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SWA1380 - diversion to KPHL after engine event

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SWA1380 - diversion to KPHL after engine event

Old 18th Apr 2018, 09:42
  #121 (permalink)  
 
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Originally Posted by Feathered;10121765On the other hand, I highly recommend reading (United Airlines) [U
Flight 232: A Story of Disaster and Survival[/U], by Laurence Gonzales et al for in-depth reporting on a fan blade failure, what caused the failure, why it was not predicted or detected in advance (the underlying fault had existed in that blade for almost 2 decades before the catastrophe), and the effects that it had on people
Although in fairness:

The Board determined that the probable cause of this accident was the inadequate consideration given to human factors limitations in the inspection and quality control procedures used by United Airlines' engine overhaul facility. These resulted in the failure to detect a fatigue crack originating from a previously undetected metallurgical defect located in a critical area of the titanium-alloy stage 1 fan disk that was manufactured by General Electric Aircraft Engines.
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Old 18th Apr 2018, 09:47
  #122 (permalink)  
 
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I doubt the shape of the mask really matters just as much as it doesn't matter if the mask is not completely over both the mouth and nose. It is not delivering air to breath like a scuba system, it's delivering supplemental oxygen because the atmosphere above 10,000ft ('ish) does not have enough. As long as some of the gas is getting through, you'll live until the aircraft descends to a safe height.
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Old 18th Apr 2018, 09:48
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Getting pretty sick of the OTT comments about the oxygen masks. Even if it is not over your nose just you mouth and you breath through your mouth, you'll be fine.

Why do I get the feeling the hysterical focus on this is by non-pilots?
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Old 18th Apr 2018, 10:00
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With the SW 3472 incident in 2016, plus the SW 438 incident in 2007, and now this, I think the focus of attention needs to be as much on the cowl as the blade. In two (perhaps all three) cases the root of an N1 fan-blade failed (due to fatigue on the 2016 incident) and the blade separated.

But in all three cases the blade appears to have missed the containment ring and struck the cowl instead, causing a complete failure of the cowl, and all the attendant risks with all that material flying off into the slipstream. If you look at the N1 containment ring on the recent incident, it appears to be untouched all the way around. But the cowl took the full force of the departing blade, and disintegrated.

The N1 blade is under considerable aerodynamic forward pressure in flight, and will naturally spring forwards when released. But in static testing for cerification the blade still seems to hit the containment ring. Yet here it appears that the blade moved forward enough to miss the containment ring, and strike the cowl. Perhaps an engineer on this board might suggest why that might be. Why would the forward speed of the aircraft have any effect on the trajectory of the departing blade?

ST
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Old 18th Apr 2018, 10:06
  #125 (permalink)  
 
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Originally Posted by BRE View Post
Regarding the injury and death, the reports just don't add up.

- There was a lot of blood -- the window looks clean.
- There was a heart attack.
- The victim of the heart attack died.
- The passenger who got sucked out died of her injuries.
- It has also been proposed that the fuselage got pierced in a position different from the window, so the injury and blood would have been elsewhere.


All in all, this could be one person or three who had this happen to them.
If you look at the footage aft of the damaged window on the exterior you see quite a lot if blood actually
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Old 18th Apr 2018, 10:37
  #126 (permalink)  
 
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Maybe the visual part of the mask donning demo should be changed?
FA's on a demo just put it close to their face but never show the mask sitting on the face like when actually using it. So people see and remember the distanced position and never realize they have to put it over nose and mouth as demanded in the vocal text.
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Old 18th Apr 2018, 10:40
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In the photo I have seen there are three people wearing the mask and they are all wearing it wrongly. The right reaction to this is to ask why and what can be done to improve the situation. Is it the design of mask, the training/communication or something else? What is the typical response? What factors affect it? Ideally the shape would be such that to wear it correctly is natural and comfortable and incorrectly difficult and uncomfortable. Is that possible? Can their be picures or diagrams on the mask? Should the safety briefing be changed?
I have often wondered why the pax masks are different to the ones attached to the crew portable O2 botttles.
I'm guessing its a combination of (as someone above has already said) the yellow mask is a one size fits all compromise and is quite flexible. This also allows it to fit in the combined space of the overhead PSU.

Re: Damaged window. A while back a BA 777 suffered a loss of the hydraulic ADP access panel in flight. The panel hit a couple of windows edge on, bits of the panel made it inside the cabin, presumably through the seal between window and frame. Unbelievable really but never underestimate the energy in a CRP or fibreglass panel at that sort of impact speed.
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Old 18th Apr 2018, 10:52
  #128 (permalink)  
 
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NTSB confirms blade off

Media briefing here:

Loss of fan blade confirmed, broken "right at the hub" and evidence of fatigue cracking at failure point. Sounds more and more like a carbon copy of N766SW / WN-3472 in 2016.
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Old 18th Apr 2018, 11:03
  #129 (permalink)  
 
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Maybe the visual part of the mask donning demo should be changed?
As has been correctly pointed out, you do not need to have the mask completely or tightly over both your mouth and nose. The mask is only producing oxygen to add to the ambient air the user is breathing in the cabin which is now at the same altitude as the aircraft. There are many pilots and passengers doing the same in high performance unpressurised singles and twins every day using nasal canulas - for a considerably longer duration than would be required in the emergency that occurred here.
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Old 18th Apr 2018, 11:19
  #130 (permalink)  
 
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Mythbusters did a pretty good episode about this several years ago. In short: no (in my view).
I've just rewatched it (season 1, episode 10). In their tests they couldn't get a crash test dummy to be sucked out of the plane, in any scenario.

However, they did blow out the window in a manner very similar to this one, and in the footage you can see how traumatic it would be for the passenger sitting next to it. Sucked out: no chance.
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Old 18th Apr 2018, 11:25
  #131 (permalink)  
 
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Amazing. On a PILOT chat forum not one discussion about what the pilots did. It's more like an engineers and health & safety chat forum. From page 1.
Mrdeux: in post #101 hinted at possible problems from a pilot perspective.
No doubt there was considerable panic/discomfort in the cabin. Well done to all, including pax.

I was interested looking at the LED's on left side. They would be out of sight from LHS FD. Equally the engine nacelle was out of sight. Much would depend on CA <10,000, or perhaps a pilot did have a look. That would be interesting to know. The reason I'm curious is that there have been engine blow-ups that damaged LED's and caused an uncontrollable UAP/roll when deployed. I wonder if they conducted a flight control/flap test at 10,000'. This is such a rare event, and certainly not trained for, so anything the rest of us could learn is immensely valuable.

I appreciate most would want to be the ground PDQ, but much can depend on where you are, where your target is and what the state of pax & cabin is. I'm not suggesting something so simple.
The report, which would tell us, could take a long time, but the passing of knowledge might be more beneficial if quicker.

Last edited by RAT 5; 18th Apr 2018 at 12:08.
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Old 18th Apr 2018, 11:45
  #132 (permalink)  
 
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Originally Posted by BRE View Post
Regarding the injury and death, the reports just don't add up.

- There was a lot of blood -- the window looks clean.
- There was a heart attack.
- The victim of the heart attack died.
- The passenger who got sucked out died of her injuries.
- It has also been proposed that the fuselage got pierced in a position different from the window, so the injury and blood would have been elsewhere.


All in all, this could be one person or three who had this happen to them.
Someone who has lost blood due to traumatic injury may suffer a cardiac arrest - or enter a state called PEA (pulseless electrically activity).

In the absence of a pulse, trained first aiders would likely start CPR and, if available, attach an AED (automated external defibrillator). Depending on the nature of the arrest the AED will decide whether or not to administer a shock.

All this activity would lead many bystanders to describe what they are witnessing as a "heart attack".
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Old 18th Apr 2018, 11:49
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Question from one of my senior students today.

During a rapid depressurisation (greater than 3 seconds) does the outflow valve move to full close, thereby increasing the total volume of air exiting the window hole?

Was it a rapid or an explosive decompression.

Once level at 10,000 are the a/c packs turned off on the operating engine(s) to minimise the airflow through the cabin and out the new hole.

Quite ironic as I covered this very subject in class 12 hrs before the accident.
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Old 18th Apr 2018, 11:49
  #134 (permalink)  
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Originally Posted by Rob Bamber View Post
I've just rewatched it (season 1, episode 10). In their tests they couldn't get a crash test dummy to be sucked out of the plane, in any scenario.

However, they did blow out the window in a manner very similar to this one, and in the footage you can see how traumatic it would be for the passenger sitting next to it. Sucked out: no chance.
The sense I got from the various reports is that whatever broke the window also hit & seriously injured the passenger, probably knocking her unconscious, and so her upper body ending up jammed in the window with her having been partially sucked out of it would fit with the reports...
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Old 18th Apr 2018, 11:54
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Amazing. On a PILOT chat forum not one discussion about what the pilots did. It's more like an engineers and health & safety chat forum
It’s not amazing when you consider that there are only eight of us pilots left on the forum
I’ve been considering the way I would prioritise my actions in this circumstance. There would be a lot to do with the depressurisation and engine fail/fire indications occurring simultaneously. The first 120 seconds would be very intense.
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Old 18th Apr 2018, 11:55
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I would imagine that after 10000 level off ,Memory items engine Severe damage complete, the next on the Cpt list is: Will those damaged Slats jam??
In the -800 I can see half the wing, and I suppose the shorter -700 she could see a bit more , including some damage. F5 with just extend was a excellent place to stop.
Flap/slat asymmetry CL is a long and windy process. For the superstitious: Blade 13 was the culprit!
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Old 18th Apr 2018, 11:57
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Originally Posted by RAT 5 View Post
Amazing. On a PILOT chat forum not one discussion about what the pilots did. It's more like an engineers and health & safety chat forum. From page 1.


No doubt there was considerable panic/discomfort in the cabin. Well done to all, including pax.

I was interested looking at the LED's on left side. They would be out of sight from LHS FD. Equally the engine nacelle was out of sight. Much would depend on CA <10,000, or perhaps a pilot did have a look. That would be interesting to know. The reason I'm curious is that there have been engine blow-ups that damaged LED's and caused an uncontrollable UAP/roll when deployed. I wonder if they conducted a flight control/flap test at 10,000'. This is such a rare event, and certainly not trained for, so anything the rest of us could learn is immensely valuable.

I appreciate most would want to be the ground PDQ, but much can depend on where you are, where your target is and what the state of pax & cabin is. I'm not suggesting something so simple.
The report, which would tell us, could take a long time, but the passing of knowledge might be more beneficial if quicker.
In one of the recordings I listened to I think I heard the pilots saying to the fire crew that they were putting the flaps down (my guess is in case a fire starts/evac). If they were lowered at this point, I'm wondering did they pull them up initially after landing, or land with zero or reduced flap, or land with a normal (but not full) flap setting then extend them fully?
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Old 18th Apr 2018, 12:05
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The sense I got from the various reports is that whatever broke the window also hit & seriously injured the passenger,
I've found the mythbusters on YouTube. The window test is at 3:00. Take a look and see if you think it's nessesary for debris to enter the cabin to cause serious injury.
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Old 18th Apr 2018, 12:14
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I have often wondered why the pax masks are different to the ones attached to the crew portable O2 botttles.
Depends on the airline. One I worked for the crew had the medical style clear fitted masks. FD had full face mask. The other (very large B777/A380 operator) crew bottles had the same round yellow masks as pax O2.

Yes it stinks, chemical generator hence the descriptions of 'smelt like fire(burning)'
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Old 18th Apr 2018, 12:22
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Some notes...

@RAT5
perhaps a pilot did have a look
BBC has what appears piece audio of the/a female pilot talking to ATC where she says someone "went out"... If the pilot had taken a look in the cabin at that time she would have known that the pax was held inside. She may have gone in later though.

About oxygen masks... Reports since the 1960s that the majority of pax dont read the safety cards. And in two well documented cases in each only 2 of 180 pax knew how to operate and put the mask on correctly. That is extremely serious. So hopefully the Darwin remarks wakens some people (dont get mad, please read the card). In documented cases, if they can get it working, people generally put the mask over their mouth only. Apart from pax negligence you have to wonder about the ergonomy of the design. Certainly something that experienced engineers should know about. So I am surprised that the design has not changed. Even a specific minor change could help.

Masks is not the only thing of course...same stories about taking carry on luggage, how to open doors, how to jump n slide, where are the lifevests and how do you put them on. One marine ferry case had multiple people putting on their vest the wrong way which caused the vests to put them head down, which drowned instead of saved a number of ferry passengers in a survivable situation.

NTSB said that part of the cowl was found 60-70 miles away. Wonder what the damage sequence will turn out to be. Fanblade, cowl, window.. Or cowl, fanblade, with window in parallel... The pax could have been hit by fragments or might have been injured by edges of the window construction. There is documentation of hits and fatal hits, but as far as i know not of such cuts/blunt.

On leading edge damage and risks... The Hawker HS door that struck and stuck to the horstab leading edge brought the plane down. During the investigations they found multiple cases where the door had opened, multiple cases in which the door was lost, but only that case led to an accident. I think it was a DC9 where maintenance forgot to refix the leading edge of the lefthand horstab. On the second flight after maintenance the plane lost the edge which caused LOC and crash. Both might be called freak accidents, but certainly inportant to obtain as much detailed data as possible. NTSB Docket system is the best, so we will get some information in the end.
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