Accident and Serious Incident Reports: FIRE
Accident and Serious Incident Reports: FIRE
Article Information
Category:
Content source:
Content control:
Definition
Accident and Incident Reports relating to accidents which involved fire.
Non-Fire Fumes
On 9 February 2023, a Boeing 777-200ER was en-route near Marseille when the cabin crew observed smoke coming from a rear galley oven which was spreading into the rear passenger cabin. After an immediate initial response and use of multiple Halon Fire extinguishers, the smoke ceased after about 20 minutes but the fumes remained. Although this meant no ongoing emergency existed, some cabin crew and passengers had experienced breathing difficulties and it was decided to return to Amsterdam. The cabin crew response to the situation was subsequently assessed as contrary to applicable procedures and relevant cabin crew training seemingly inadequate.
On 23 February 2016, a Boeing 737-800 departing New Chitose encountered sudden-onset and unforecast heavy snowfall whilst taxiing out. When the right engine ran down and cabin crew reports of unusual smells in the cabin and flames coming from the right engine were received, it was decided that an emergency evacuation was required. During this evacuation three passengers were injured, one seriously. The engine fire was found to have been in the tailpipe and caused by an oil leak due to engine fan blade and compressor icing which had also led to vapourised engine oil contaminating the air conditioning system.
On 16 March 2020, a PW150A-powered Bombardier DHC8-400 crew declared a PAN and turned back to Port Moresby after abnormal fumes and (much later) some visible ‘smoke’ which had become apparent after takeoff began to intensify causing some passengers breathing difficulties. Once clear of the landing runway, a precautionary rapid disembarkation was completed. The Investigation found that the source of the smoke/fumes was oil leaking from a failed right engine bearing seal. The failure was found to have occurred ahead of the recommended inspection interval for the seal concerned, a risk which engine manufacturer Pratt & Whitney Canada was aware of.
On 15 December 2019, an Airbus A330-200 turned back to Sydney shortly after departure when a major hydraulic system leak was annunciated. The return was uneventful until engine shutdown after clearing the runway following which APU use for air conditioning was followed by a gradual build up of hydraulic haze and fumes which eventually prompted an emergency evacuation. The Investigation found that fluid leaking from ruptured rudder servo hose had entered the APU air intake. The resulting evacuation was found to have been somewhat disorganised with this being attributed mainly to a combination of inadequate cabin crew procedures and training.
On 5 August 2019, an Airbus A321 crew declared a MAYDAY immediately after clearing the landing runway at Valencia when a hold smoke warning was annunciated. An emergency evacuation was completed without injuries. This warning followed “white smoke” from the air conditioning system entering both the passenger cabin and flight deck in the four minutes before landing which had prompted the pilots to don oxygen masks. The Investigation found the white smoke was the direct consequence of an oil leak from the right engine as a result of the misalignment and breakage of a bearing and its associated hydraulic seal.
Dangerous Goods
On 27 October 2019, an under-floor hold fire warning was annunciated in the flight deck of a Boeing 737-900 which had been pushed back at Paris CDG and was about to begin taxiing. Since there were no signs of fire in the passenger cabin or during an emergency services external inspection, a non-emergency disembarkation of all occupants was made. The hold concerned was then opened and fire damage sourced to the overheated lithium battery in a passenger wheelchair was discovered. The Investigation identified a number of weaknesses in both the applicable loading procedures and compliance with the ones in place.
On 28 July 2011, 50 minutes after take off from Incheon, the crew of an Asiana Boeing 747-400F declared an emergency advising a main deck fire and an intention to divert to Jeju. The effects of the rapidly escalating fire eventually made it impossible to retain control and the aircraft crashed into the sea. The Investigation concluded that the origin of the fire was two adjacent pallets towards the rear of the main deck which contained Dangerous Goods shipments including Lithium ion batteries and flammable substances and that the aircraft had broken apart in mid-air following the loss of control.
On 7 October 2013 a fire was discovered in the rear hold of an Airbus A330 shortly after it had arrived at its parking stand after an international passenger flight. The fire was eventually extinguished but only after substantial fire damage had been caused to the hold. The subsequent Investigation found that the actions of the flight crew, ground crew and airport fire service following the discovery of the fire had all been unsatisfactory. It also established that the source of the fire had been inadequately packed dangerous goods in passengers checked baggage on the just-completed flight.
On 6 December 2013, a Boeing 737-800 passenger aircraft was flown from Amman to Dubai out of revenue service with a quantity of 'live' boxed chemical oxygen generators on board as cargo without the awareness of the aircraft commander. The subsequent Investigation found that this was possible because of a wholesale failure of the aircraft operator to effectively oversee operational risk implicit in sub contracting heavy maintenance. As a result of the investigation, a previously unreported flight by the same operator in revenue service which had also carried live oxygen generators was disclosed.
On 3 September 2010, a UPS Boeing 747-400 freighter flight crew became aware of a main deck cargo fire 22 minutes after take off from Dubai. An emergency was declared and an air turn back commenced but a rapid build up of smoke on the flight deck made it increasingly difficult to see on the flight deck and to control the aircraft. An unsuccessful attempt to land at Dubai was followed by complete loss of flight control authority due to fire damage and terrain impact followed. The fire was attributed to auto-ignition of undeclared Dangerous Goods originally loaded in Hong Kong.
Fire - Cabin Baggage Origin
On 10 February 2007, smoke was observed coming from an overhead locker on an Airbus A320 which had just departed from New York JFK. It was successfully dealt by cabin crew fire extinguisher use whilst an emergency was declared and a precautionary air turn back made with the aircraft back on the ground six minutes later. The subsequent investigation attributed the fire to a short circuit of unexplained origin in one of a number of spare lithium batteries contained in a passenger's camera case, some packaged an some loose which had led to three of then sustaining fire damage.
B738 diversion into KCOS following in-flight fire. The fire started after a passenger's air purifier device caught fire whilst in use during the flight. The user received minor burns and the aircraft cabin sustained minor damage.
Fire - Cargo Origin
On 2 July 2021, during pre-departure loading of a Boeing 777-300 at Heathrow prior to passenger boarding with only the operating crew on board, a rear hold fire warning was annunciated and smoke and fumes subsequently entered the passenger cabin. The Investigation found that the source was a refrigerated container which had been subject to abnormal external impact prior to or during loading causing a short circuit in its battery pack. The refrigeration system involved was found by design to inhibit fire following a short circuit but it was noted that QRH response procedures did not apply to the circumstances.
On 28 July 2011, 50 minutes after take off from Incheon, the crew of an Asiana Boeing 747-400F declared an emergency advising a main deck fire and an intention to divert to Jeju. The effects of the rapidly escalating fire eventually made it impossible to retain control and the aircraft crashed into the sea. The Investigation concluded that the origin of the fire was two adjacent pallets towards the rear of the main deck which contained Dangerous Goods shipments including Lithium ion batteries and flammable substances and that the aircraft had broken apart in mid-air following the loss of control.
On 22 April 2013, a lower deck smoke warning occurred on an Airbus A330-300 almost 90 minutes into the cruise and over land. The warning remained on after the prescribed crew response and after an uneventful MAYDAY diversion was completed, the hold was found to be full of smoke and fire eventually broke out after all occupants had left the aircraft. The Investigation was unable to determine the fire origin but noted the success of the fire suppression system whilst the aircraft remained airborne and issues relating to the post landing response, especially communications with the fire service.
On 7 October 2013 a fire was discovered in the rear hold of an Airbus A330 shortly after it had arrived at its parking stand after an international passenger flight. The fire was eventually extinguished but only after substantial fire damage had been caused to the hold. The subsequent Investigation found that the actions of the flight crew, ground crew and airport fire service following the discovery of the fire had all been unsatisfactory. It also established that the source of the fire had been inadequately packed dangerous goods in passengers checked baggage on the just-completed flight.
On 3 September 2010, a UPS Boeing 747-400 freighter flight crew became aware of a main deck cargo fire 22 minutes after take off from Dubai. An emergency was declared and an air turn back commenced but a rapid build up of smoke on the flight deck made it increasingly difficult to see on the flight deck and to control the aircraft. An unsuccessful attempt to land at Dubai was followed by complete loss of flight control authority due to fire damage and terrain impact followed. The fire was attributed to auto-ignition of undeclared Dangerous Goods originally loaded in Hong Kong.
Fire - Electrical Origin
On 12 July 2013 an unoccupied and unpowered Boeing 787-8, remotely parked at London Heathrow after an arrival earlier the same day caught fire. An investigation found that the source of the fire was an uncontained thermal runaway in the lithium-metal battery within an Emergency Locator Transmitter (ELT). Fifteen Safety Recommendations, all but one to the FAA, were made as a result of the Investigation.
On 31 January 2011, a Singapore Airlines Airbus A380-800 was in the cruise when there was sudden loud noise and signs of associated electrical smoke and potential burning in a toilet compartment with a corresponding ECAM smoke alert. After a fire extinguisher had been discharged into the apparent source, there were no further signs of fire or smoke. Subsequent investigation found signs of burning below the toilet floor and it was concluded that excessive current caused by a short circuit which had resulted from a degraded cable had been the likely cause, with over current protection limiting the damage caused by overheating.
On 29 July 2011 an oxygen-fed fire started in the flight deck of an Egypt Air Boeing 777-200 about to depart from Cairo with most passengers boarded. The fire rapidly took hold despite attempts at extinguishing it but all passengers were safely evacuated via the still-attached air bridge access to doors 1L and 2L. The flight deck and adjacent structure was severely damaged. The Investigation could not conclusively determine the cause of the fire but suspected that wiring damage attributable to inadequately secured cabling may have provided a source of ignition for an oxygen leak from the crew emergency supply
On 7 January 2013, a battery fire on a Japan Air Lines Boeing 787-8 began almost immediately after passengers and crew had left the aircraft after its arrival at Boston on a scheduled passenger flight from Tokyo Narita. The primary structure of the aircraft was undamaged. Investigation found that an internal short circuit within a cell of the APU lithium-ion battery had led to uncontained thermal runaway in the battery leading to the release of smoke and fire. The origin of the malfunction was attributed to system design deficiency and the failure of the type certification process to detect this.
On 25 May 2016, an Embraer ERJ 190 experienced a major electrical system failure soon after reaching its cruise altitude of FL 360. ATC were advised of problems and a descent to enable the APU to be started was made. This action restored most of the lost systems and the crew, not having declared an emergency, elected to complete their planned 400nm flight. The Investigation found that liquid contamination of an underfloor avionics bay had caused the electrical failure which had also involved fire and smoke without crew awareness because the smoke detection and air recirculation systems had been unpowered.
Fire - Fuel Origin
On 10 February 2023, a Boeing 767-300ER had problems setting climb thrust after takeoff from Edinburgh and a right engine control fault was annunciated. It was decided that the intended transatlantic flight should divert to Prestwick. Right engine vibration became apparent and it was set to idle and shutdown after landing. On arrival at the assigned parking position, fuel was seen leaking from the right wing and a rapid passenger disembarkation was completed. Engine imbalance after turbine blade fracture was found to have caused the fuel leak and a risk of more potentially serious consequences after this scenario was identified.
On 20 July 2021, a Boeing 747-8F experienced a series of problems with excessive engine speed and fire affecting the left outboard engine soon after takeoff from Hong Kong. Although the engine was shut down, the fire continued until just before landing. About twenty minutes after landing, trapped residual leaked fuel then auto-ignited, and that fire was quickly extinguished. The origin of the engine malfunction and continuing airborne fire was identified as improper installation of a component in the engine’s Fuel Metering Unit at build, which caused a fuel leak that was the sole origin of the engine malfunction.
On 8 February 2021, an Embraer 500 Phenom 100 (9H-FAM) crew lost control of their aircraft shortly before the intended touchdown when it stalled due to airframe ice contamination. The resulting runway impact collapsed the nose and main gear, the latter causing fuel leak and resultant fire as the aircraft slid along the runway before veering off it. The Investigation found that flight in icing conditions during the approach had not been accompanied by the prescribed use of the airframe de-icing system and that such non compliance appeared to be routine and its dangers unappreciated.
On 18 April 2018, an engine fire warning was annunciated on an Airbus 330-300 which had just taken off from Atlanta. The warning remained after engine shutdown but was eventually replaced by a fire detection caution. Although not visible to the crew, a continued/reignited engine fire was subsequently seen by ATC on final approach and extinguished after landing. The Investigation concluded that the avoidable delay in the return to land had considerably increased the engine and pylon damage and noted that continuation of the fire had been facilitated by hydraulic fluid passing through a valve held partly open by debris.
On 2 July 2017, the left engine of a Bombarier CRJ 700A exiting the runway after landing at Denver caught fire and continued burning after the aircraft had been stopped on the taxiway and the engine shut down. The Investigation found that the fuel supply to the fuel-operated engine performance valve had failed and the quantity of fuel which then leaked had overwhelmed the engine cowl drain capacity and ignited. A history of similar failures was found and this one resulted in the introduction of additional mandatory in-serviced checks pending the replacement of the valve concerned with an improved design.
Fire - Power Plant origin
On 20 February 2021, a Boeing 777-200 climbing through 12,500 feet experienced a sudden right engine failure and fire shortly after thrust had been increased before entering airspace where moderate turbulence was expected. Despite actioning the corresponding drills, the fire did not go out until shortly before landing back at Denver. Engine debris fell to the ground over a wide area, fortuitously with only damage and no injuries. The failure was found to have been initiated by the fatigue failure of a single fan blade after required routine inspections had failed to find early-stage evidence of such a risk.
On 20 February 2021, a Boeing 747-400BCF engine catastrophically failed as it passed 800 feet agl after takeoff from Maastricht and an uneventful diversion to Liege followed. It was subsequently found that debris ejected from the failed engine had resulted in injury to persons and property damage on the ground. Engine failure was attributed to a previous operator of the aircraft’s failure to incorporate an optional Service Bulletin during routine maintenance and the absence of a review of this decision by the current operator. The absence of any risk assessment for third parties below a regular flight path was noted.
On 23 February 2016, a Boeing 737-800 departing New Chitose encountered sudden-onset and unforecast heavy snowfall whilst taxiing out. When the right engine ran down and cabin crew reports of unusual smells in the cabin and flames coming from the right engine were received, it was decided that an emergency evacuation was required. During this evacuation three passengers were injured, one seriously. The engine fire was found to have been in the tailpipe and caused by an oil leak due to engine fan blade and compressor icing which had also led to vapourised engine oil contaminating the air conditioning system.
On 2 October 2021, an Airbus A320neo ingested a large bird into its right engine (a Pratt & Whitney PW1100G) during takeoff at Atlantic City and a high speed rejected takeoff followed. When leaked fuel pooling within the engine cowling subsequently ignited, an on-runway emergency evacuation was completed with the fire service in attendance. The Investigation identified the ingested bird as a bald eagle with a mass above the applicable certification standard and the fuel leak a secondary consequence of a fan blade broken by bird impact. Engine component design improvements to address the fire risk following large bird ingestion are being developed.
On 18 April 2018, an engine fire warning was annunciated on an Airbus 330-300 which had just taken off from Atlanta. The warning remained after engine shutdown but was eventually replaced by a fire detection caution. Although not visible to the crew, a continued/reignited engine fire was subsequently seen by ATC on final approach and extinguished after landing. The Investigation concluded that the avoidable delay in the return to land had considerably increased the engine and pylon damage and noted that continuation of the fire had been facilitated by hydraulic fluid passing through a valve held partly open by debris.
Fire - Underfloor Origin
On 27 October 2019, an under-floor hold fire warning was annunciated in the flight deck of a Boeing 737-900 which had been pushed back at Paris CDG and was about to begin taxiing. Since there were no signs of fire in the passenger cabin or during an emergency services external inspection, a non-emergency disembarkation of all occupants was made. The hold concerned was then opened and fire damage sourced to the overheated lithium battery in a passenger wheelchair was discovered. The Investigation identified a number of weaknesses in both the applicable loading procedures and compliance with the ones in place.
On 29 July 2011 an oxygen-fed fire started in the flight deck of an Egypt Air Boeing 777-200 about to depart from Cairo with most passengers boarded. The fire rapidly took hold despite attempts at extinguishing it but all passengers were safely evacuated via the still-attached air bridge access to doors 1L and 2L. The flight deck and adjacent structure was severely damaged. The Investigation could not conclusively determine the cause of the fire but suspected that wiring damage attributable to inadequately secured cabling may have provided a source of ignition for an oxygen leak from the crew emergency supply
On 31 January 2011, a Singapore Airlines Airbus A380-800 was in the cruise when there was sudden loud noise and signs of associated electrical smoke and potential burning in a toilet compartment with a corresponding ECAM smoke alert. After a fire extinguisher had been discharged into the apparent source, there were no further signs of fire or smoke. Subsequent investigation found signs of burning below the toilet floor and it was concluded that excessive current caused by a short circuit which had resulted from a degraded cable had been the likely cause, with over current protection limiting the damage caused by overheating.
On 7 January 2013, a battery fire on a Japan Air Lines Boeing 787-8 began almost immediately after passengers and crew had left the aircraft after its arrival at Boston on a scheduled passenger flight from Tokyo Narita. The primary structure of the aircraft was undamaged. Investigation found that an internal short circuit within a cell of the APU lithium-ion battery had led to uncontained thermal runaway in the battery leading to the release of smoke and fire. The origin of the malfunction was attributed to system design deficiency and the failure of the type certification process to detect this.
On 25 May 2016, an Embraer ERJ 190 experienced a major electrical system failure soon after reaching its cruise altitude of FL 360. ATC were advised of problems and a descent to enable the APU to be started was made. This action restored most of the lost systems and the crew, not having declared an emergency, elected to complete their planned 400nm flight. The Investigation found that liquid contamination of an underfloor avionics bay had caused the electrical failure which had also involved fire and smoke without crew awareness because the smoke detection and air recirculation systems had been unpowered.
Fire - Galley
none on SKYbrary
Fire - Wing
On 1 September 2018, a Boeing 737-800, making its second night approach to Sochi beneath a large convective storm with low level windshear reported, floated almost halfway along the wet runway before overrunning it by approximately 400 metres and breaching the perimeter fence before stopping. A small fire did not prevent all occupants from safely evacuating. The Investigation attributed the accident to crew disregard of a number of windshear warnings and a subsequent encounter with horizontal windshear resulting in a late touchdown and noted that the first approach had meant that the crew had been poorly prepared for the second.
On 5 January 2018, an out of service Boeing 737-800 was pushed back at night into collision with an in-service Boeing 737-800 waiting on the taxiway for a marshaller to arrive and direct it onto the adjacent terminal gate. The first aircraft s tail collided with the second aircraft s right wing and a fire started. The evacuation of the second aircraft was delayed by non-availability of cabin emergency lighting. The Investigation attributed the collision to failure of the apron controller and pushback crew to follow documented procedures or take reasonable care to ensure that it was safe to begin the pushback.
On 28 October 2017 the left main landing gear of an MD10-10F that had just touched down at Fort Lauderdale collapsed which led to the aircraft departing the side of the runway and catching fire. The Investigation found that the collapse had occurred because of metal fatigue which had developed in the absence of protective plating on part of the leg assembly. The reason for this could not be determined but it was noted that had the aircraft operator’s component overhaul interval not been longer than the corresponding manufacturer recommendation then the collapse would probably not have occurred.
On 27 November 2010, collateral damage to the wing of an IL-76 in the vicinity of an uncontained engine failure, which occurred soon after take-off from Karachi, led to fuel in that wing igniting. Descent from a maximum height of 600 feet occurred accompanied by a steadily increasing right bank. Just under a minute after take-off ground impact occurred and impact forces and fire destroyed the aircraft. The Investigation concluded that the engine failure was attributable to component fatigue in the LP compressor and that it would have been impossible for the crew to retain control.
On 27 June 2016, a Boeing 777-300ER powered by GE90-115B engines returned to Singapore when what was initially identified as a suspected right engine oil quantity indication problem evidenced other abnormal symptoms relating to the same engine. The engine caught fire on landing. The substantial fire was quickly contained and an emergency evacuation was not performed. The cause of the low oil quantity indication and the fire was a failure of the right engine Main Fuel Oil Heat Exchanger which had resulted in lubrication of the whole of the affected engine by a mix of jet fuel and oil.
De-Ice Fluid Contamination
On 20 January 2015, The APU of a Fokker 100 being routinely de-iced prior to departing Nuremburg oversped as a result of the ignition of ingested de-icing fluid in the APU. This led to its explosive uncontained failure as the result of which ejected debris entered the aft cabin and smoke occurred. No occupants were injured and all were promptly disembarked. The Investigation found that the de-icing contractor involved had not followed manufacturer-issued aircraft-specific de-icing procedures and in the continued absence of any applicable safety regulatory oversight of ground de-icing activity, corresponding Safety Recommendations were made.
On 2 March 2009, communication difficulties and inadequate operator procedures led to an Airbus A320-200 being de-iced inappropriately prior to departure from Vasteras and fumes entered the air conditioning system via the APU. Although steps were then taken before departure in an attempt to clear the contamination, it returned once airborne. The flight crew decided to don their oxygen masks and complete the flight to Poznan. Similar fumes in the passenger cabin led to only temporary effects which were alleviated by the use of therapeutic oxygen. The Investigation concluded that no health risks arose from exposure to the fumes involved.
On 26 January 2006, when fixed ground electrical power was connected to an Avro RJ100 which had just reached its destination parking gate at Zurich, a flash fire occurred which was visible in the flight deck and an emergency evacuation was ordered. As the air bridge was by this time attached to door 1L,the cabin crew deplaned the passengers that way and no slides were deployed. The Investigation concluded that the fire had been caused by contamination of the ground power connector with ramp de icing fluid and found that there has been similar previous events.
Electrical Fumes - No Fire
On 22 March 2021, the pilots of a Boeing 747-8F which had just reached its initial cruise level after departing Dubai observed smoke and sparks coming from the window heating system and declared a PAN advising their intention to dump fuel and return to Dubai. With the faulty system switched off, this was accomplished without further event. It was found that the cause of the system malfunction was a design-related vulnerability with a history of recurrence which had not been adequately addressed by the aircraft manufacturer and the FAA as safety regulator following relevant NTSB Safety Recommendations made in 2007.
On 29 September 2017, the crew of an Airbus A320 detected a smell of burning plastic and simultaneously observed black smoke entering the flight deck near the right side rudder pedals. Completion of appropriate response procedures reduced the smoke and a diversion to Athens with a MAYDAY declared was without further event. The origin of the smoke and fumes was traced to the failure of the static inverter which was part of a batch which had been previously notified as faulty but not identified as such by the aircraft operator’s maintenance organisation which has since modified its relevant procedures.
On 6 February 2019, an Airbus A330-200 Captain’s Audio Control Panel (ACP) malfunctioned and began to emit smoke and electrical fumes after coffee was spilt on it. Subsequently, the right side ACP also failed, becoming hot enough to begin melting its plastic. Given the consequent significant communications difficulties, a turnback to Shannon was with both pilots taking turns to go on oxygen. The Investigation found that flight deck drinks were routinely served in unlidded cups with the cup size in use incompatible with the available cup holders. Pending provision of suitably-sized cups, the operator decided to begin providing cup lids.
On 24 August 2016, an ATR 72-600 experienced a static inverter failure which resulted in smoke and fumes which were identifiably electrical. Oxygen masks were donned, a MAYDAY declared and after the appropriate procedures had been followed, the smoke / fumes ceased. The Investigation noted a long history of capacitor failures affecting this unit which continued to be addressed by successive non-mandatory upgrades including another after this event. However, it was also found that there was no guidance on the re-instatement of systems disabled during the initial response to such events, in particular the total loss of AC electrical power.
On 13 March 2013, smoke and fumes were immediately evident when the cable of an external GPU was connected to an ERJ170 aircraft on arrival after flight with passengers still on board. A precautionary rapid disembarkation was conducted. The Investigation found that a short circuit had caused extensive heat damage to the internal part of the aircraft GPU receptacle and minor damage to the surrounding structure and that the short circuit had occurred due to metallic FOD lodged within the external connecting box of aircraft GPU receptacle.
Landing Gear Overheat
On 8 November 2022, a De Havilland Canada DHC8-200 experienced radio altimeter failure during descent into Sydney. The crew were unaware this would prevent use of reverse pitch after touchdown and the consequent implications for brake use and temperature on the long taxi in. The brakes slowly became less effective and failed and caught fire as the aircraft reached its gate. A successful emergency evacuation followed and the airport fire service extinguished the brake fires. It was concluded that the aircraft operator had provided insufficient guidance on both radio altimeter failure and the reversion of both engines to manual control.
On 6 April 2022, a Boeing 767-300 lost left engine oil pressure whilst eastbound and passing south of Cork and diverted to Shannon after declaring an emergency on account of intended engine shutdown. During the subsequent taxi in, a fire was observed and extinguished and the aircraft towed to the terminal after an initial fire service request for evacuation had been withdrawn. An engine oil leak from a chip detector which had been routinely inspected by a company engineer prior to departure but not reinstalled correctly was found to have caused the leak and thus the loss of oil pressure.
On 10 August 2019, the left Rolls Royce Trent 1000 engine of a Boeing 787-8 just airborne from Rome Fiumicino suddenly malfunctioned and was shut down. A MAYDAY was declared, and the flight returned for an overweight landing during which all four left main gear tyres deflated. The underlying cause of the engine failure was found to have been intermediate-pressure turbine blade detachment attributable to previously identified serviceability issues. Wider concerns were identified in relation to underlying engine certification standards and to the hazard created by ejection of large quantities of engine debris into a densely populated area.
On 15 August 2019, a Boeing 767-300 made a high speed rejected takeoff because of increasing noise from an unsecured flight deck sliding window. Whilst subsequently taxiing during the calculated brake cooling time, fire broke out in the left main gear bay and the aircraft was stopped and an emergency evacuation was carried out whilst the fire was being successfully extinguished. The Investigation did not identify any specific cause for the brake unit fires but noted that the reject had been called when 3 knots above V1 and that the maximum speed subsequently reached had been 14 knots above it.
On 16 April 2012, a Virgin Atlantic A330-300 made an air turnback to London Gatwick after repetitive hold smoke detector warnings began to occur during the climb. Continuing uncertainty about whether the warnings, which continued after landing, were false led to the decision to order an emergency evacuation on the runway. Subsequent investigation found that the smoke warnings had all been false and had mainly come from one faulty detector. It also found that aspects of the way the evacuation had taken place had indicated where there were opportunities to try and improve passenger behaviour.
Post Crash Fire
On 17 August 2023, a privately operated Hawker Beechcraft 390 Premier 1 on final approach to Subang suddenly departed controlled flight in benign weather conditions and crashed. The aircraft was destroyed by the impact and post crash fire and the eight occupants and two persons on the ground were killed. Control of the aircraft was lost after the aircraft lift dump spoilers were inadvertently deployed. The context for this inappropriate action was found to have been deviations from standard operating procedures, inadequate pilot training, regulatory grey areas and deficiencies in communication and decision-making between the two pilots during the flight.
On 9 August 2024, an ATR 72-500 at FL170 encountered weather conditions which led to airframe icing. Indicated airspeed decreased quickly without corrective action despite corresponding alerts and almost immediately after an ‘INCREASE SPEED’ alert during a turn, the aircraft stalled eventually entering a flat spin until impacting terrain in a residential area. Impact and a post-crash fire destroyed the aircraft and all occupants were killed. The Investigation is continuing.
On 8 February 2021, an Embraer 500 Phenom 100 (9H-FAM) crew lost control of their aircraft shortly before the intended touchdown when it stalled due to airframe ice contamination. The resulting runway impact collapsed the nose and main gear, the latter causing fuel leak and resultant fire as the aircraft slid along the runway before veering off it. The Investigation found that flight in icing conditions during the approach had not been accompanied by the prescribed use of the airframe de-icing system and that such non compliance appeared to be routine and its dangers unappreciated.
On 15 January 2023, an ATR 72-500 positioning visually for an approach to Pokhara suddenly departed controlled flight and impacted terrain. The aircraft was destroyed by the impact and all 71 occupants were killed. A type-experienced Training Captain was overseeing new airport familiarisation for a Line Captain acting as Pilot Flying. The Training Captain unintentionally feathered both propellers in response to a call for Flaps 30 but did not recognise their error or respond to calls that no power was coming from the engines. The airline’s operational safety-related processes and Regulatory oversight of them were both assessed as comprehensively inadequate.
On 26 December 2019, an Airbus Helicopters AS350 on a commercial sightseeing flight over the Hawaiian island of Kauai impacted terrain and was destroyed killing all seven occupants. The Investigation concluded that the experienced pilot had decided to continue the flight into unexpectedly encountered cloud contrary to Company Policy. Contributory factors were identified as the delayed implementation of a Hawaiian aviation weather camera programme, an absence of regulatory leadership in the development of a weather training program for Hawaiian air tour pilots and an overall lack of effective regulatory monitoring and oversight of Hawaiian air tour operators’ weather-related operating practices.
Related Articles
For all accident reports held on SKYbrary, see the main section on Accident Reports.
Categories
