have seen the vids, inside and outside.

Dont tell me the RFF said stay put, we will control it, when they were driving away from the burning a/c to stay on tarmac. No way.

The pilots can use the tail cam. Even the tower could see it from afar (hence the fire crew without request). And as the FC has legs, they can eyeball the situation any time they want to.

So sorry, no excuses. Bad call. Lucky escape.

[gatbusdriver]

I truly am sorry. I clearly have been missing the facts.

So when were the flight crew aware of the state of their aeroplane?

The only reason I ask is I'm just trying to learn from the event.

[parabellum]

hence the fire crew without request


Already tried to explain it to you once Julio747 but you seem impervious to anything except your own, totally fact free, assessment.


Once the a/c turned back the engineers would have been studying the telemetry from the aircraft and may well have advised fire and/or tower of a possible fuel leak. We have no idea at all of the communication between the aircraft and Singapore Ops/ATC/Fire services, from the time it turned back until it spoke to Singapore tower on arrival, none whatsoever.

[fox niner]

Are they going to fix her, or is it a write-off?

[maligno]

i really expect that "captain" get his license cancelled with immediate effect...ZERO judgement

[Julio747]

I truly am sorry. I clearly have been missing the facts.

So when were the flight crew aware of the state of their aeroplane?

The only reason I ask is I'm just trying to learn from the event.



But for sure the cc could see it before wheels stop. Are you suggesting they may not have informed the flight deck?

The RFF was on the move before wheels stop. Did they omit to tell anyone do you think?

Each of these is highly unlikely.

Even in the absence of any comms, the RFF racing past might have been a clue that something was awry.

And as at was twilight, the huge glow on the RHS might have been another clue.

The fact that they stopped on the runway and didn't taxi to gate suggests maybe they knew they had a fire before wheels stop. What do you think, GBD?

So you are right. I dont know for sure when they first learnt of the fire. I am making educated guesses and opining. I will be happy to admit I was wrong if it turns out the FD was blissfully unaware of the raging inferno because they were busy with other stuff and simply forgot to clear the runway....

[readywhenreaching]

Singapore AAIB released an interim statement (http://www.mot.gov.sg/uploadedFiles/Ministry_of_Transport/Content_Blocks/About_MOT/Air_Transport/AAIB/B777-300ER%20Engine%20Fire.%20Interim%20Statement%20-%202016-07-29.pdf) (pdf)

AAIB:
3. The investigation is still in the preliminary stage. These are the key findings so
far:
• Fuel was found present in the oil system of the right engine, which is not a
normal condition. Investigators have determined that fuel entered the oil
system as a result of a crack in a tube in the engine’s main fuel oil heat
exchanger (MFOHE).
• GE Aviation had issued a Service Bulletin (SB) in December 2014 identifying
certain MFOHEs to be removed from the engines, inspected for cracks in the
fuel tubes, and for repair actions and improvement works to be undertaken.
GE Aviation had recommended that the actions called for by the SB be
carried out no later than the next occasion when the engine is sent for
maintenance work in an engine shop.
• The engine of flight SQ368 which had caught fire had last undergone an
engine shop visit in March 2014, just before the SB was issued.
4. The AAIB has issued interim safety recommendations to the following parties:
• GE Aviation, as the engine manufacturer and holder of the engine type
certificate, to review the need to accelerate the implementation of the
recommendations in its main fuel oil heat exchanger Service Bulletin of
December 2014, to prevent another fire or other hazardous incident from
arising as a result of fuel leakage into the engine oil system.
The information provided herein is of an interim nature. Readers are
advised that new information may become available that may alter this
interim statement prior to the publication of the Final report
• The Boeing Company, as the aircraft manufacturer, to review the need for
operational procedures in the event a flight crew encounters a similar fuel
leak situation in flight.
• US Federal Aviation Administration
o to require the Boeing Company to review the need for operational
procedures in the event a flight crew encounters a similar fuel leak
situation in flight; and
o to require GE Aviation to review the need to accelerate the implementation
of the recommendations in its main fuel oil heat exchanger Service
Bulletin of December 2014.

[HighAndFlighty]

But props to tdracer for correctly picking the heat exchanger as the culprit in post #229.

[Julio747]

That report was issued long ago, 3rd august as I recall, and posted long ago...

And point 5 is missing, other factors related to the incident are still being investigated.

Please try to read the thread and keep up.

[bigal cessna]

They say the investigation will take months - download the engine data computer-- cvr -- the flight recorder-- or -----turn on the fuel boost pumps and see where the leak is ----

[sabenaboy]

Any news yet about the investigation of this incident and the decision not to evacuate?

[oldchina]

Any news yet about the investigation of this incident and the decision not to evacuate?

Probably plenty of "news" for those who really need to know ...

[sabenaboy]

Probably plenty of "news" for those who really need to know...
We discussed the Singapore368 incident in a recurrent CRM course last week in our company. All the crewmembers (cabin and cockpit) that were attending were amazed that there was no evacuation. I think this case will be interesting for all cabin and flight crews! Was there a good reason NOT to evacuate or were there mistakes made? (communication)

One could say that all crewmembers wordwide "really" needs to know!
The outcome and final report will become a very interesting CRM learning tool!

[akaSylvia]

The outcome and final report will become a very interesting CRM learning tool!

I agree. I'm glad they are taking their time though; as always, it would be too easy to just write it up as crew failure and not bother to dig any deeper.

[Non-Driver]

Final Report out:

https://www.mot.gov.sg/uploadedFiles/Ministry_of_Transport/Content_Blocks/About_MOT/Air_Transport/AAIB/CAS122%20-%20B777-300ER%20Registration%209V-SWB%20Engine%20%20Fire%2027%20Jun%2016%20Final%20Report.pdf

[rog747]

:rolleyes: up to page 17 good grief

as for page 18 - blimey


excuse me if you are told by ATC then again by the AFC that you have a big fire just as you are coming to a halt plus the CC are calling you like mad saying heat in the cabin but you have no fire warning in the cockpit do you still dither on an EVAC decision when you have already made your mind up it seems ?
then eventually taking instructions to not do so from the AFC who by the way have kept you hanging on for what seems an age

i knew this would be the outcome notwithstanding the RH offending engine was not shut down during the return to SIN despite showing several signs saying I'm not very well

[andrasz]

https://www.mot.gov.sg/uploadedFiles/Ministry_of_Transport/Content_Blocks/About_MOT/Air_Transport/AAIB/CAS122%20-%20B777-300ER%20Registration%209V-SWB%20Engine%20%20Fire%2027%20Jun%2016%20Final%20Report.pdf

As expected the report delicately tiptoes around all the questions we have been asking, not offering too many answers.

[andycba]

I for one will not fly Singapore again based on this...

[lomapaseo]

Excellent report in addressing lessons learned against the certification requirements.

I would trust the implementation across the world fleet and I would not hesitate to fly any aircraft that embraces these recommendations.

If the CAAM (continued airworthiness Assessment methodology) process really works the way it was intended then all other engine manufacturers and installers will have also taken a re-look for possible actions in their fleets

[WingNut60]

The airline operator review its training programme to develop its pilots’
ability to always consider alternatives and other resources when they
encounter a situation that is not dealt with by any checklist.
[TSIB Recommendation RA-2017-012]

Somewhat of a paradox .... follow the procedures but think outside the box.
Not a strong point anywhere in Asia.

[Octane]

Why wouldn't you shut down an obviously unhealthy engine? Furthermore, why wasn't the failure to do so not discussed in the report? I don't get it..

[Fluke]

Thanks for posting the report.


On first read I feel the report is ok. Sure it tiptoes but we shouldn't be here to throw stones.
I am a little concerned with the overriding reliance of the commander/crew on the fire chief's recommendations. I know in Singapore, ATC can be very disrupting in a non normal situation and that they have no knowledge of the term "standby". I can guess the fire crews are of probably the same ilk.
I know LHR has a discrete fire frequency but was not aware this was also the procedure at Changi.

Also assuming the augmenting crew were in the cockpit, perhaps they could be more involved with communications with the cabin. However this accident could easily have occurred with a 2 man crew and our drills should cover all situations.

I think I will stick with my training, use the fire chief to confirm the presence of the fire ( no fire warning in the aircraft ) and just evacuate.

[Dropp the Pilot]

If we could just take a minute before you run off for your pitchforks and torches, the mob might wish to know that there are no (NO) procedures for low oil quantity indication on the 777.

[notapilot15]

No procedure for low oil warning
Ignored fuel disagreement warning
Crew didn't have a clue
Ops told to proceed
Ops didn't want to shutdown engine
FC put PIC on standby for 4 minutes
FC says disembark, do not evacuate.

AAIB says, PIC shouldn't depend on FC.

Going forward every PIC has to make a judgement call on whether to trust FC or not.

Passengers should hug their loved ones again and celebrate their second chance.

[framer]

FC is just one more bit of information. Probably quite good information but just another source to use to make your decision.

[sierra5913]

FC is just one more bit of information. Probably quite good information but just another source to use to make your decision.

Agreed. But can we deduce from the conversation, as written on the report, that the Capt pretty much offloaded that decision to the FC?

[Another Number]

I found this concerning:
There was one camera installed on the leading edge of the right
horizontal stabiliser. This camera could provide the flight crew with a
vantage view of the fire.
According to the flight crew, they would usually switch on this camera
system when they are taxiing the aircraft, as required by the operating
procedures. However, in this occurrence, they did not switch on the
system because they had not reached the taxiing phase as they had
been instructed by ATC to stop at the intersection between the runway
and rapid exit taxiway E7Other than that, and points already mentioned, I think the "sniff test" is a cop-out, and that the MFOHE checks and replacements should be completed by "yesterday".

[Sqwak7700]

Ops told to proceed
Ops didn't want to shutdown engine
FC put PIC on standby for 4 minutes
FC says disembark, do not evacuate.

AAIB says, PIC shouldn't depend on FC.

You should always be careful trusting the opinion of people with no skin in the game.

There is a very important link between crew and passengers, and that is being on the same boat. Instead of listening to so much advise from those safely on the ground, the crew should have listened to their instincts.

I can guarantee you their instincts where spot on and I am sure when the full CVR transcript is released (ha!) you will clearly see it.

[wheels_down]

Pilots are not Pilots anymore.

Now Flying Computer Managers.

[Bug Smasher Smasher]

FC is just one more bit of information. Probably quite good information but just another source to use to make your decision.
Spot on. The FC is just one source of information.
He's not the source of a decision.

[rcsa]

I for one will not fly Singapore again based on this...

Andy - why?

[darkbarly]

A good reminder that your average jet engine pumps a lot more fuel around its internal plumbing than is actually metered and used. Consequently the fuel flow per hour indication is misleading for leak scenario purposes or checklists. And a massive leak source mask.

Allowing the engine to run with low oil Qty + reduced oil pressure + No Procedure + fumes + vibes + errant fuel status would worry me. Me + worry = Fuel off + land.

As an aside, sniffing used synthetic engine oil is a recommended practise for engineers, really?

[PAXboy]

I do think that PPRuNErs can pat themselves on the back. When the accident occured, the MFOHE was identified in here fairly quickly as a likely culprit. Also, I think, the cameras as a source of information.

[greybeard]

Possible ETOPS fleet change if it was shut down, statistics rule?

:confused:

[YRP]

It is interesting how the report dances around the decision to evacuate or not but avoids reaching a conclusion on that.

It comments on the crew not getting as much info as they could have but holds back on the decision itself.

The transcript is interesting: fire commander reports that fire is pretty big and that he is attempting to control it. It is some time before it is reported under control. It is hard to believe that first transmission from the FC didn't lead to evac. Maybe the crew made the right call, but it must have taken extreme coolness to stay put at that point.

[Sailvi767]

Andy - why?

Perhaps because they had a Captain onboard who appears incapable of making any decision.

[KelvinD]

I read it differently. All the combined brains of the technical department failed to spot symptoms of a problem that had been known about for a couple of years. So, if they didn't spot it, what chance did the pilot have with his limited resources (while managing an ailing aircraft at the same time)?
The bloke in charge of the fire service was accurate and up to date with his updates and was obviously very sensitive to the possibility that an evacuation via slides may not have been the safest option for the passengers. Presumably, he was aware of the potential danger of pooled, unburned fuel on the ground below the aircraft.
At no stage were the cabin crew calling like mad, telling the pilot there was heat. The pilot was busy attending to all the other things going on so the CC told their boss who told the IFS who can't remember if he passed that on to the flight deck. I would take that to mean "No, I didn't pass it on".
As for "shutting down an unhealthy engine"; that is discussed in the report and the answer seems to be that there was only 1 indication that was anything wrong, a low oil quantity alert. Other indicators showed it may be a defective indication as temperatures and oil pressures were OK.
The bottom line is not some sort of failure on the part of either the crew, the fire service or anyone else. The real culprit is the engine manufacturer who continued using the same fuel cooling system that had been shown to have failed more than once in the past. They had acknowledged this and issued a bulletin saying it should be checked the next time the engine is for maintenance and this was issued after the engine's last maintenance was done..

[PT6Driver]

KelvinD.
The cabin crew were trying to contact the flight deck:
During the initial stages of the fire, several cabin crew members tried to contact the flight crew through the cabin interphone. However, only one call was answered by a flight crew member and he informed the cabin crew that they were aware of the situation and were handling it.

[PT6Driver]

Touchdown was at 0649. The fire was observed approx 20 seconds later. The fire service arrived 57 seconds after the aircraft stopped. ( a very quick and fortuitous time). The fire was put out at 0653 some 4 minutes after initiation.
Some may say a very quick time however to put that in perspective during the Manchester fire the hull was breached betwean 5 and 20 seconds after stopping and the windows gave within a minute of stopping.
Approx 5 Passengers had died from the effect of the flames and heat (the rest from the effects of the toxic smoke) by, at the latest 1:30 minutes after stopping.
Compare this to the timeline of the Singapore incident and work out what they were chatting about at that point.

[PT6Driver]

The Captain knows he has a fire despite not having any fire indications in the cockpit, because the tower has told him so.
Apart from giving a "cabin crew at stations" call ( or the Singapore equivalent) what does the crew do?
Contact is established with the FC at 0651:50 around 2 minutes after being told of a fire. No attempt to contact the cabin and establish what they could see. No attempt to turn on the video. No reported attempt to ask the tower.
Instead wait for the FC who inspite of saying the fire is a big one recomends disembarkation not evacuation. The FC was confident he would get the fire under control, however fire is unpredictable. Just look at what happened to that poor firefighter who lost his life in Dubai.
The Captain who is initially evacuation minded, defers to the FC and effectively absolves himself of responsibility and allows the FC to become the decision maker. Perhaps he woild like to donate his salary to the FC as well.

[DingerX]

As for "shutting down an unhealthy engine"; that is discussed in the report and the answer seems to be that there was only 1 indication that was anything wrong, a low oil quantity alert. Other indicators showed it may be a defective indication as temperatures and oil pressures were OK.
I beg to differ with your alternative reading. Per the report, the first indication was a low oil quantity, with fluctuations in oil pressure and a higher oil temperature (in normal range, but when taken together with low oil quantity tell a story).

And it's not true that the crew offloaded all their decisions to the ground:
At 0328 hrs, the engineer sent a message via the Aircraft Communication and Reporting System (ACARS) to the flight crew informing them about the recommendation by the technical services personnel for the aircraft to return to Singapore and requesting them to contact the engineering
control centre.

The crew then spent 20 minutes arguing to continue to Milan. After that, they got engine vibrations and made another phone call, presumably to convince their colleagues that they could still make it to Milan with the #2 engine at idle. In the middle of the debate, they get a call from the back that the cabin is filling with smoke. So then they agree to return, at #2 idle and bleed off, but leaving the pack on.
Only on a second call do they switch the pack off.

They repeatedly told ATC that they had no problem, the FUEL DISAGREE message they disagreed with, and, when the FC told them to disembark from the left side of their burning aircraft, they wanted to make absolutely sure that they weren't supposed to evacuate. Heck, they didn't even use the bottles until ARFF asked them about it. Probably didn't think they were necessary.

I'm just sayin'. That's not offloading decision-making.

My favorite recommendation:
The aircraft manufacturer evaluate the need for providing guidance on
how to perform fuel leak check with the engines operated at unequal
thrust. [TSIB Recommendation RA-2017-023]

[tdracer]

My favorite recommendation:

Quote:
The aircraft manufacturer evaluate the need for providing guidance on
how to perform fuel leak check with the engines operated at unequal
thrust. [TSIB Recommendation RA-2017-023]
Dinger, there already is a system along that line (not sure if it's been fully implemented through the Boeing fleet yet but it was an FAA mandate). Basically, it compares fuel used (according to the engine fuel flow indications) with fuel remaining (according to FQIS). If it differs significantly it sets an EICAS message. Although it wouldn't catch a leak downstream of the fuel flow meter, it would help indicate a fuel leak of this type (fuel/oil heat exchanger). However the problem is neither the FQIS or the fuel flow meter systems are super accurate, so the limits are set rather loose to avoid nuisance alerts.

[expat400]

For me the big question is:

If you have operated an engine in idle for a long time before landing due to suspected damage, why would you use the reverser on that engine?

If they hadn't used the reverser this thread would never happened.

[DingerX]

tdracer, maybe I'm misunderstanding something, since it sounds like what you are describing is the Calculated fuel that, in fact, did catch the leak and did send an EICAS message, but was ignored.

I find it interesting to work through the logic. Here's what the report says:

At 0521 hrs, the flight crew received a FUEL DISAGREE message on the EICAS. The flight crew performed the FUEL DISAGREE checklist. The FUEL DISAGREE checklist suggested four scenarios in which a fuel leak should be suspected and when the flight crew should perform the FUEL LEAK checklist. One such scenario is when the TOTALIZER fuel quantity is less than the CALCULATED.
And the footnote:
The CALCULATED fuel quantity is determined by the flight management computer by subtracting the fuel used (calculated basing on fuel flow figures as measured by sensors in the engines) from the total fuel quantity at the start of the flight fuel quantity.

So, as I understand it, the totalizer and the calculated (via FQIS) numbers disagreed, and it kicked a message. The flight crew disregarded the message, because they assumed that the Calculated quantity was the FMS' version of the planned fuel remaining quantity, based on predicted performance according to what planned engine settings were and the aircraft's route. (Does the FMC use Calculated fuel as the basis for its Arrival Fuel Prediction?)

Since the FMS did not have an option for calculating performance based on one engine running at idle, they ran the numbers with one engine INOP.

So they figured that since

A) earlier, they found themselves with 600 kg more fuel than planned
B) the FMS was calculating performance for a route they were not taking, and
C) the right engine was consuming fuel at idle, rather than being shut down, as the FMS thought

that the FUEL DISAGREE message was spurious. They did some back-of-the-envelope calculations and decided they didn't need to do a fuel leak check, presumably because that would involve having to shut their engine down.


In other words, when they got the message, they made up a definition of "CALCULATED" fuel where the calculations were based on the FMS instead of the EQIS. In their imaginary world, there wasn't a problem.

And that's why I'm amused by the recommendation. Someone no doubt who is not as ignorant as I will gladly explain to me:

1. Outside of ETOPS certification, why on a twin with one good engine and near several suitable airports, would it make more sense to reduce a malfunctioning engine to idle than to shut it down?
2. What the benefit is of a fuel leak test with both engines operating, but asymmetrically? How often does a FUEL DISAGREE EICAS message pop up on an already-malfunctioning engine without there being a fuel leak?


In the report's defense, it does make the comment:
During the initial training to operate this aircraft, the operator provides training to all its pilots to understand the requirements of the FUEL
DISAGREE checklist. However, in this case, the flight crew appeared to have misinterpreted certain requirements of this checklist even though they have undergone the training.

[PT6Driver]

Presumably if they had shut down the engine they would have needed to follow the checklist and land at the nearest suitable airport which would not have been Singapore. The recommendations from base were no doubt influenced by the same desire to get the aircraft back to base.

[procede]

1. Outside of ETOPS certification, why on a twin with one good engine and near several suitable airports, would it make more sense to reduce a malfunctioning engine to idle than to shut it down?

Engine failure lesson 1: An engine at idle still produces some electricy, hydraulics, bleed air and less drag. It is always better to have it at idle than to shut it down. You only shut it down if you really, really have to.

[megan]

Didn't fly big machinery, but a tale of small twin turbine. In cruise and oil pressure dropped into the yellow and temp reduction of 10°. Reduced power to idle and pressure was in the bottom of allowable. No APU, kept engine running so as to have auxiliaries available, and should our "good" engine decide to take a holiday. Upon landing and shutting down ramp advised of a puddle of oil on the tarmac. Checking the dipstick no oil was evident. Cause, a split in the reservoir to pump line. So while the engine was running it was sucking in air and aerating the oil, explaining the drop in both pressure and temp. The instant of shutting down all the oil drained out of the split.

Earlier in life had been given the advice, "never shut down an engine capable of providing power".

[david1300]

This video from inside the cabin shows a remarkably calm environment. (Certainly less panicky than some posters on here)
V0k7Kqd82EY

[wiggy]

Dinger

The flight crew disregarded the message, because they assumed that the Calculated quantity was the FMS' version of the planned fuel remaining quantity, based on predicted performance according to what planned engine settings were and the aircraft's route.)


The fuel disagree/leak checklists for the 777 are quite explicit that "calculated" for fault finding/QRH purposes is the instantaneous calculated on board fuel ( i.e. initial onload minus the integrated flow), and that is the number to be compared with the FQIS tanks totaliser figure; both are displayed for easy comparison, right next to each other, on FMS page Progress 2 (in our case). Since they are instantaneous, not predicted figures, there's no need for any future performance input/knowledge of route, etc.

On most flights the two figures will be well within a within a tonne of each other. Now from the report it seems the SIN crew had a 4 tonne mismatch (!!!!) so unfortunately it looks like they well and truely managed to over analyse things and talked themselves out of actioning the Fuel Leak checklist...however...

Don't want to offend tdracer or Boeing but you mention the comment in the report about the training of the fuel disagree/fuel leak checklist, and I'd say that could well be a fair cop.......FWIW for the 777 this has been a very "hot" item for trainers for a while at at least one outfit I know of. The checklists are somewhat protracted (for good reason), convoluted, but there are one or two interestingly worded questions and as a result using the electronic checklist it is quite easy to end up ticking the wrong box and going up a blind or misleading alley, or not going up an alley at all (such as going into the Fuel imbalance Checklist but then not going on to action the Fuel Leak Checklist....when in fact taking a step back it might be obvious it is the sensible thing to do).....

Does the FMC use Calculated fuel as the basis for its Arrival Fuel Prediction?)

FWIW Arrival fuel prediction (FMS progress page 1) does use the calculated fuel minus predicted burn, winds, temps etc etc. There is an option, rarely used to switch to using the FQIS quantity..but in any event you shouldn't be using that predicted figure arrival as a decider for Fuel leak analysis, it's the instantaneous calculated fuel vs. gauged fuel tanks that matters..

[unobtanium]

It is interesting how the report dances around the decision to evacuate or not but avoids reaching a conclusion on that.



Anyone familiar with the work culture in Singapore, knows the answer to that question. I wonder what the status of the crew is at the moment.

[andrasz]

Concur 100%. I would extend the question to the status of the FC as well...

[andycba]

@RCSA - it is simple. The risks of fire are so unpredictable and great, and the rapidity at which toxic effects can spread, is that the decision not to evacuate even with this 'safe' outcome is far worse than evacuating immediately before the option is taken away. BA in Vegas is a sterling example of how to do it properly. Singapore were lucky. Aviation does not need lucky.

[parabellum]

Absolutely no similarities between the BA incident in Las Vegas and the SQ incident at Changi - the evacuation in Las Vegas wasn't so hot either, pax walking away with their carry on luggage, imagine the congestion in the aisles that must have caused.

[RatherBeFlying]

You would think that after the Sewol capsize, where pax were instructed to remain their cabins and were later found drowned, that captains would be more inclined to evacuate before it's too late.

The lesson has not been learned in Singapore.

Next time the luck might not hold.

[Octane]

Would a windmilling engine at cruise (i.e. shut down) still produce some degree of hydraulic pressure and electrical generation? What sort of speed would the engine be rotating at compared to idle? Or does a complete shutdown isolate everything? Just trying to understand what is to be gained by leaving a sick engine running at idle for hours. Apologies if it's a daft question...

[wiggy]

Just trying to understand what is to be gained by leaving a sick engine running at idle for hours. Apologies if it's a daft question...


On a general point one consideration certainly on a twin is if the "sick" engine is still capable in extremis of producing useable thrust if needed then it might be sensible to leave it running......as long as procedures don't say otherwise.

However in the context of this incident they had more than a slightly "sick" engine...certainly as I read the report if the crew had gone through the Fuel Disagree checklist fully and correctly they would have been led onwards into actioning the Fuel Leak checklist, at which point they hopefully would have realised that the engine was more than just slightly "sick". The QRH would have been telling the crew they had an engine Fuel Leak and that they needed to shut it down, not leave it at idle...but for reasons various they never got as far as the Fuel Leak checklist (see my previous comment about the 777 checklist).

[Octane]

Thanks Wiggy,
What about the first part of my question?

[wiggy]

TBH I'd be sticking my neck out offering up numbers since I haven't seen a real windmilling engine in a long long time :) and never on a real 777. Might be one for those who do or who involved in airtests to answer.

[tdracer]

Would a windmilling engine at cruise (i.e. shut down) still produce some degree of hydraulic pressure and electrical generation? What sort of speed would the engine be rotating at compared to idle?
A windmilling engine can produce some hydraulic pressure - in fact some aircraft can get away without a RAT because in an all-engine out condition there is sufficient hydraulic pressure from the windmilling engines to allow basic aircraft control (the 747-400 (and earlier 747 models) fall into this category - however the 747-8 needs a RAT). However the GE90 on the 777 does not produce much hydraulic pressure when windmilling (big fan, little core means relatively low N2 windmill speeds) - hence the 777 needs a RAT. Some newer installations (e.g. the GEnx) actually disconnect the hydraulic pump for an engine shut-down in flight to increase the windmill N2 sufficiently to make a windmill re-start physically possible.
There is no meaningful electrical generation on most windmilling engines - once N2 (N3) drops below 50%, the IDG drive disconnects.

[Octane]

Hi td,

Thanks for the detailed response to my question. Curiosity satisfied, much appreciated.

Related to this thread, I sent this to my brother a while back. (He's the real pilot, I'm the armchair pilot as you may have gathered)

"If those guys were driving their car home from work and the instruments were giving odd indications, the engine started vibrating and producing fumes I'm sure they'd pull over and turn the thing off 100% of the time. Wouldn't they? I doubt they'd keep driving home hoping she'll be right mate...?!" Am I being a bit harsh?

Bro hasn't replied, he's a bit busy. In the middle of a B777 endorsement ironically! :-)
Loads of SIM work of course but he says the 777 is easier to fly than the 737. One thing I found a bit astonishing, he has yet to see/ touch/ feel/ kick the tyres of a real 777 aircraft. The 1st time he gets to, is when he flies one to LA!


That's why I thought I'd ask you gentleman/ ladies all those questions..

[wiggy]

Thanks tdracer, interesting stuff.

Octane:


"If those guys were driving their car home from work and the instruments were giving odd indications, the engine started vibrating and producing fumes I'm sure they'd pull over and turn the thing off 100% of the time. Wouldn't they? I doubt they'd keep driving home hoping she'll be right mate...?!" Am I being a bit harsh?


Fair point, but companies these days don't like folks going off piste (especially on a twin) and shutting engines down if it is not a QRH requirement or a catastrophic problem outside the scope of the QRH.

Just out of interest if your brother has time ( though I'm guessing he won"t) ask him to have a look at the report and the 777 QRH, look at the early symptoms of engine issues on the SQ flight and see which relevant checklist has a requirement to shut the miss behaving engine down. FWIW the crew hadn't had a low oil pressure or high oil temp EICAS warning, the vibrations don't add up to being severe and were the flight crew really aware how severe was the fumes smell was in the cabin?

Ultimately it seems the crew thought they in conjunction with the company engineers on satcom had solved or at least contained the problem and hadn't had to shut the engine down.....I suspect the real "**** me " moment might have occurred quite quickly thereafter if they had run the Fuel disagree/Leak checklists properly though the one engine at idle would have might have delayed diagnosis (sorry to bring that up again but TBF it is also mentioned in the report's safety recommendations) but they never got there, possibly because to some extent they got sidetracked talking to "company" and perhaps convinced by the ground that the engine was ok.

There's a danger to modern comms...

[expat400]

Once again. The problem here wasn't that they kept the engine running. I would have done the same (unless told different by the QRH). But I can't understand why they used it for reverse after landing. That is what triggered the fire, not the engine problem in itself.

[torquemada60]

I used to be a fan of Singapore Airlines. Flying all over the world. However the past few years that airline has lost my respect. Price of tickets is the highest of any airlines in Asia, service is sometimes times rude and robotic with a hint of arrogance. Accidents such as this one confirm that I made the right choice not to fly with them. And I am not alone thinking like this.

[wiggy]

The problem here wasn't that they kept the engine running. I would have done the same (unless told different by the QRH)

You want to stick by the QRH/ECL? Fair enough, absolutely no argument from me, but dare I point out that in that case you wouldn't have done the same as this crew because you would had actioned QRH/ECL fully and correctly, identified an engine fuel leak and shut the offending engine down in flight.

In short on the triple an Engine fuel leak = appropriate engine shutdown on the 777, there's no QRH option/ECL option to keep running at idle and land but not use reverse.

[expat400]

Of course Wiggy. No arguments about that.

[wiggy]

Sorry, expat we might have crossed in editing.


TBH I do have some sympathy with the SQ crew, it has been shown in the sim that it is entirely possible for anybody to make a complete dogs dinner of the 777 Fuel Disagree/Fuel leak checklist, some of it is down to language used, some of it is being suckered in by logic branches produced by the ECL( Electronic CheckList). You really have to have a hard think about the exact question asked, the fuel system itself and what the checklist is trying to achieve before clicking the "yes" or "no" boxes.

[sudden twang]

I'm with Wiggy on this one. The report doesn't suggest that the SFF ECL was run. If it had been then it would have called for a diversion.