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Final report on CX780 accident published

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Final report on CX780 accident published

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Old 5th Sep 2013, 01:51
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Final report on CX780 accident published

English isn't perfect, but makes for interesting reading nevertheless.

Link to page:

Civil Aviation Department - Reports

Link to report .pdf:

http://www.cad.gov.hk/reports/2%20Fi...0compliant.pdf
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Old 5th Sep 2013, 03:10
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As usual an excellent investigation and report.

I sense three areas that might elicit discussion on this board since no design changes are anticipated to eliminate this type of failure.

The continued possibility that fuel contamination may occur in the future if the fueling recommendations are not adhered to.

The minimal actions that the crew may employ in some phases of flight if the contamination should cause a sudden onset of engine control problems.

The mechanism on how this type of contamination affects engine control systems.

The last item is probably only suitable in a tech forum.
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Old 5th Sep 2013, 03:15
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Ground & Other Ops Forums-Questions.

Refer to "B737 Smoking Brakes Scenario."

Then think of the casualties after this evacuation.

Fire dept attacking hot brakes with water, I think not! Classic formula for exploding tyres/wheels is NOT the environment in which to deposit the passengers.

Can we PLEASE think again on the criteria for chucking the pax down the slides and into hospital?!?!
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Old 5th Sep 2013, 03:29
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I don't wish to get drawn into a wider discussion on when/when not to evacuate, but I think it's worth pointing out that while on paper 62 pax and crew were injured during the evacuation, only one of those required hospital treatment for a broken ankle.
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Old 5th Sep 2013, 03:51
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Wow that was a good outcome from a tricky situation.
Thanks for posting it.
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Old 5th Sep 2013, 08:52
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Yep, our boys did well. I could only hope to perform as well in the future and fingers crossed I won't have to.
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Old 5th Sep 2013, 09:10
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I'm curious as to the lack of any consideration or discussion in the report of the decision (however right or wrong) to have continued the flight to destination with faults showing on engines and one engine ineffective relatively early in the flight.
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Old 5th Sep 2013, 09:20
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I'm curious as to the lack of any consideration or discussion in the report of the decision (however right or wrong) to have continued the flight to destination with faults showing on engines and one engine ineffective relatively early in the flight.
I'm curious about your lack of reading skills. Obviously you did not read the report, as those questions are addressed several times in the report.

Troll much?
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Old 5th Sep 2013, 09:42
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Phew! Reckon my pulse went up a bit as I read the History of the Flight.
I'd like to hear from the pilots themselves on the QT if, after years of hindsight, there's anything (or nothing) they'd have changed in the way they handled a not at all straightforward situation.
Well done - but, of course, that's what we expect from CX crew
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Old 5th Sep 2013, 10:28
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Well handled by the crew from reading the report.
One surprising factor was the relatively high percentage of injuries to the crew from the disembarkation, who you would think would be more practised in this exercise. The report does not go into detail of the way the injuries were sustained but I suspect they were collision injuries due to a failure of the passengers to move away from the base of the slide after evacuating the aircraft, something that rarely occurs in training and currency checks.

Last edited by ROSUN; 5th Sep 2013 at 10:31.
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Old 5th Sep 2013, 11:10
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I know I'm swimming upstream but I really hope we can avoid the typical PPRuNe second guessing of the crew's actions that usually accompany such reports. Those boys did a whale of a job in a situation none of us has ever even contemplated, never mind being trained for it.
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Old 5th Sep 2013, 11:58
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Tell me again about the coming wave of remotely-piloted airliners.....
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Old 5th Sep 2013, 13:57
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Why didn't he shut down that one stuck at hi power?
Seems like a no brainer, duh!
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Old 5th Sep 2013, 14:06
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Great flying, job well done!
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Old 5th Sep 2013, 14:23
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Superb bit of technical writing, even I understood it.
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Old 5th Sep 2013, 14:36
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Killaroo,
The earlier publication “Accident Bulletin 1/2011 (An update Bulletin to Accident Bulletins 1/2010 and 3/2010)”
includes a paragraph 5, copied below (my bold):
“5. At 0530 hr, the ECAM caution message “ENG 1 STALL” was annunciated. The commander moved the No. 1 thrust lever to idle position. He then tested the engines by gently advancing and retarding the thrust levers. However, only No. 1 engine responded with stepped increase in N1 and did not reduce when the thrust lever was retarded. No. 2 engine remained at idle during the test. In an attempt to recover No. 2 engine control, the crew carried out a shutdown and restart on No. 2 engine in accordance with the Flight Crew Operating Manual (FCOM) procedures. However, the engine could only operate at sub-idle condition for the remainder of the flight. The No. 1 engine was stuck at approximately 74% N1 during the approach and reduced to about 70% N1 at touchdown. The No. 2 engine remained stuck at about 17% N1 throughout the approach and landing.”


One can only speculate as to the engine delivered and aircraft required thrust behaviour and consequences that would occur if Engine 1 had also been shutdown.


J.O. said it rather well
Those boys did a whale of a job in a situation none of us has ever even contemplated, never mind being trained for it.
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Old 5th Sep 2013, 15:01
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When reading it one has to remember that if you were in that situation, you don't know what will happen next and No. 1 engine may have decreased down to 17% or lower at any point.

You've no idea why what's happened has happened, and you don't know how much worse it may get. Hand flying under that pressure is hard work, when you're so focused on the why and what next.
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Old 5th Sep 2013, 15:42
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required thrust behaviour and consequences that would occur if Engine 1 had also been shutdown.
- not much to 'speculate' on, really - it would probably have crashed.

A great piece of flying in circumstances that must have been very difficult to determine.
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Old 5th Sep 2013, 15:44
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Sqwak7700

I'm curious as to the lack of any consideration or discussion in the report of the decision (however right or wrong) to have continued the flight to destination with faults showing on engines and one engine ineffective relatively early in the flight.
I'm curious about your lack of reading skills. Obviously you did not read the report, as those questions are addressed several times in the report.

Troll much?
Thank you for your concern. Well my reading skills aren't what they used to be when I worked on the design of the RB211 forty odd years ago, and I'm not trolling.

It's a long report, I've not read every word. I see the first maintenance engineer gave advice and based on that the crew made the decision to continue. By the time ME2 was involved VHHH was clearly the only possibility. I still haven't found any discussion - just a one liner "reasonable". Maybe no more needs to be said.

Much trust in one engine flying. Pleased to have been involved in the early stages of design of such a reliable power plant. However, for right or for wrong I would have been very tempted to head straight for Singapore. In hindsight the decision to continue to destination proved to be problematic. Maybe I'm being oversensitive living just a stone's throw from Kegworth.
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Old 5th Sep 2013, 15:58
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I'd like to hear from the pilots themselves on the QT if, after years of hindsight, there's anything (or nothing) they'd have changed in the way they handled a not at all straightforward situation.
I think in hindsight, they would have landed ASPAP (Red!). However, they didn't know what was going on or how serious it was at the time, and I'm not sure I would have handled it any differently.



But, it was very well handled. Good show chaps!
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