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A321 AAIB Report: Mayday/emergency landing due to fuel additive error

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A321 AAIB Report: Mayday/emergency landing due to fuel additive error

Old 22nd Apr 2020, 11:26
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A321 AAIB Report: Mayday/emergency landing due to fuel additive error

As reported on the BBC: Plane engine stalled and caught fire after 'engineer's fuel error' (there's a link to the AAIB bulletin).

An A321 taking off from LGW on 26th Feb had engine problems at 500ft, leading to a Mayday call and emergency landing. Fortunately not a bad outcome, but it must have been an exciting few minutes.
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Old 22nd Apr 2020, 12:28
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The bit that surprises me is that an aircraft engineer did not know what PPM meant and apparently Googled it without finding out its proper meaning.

As usual with the press there is no recognition, and probably no understanding, of the difference between a flame as result of a surge and "caught fire".

Fortunately, as it happened just after midnight, there were no schools occupied.
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Old 22nd Apr 2020, 13:03
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So what "comedian" of an engineer did it then? Which company and who/where was the supervisor? Talk about basic error! Should not be working on aircraft, take their licence away, if they had one!
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Old 22nd Apr 2020, 13:21
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I can see how the guy made a mistake with regards to the PPM what I think is of larger concern is that he seems unaware of how to use Airnav properly.
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Old 22nd Apr 2020, 13:35
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Originally Posted by Dave Gittins View Post
The bit that surprises me is that an aircraft engineer did not know what PPM meant and apparently Googled it without finding out its proper meaning.

As usual with the press there is no recognition, and probably no understanding, of the difference between a flame as result of a surge and "caught fire".

Fortunately, as it happened just after midnight, there were no schools occupied.
And the press interpreted "A "stall" message was displayed in the cockpit three times" to mean the second engine stalled. I'm assuming the stall warnings were due to low-airspeed and high AOA.
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Old 22nd Apr 2020, 15:38
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By my reading of the AAIB Bulletin the guy who made the mistake on the concentration was not the one who had trouble using Airnav. Seemingly two different organisations. But you are right there are other things in there potentially of larger concern than the additive concentration error.
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Old 22nd Apr 2020, 15:59
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It was two different guys from two different maintenance organisations involved in this.
I'm surprised that a B1 Engineer wouldn't know what ppm meant, but it's really scary that the engineer at LGW was unable to use Airnav, pretty much everyone I know and have worked with can happily switch between Airnav and AirnavX. (personally I'm not a fan of AirnavX).
It's quite easy to screw up the effectivity in the A330 & A340 manuals in Airnav but this is due to the different weight variants, the A320 should be fairly straightforward so I've no idea how he ended up using a manual for a NEO.
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Old 22nd Apr 2020, 16:04
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Although the report does not explicitly say so, it does say at the start that it is circulated to the Cyprus authorities, otherwise seemingly uninvolved. Later it states the aircraft went to an un-named AMO in late January for a major check.

G-POWN is shown on FlightRadar as positioning Stansted to Larnaca on 20 January, no information until returning same route on 24 February. The incident flights occurred the following day, 25 February.
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Old 22nd Apr 2020, 16:43
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I know who did the heavy check in LCA (we did some work on that aircraft for them) but I've no idea who was looking after the line maintenance in LGW.
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Old 22nd Apr 2020, 17:24
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Thanks guys - on re-reading I see now that the Fuel additive procedure was done at an AMO in Europe and only the troubleshooting was done at LGW. So 2 basic errors on the same snag by 2 different engineers - what are the odds on that?.
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Old 22nd Apr 2020, 18:02
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"Plane engine stalled and caught fire"


No fire.

Titan A321 at London on Feb 26th 2020, left engine surged, engine stall indications for right engine
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Old 22nd Apr 2020, 18:39
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Originally Posted by cashash View Post
Thanks guys - on re-reading I see now that the Fuel additive procedure was done at an AMO in Europe and only the troubleshooting was done at LGW. So 2 basic errors on the same snag by 2 different engineers - what are the odds on that?.
It may or may not be significant, but the FR24 ground track for the positioning flight back from maintenance at LCA started from outside the Bird Aviation hangar.


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Old 22nd Apr 2020, 19:17
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Are we sure it was caused by a fueling error?

Were any official investigators involved complete with causes effect documentation?
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Old 22nd Apr 2020, 19:43
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Originally Posted by lomapaseo View Post
Are we sure it was caused by a fueling error?

Were any official investigators involved complete with causes effect documentation?
Er, the AAIB is UK equivalent of US NTSB,
the answer is yes to both your points, you might want to go back to the spotters balcony now and leave further discussions to grown ups

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Old 22nd Apr 2020, 19:47
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Originally Posted by lomapaseo View Post
Are we sure it was caused by a fueling error?

Were any official investigators involved complete with causes effect documentation?
Bearing in mind that it's an ongoing investigation:

"The excessive level of Kathon in the aircraft’s fuel system is suspected to have caused the subsequent problems with the aircraft’s engines, including those experienced during the incident flight. The AAIB is also aware of other events where engine performance was affected by over-dosing of fuel with biocide. Visual inspection confirmed the presence of abnormal deposits within both engines downstream of the fuel spray nozzles. The influence of the over-dosed fuel on the engines’ HMUs and other fuel system components is subject to the ongoing AAIB investigation."

https://assets.publishing.service.go...020_G-POWN.pdf
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Old 22nd Apr 2020, 20:32
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The reverend. I initially thought the same about the stall thing, but the interim report does state an engine stall warning was displayed. A new one on my, any 'Bus driver out there that could elaborate please?
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Old 22nd Apr 2020, 20:44
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interesting. so now no approved treatment for fuel tanks in EASA countries. So is anything airworthy. Also note only one mention of a tech log entry ?
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Old 22nd Apr 2020, 20:52
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Originally Posted by 2Planks View Post
The reverend. I initially thought the same about the stall thing, but the interim report does state an engine stall warning was displayed. A new one on my, any 'Bus driver out there that could elaborate please?
Not unique to Airbus - the newer Boeing designs will pop an EICAS message for an engine stall if it's unrecoverable or repetitive stalls - driven by logic in the FADEC.

Ivor, you just embarrassed yourself. Lomapaseo is far from a spectator - I suspect he's forgotten more about big turbofan engines than you'll ever know. At the risk of putting words in loma's mouth, like me, he's rather surprised that excessive much additive in the fuel could cause an engine malfunction/stall so quickly (long term effects - as residue builds up the fuel metering unit - is different). So we're hoping that the investigation would include testing with high levels of the anti-fungal additive - rig testing and full scale engine tests - to determine the exact effects and if the additive was in fact the root cause.
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Old 22nd Apr 2020, 21:10
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2planks and the reverend

Google ECAM Warnings for Airbus

Basically EVERYTHING is monitored by FADEC/SDAC ( Google is your friend 😃 )

The lower central tv screen will show a warning and identify Eng 1 2 3 or 4 as in a stalled/reversed airflow condition and this is a pilot memory item to clear the stall in the engine ( thrust levers to idle/ as appropriate )

It is possible to aerodynamically stall a modern Airbus but that is not what happened here and would require a PowerPoint Presentation to explain🤓🤓

So basically engine airflow was disrupted and this can cause airflow reversal which causes the flame. Imagine your Lamborghini Aventador spitting flames out of its exhaust 🤣🤣🤣
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Old 22nd Apr 2020, 21:15
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FAA SAIB issued on the subject. https://rgl.faa.gov/Regulatory_and_G..._Corrected.pdf
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