SQ-368 (engine & wing on fire) final report out
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
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
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]
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]
Not a strong point anywhere in Asia.
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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 02:10.
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.
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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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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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.
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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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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I found this concerning:
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".
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
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
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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.
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.
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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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?
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?
Paxing All Over The World
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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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.
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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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..
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..
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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.
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.
