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

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

Old 14th Mar 2017, 19:34
  #821 (permalink)  
 
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final report

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

Last edited by rog747; 14th Mar 2017 at 19:45.
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Old 14th Mar 2017, 23:52
  #822 (permalink)  
 
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SQ-368 (engine & wing on fire) final report out

https://www.mot.gov.sg/uploadedFiles...l%20Report.pdf

As expected the report delicately tiptoes around all the questions we have been asking, not offering too many answers.
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Old 15th Mar 2017, 00:45
  #823 (permalink)  
 
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I for one will not fly Singapore again based on this...
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Old 15th Mar 2017, 01:17
  #824 (permalink)  
 
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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
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Old 15th Mar 2017, 01:28
  #825 (permalink)  
 
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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.
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Old 15th Mar 2017, 01:37
  #826 (permalink)  
 
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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..

Last edited by Octane; 15th Mar 2017 at 03:10.
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Old 15th Mar 2017, 01:39
  #827 (permalink)  
 
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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.
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Old 15th Mar 2017, 01:54
  #828 (permalink)  
 
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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.
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Old 15th Mar 2017, 02:25
  #829 (permalink)  
 
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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.
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Old 15th Mar 2017, 03:20
  #830 (permalink)  
 
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FC is just one more bit of information. Probably quite good information but just another source to use to make your decision.
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Old 15th Mar 2017, 04:03
  #831 (permalink)  
 
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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?
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Old 15th Mar 2017, 04:45
  #832 (permalink)  
 
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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 E7
Other 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".
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Old 15th Mar 2017, 04:45
  #833 (permalink)  
 
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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.
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Old 15th Mar 2017, 05:02
  #834 (permalink)  
 
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Pilots are not Pilots anymore.

Now Flying Computer Managers.
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Old 15th Mar 2017, 08:37
  #835 (permalink)  
 
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Originally Posted by framer View Post
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.
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Old 15th Mar 2017, 09:06
  #836 (permalink)  
 
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Originally Posted by andycba View Post
I for one will not fly Singapore again based on this...
Andy - why?
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Old 15th Mar 2017, 10:35
  #837 (permalink)  
 
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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?
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Old 15th Mar 2017, 11:13
  #838 (permalink)  
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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.
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Old 15th Mar 2017, 14:15
  #839 (permalink)  
 
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Possible ETOPS fleet change if it was shut down, statistics rule?

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Old 15th Mar 2017, 16:33
  #840 (permalink)  
YRP
 
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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.
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