Singapore Airlines engine caught fire on landing 27-06-2016

Singapore Airlines engine caught fire on landing 27-06-2016

Official timeline, given by the Changi Airport Group (CAG):

• 06:49L SQ368 landed

• 06:51L fire fighter arrive

• 06:54L fire brought under control

• 07:10L passengers disembark

• 08:18L aircraft towed to remote parking pay

• 08:20L clean-up and repair of runway begins

• 10:59L replacement flight (SQ368) departs

• 11:30L runway 2 reopens following inspection

Singapore Airlines flight SQ 368 from Singapore-Changi Airport to Milan (Italy) departed at 02:23 L .

About 90 minutes into flight, while in the cruise at 30.000 ft (FL 300) over the Bay of Bengal about 30 miles (50 km) southwest of Phuket (Thailand) the pilots discontinued the flight and headed back to Singapore on a lower than normal altitude. According to media reports the pilots received an engine oil warning associated with a fuel leak. Changi Airport was informed and fire trucks were alerted to be on standby for the landing as a precautionary measure.

At 06:45L , the Boeing 777-300 normally touched down on runway 20C(enter) at Changi Airport. But immediately afterwards, a fire was seen on the right wing which was engulfed in flames seconds later. The pilots stopped on the runway and the airport fire services rushed to the scene but it took them about 5 minutes until the fire was finally put out. During that time all passengers remained on board.

There was no emergency evacuation. The passengers kept calm and collected and there was no panic in the cabin. All on board later left the aircraft on the runway via mobile airstairs. Fortunately, there were no injuries among the passengers or crewmembers.

CONCLUSION

From the information gathered, the following findings are made. These findings should not be read as apportioning blame or liability to any particular organization or individual.

• The fuel leak in the occurrence flight was a result of a cracked tube within the MFOHE (Main Fuel Oil Heat Exchanger) of the right engine. Fuel leaked into various areas of the engine through the core of the engine and the fan duct.

• When the thrust reverser was deployed during landing, the conditions at the area aft of the turkey feather seal of the core exhaust nozzle resulted in hot surface ignition of the fuel that had leaked from the MFOHE into the various areas of the right engine.

• As the fire developed, it propagated towards the forward section of the engine and entered the core of the engine through the fan booster inlet.

• The methods that were used to detect fuel leakage into the engine system by the operator and engine manufacturer were not able to detect the fuel leak that resulted from the cracked tube within the MFOHE when it occurred in that event flight.

• The engine manufacturer issued SB 79-0034 to address the issue of possible fuel leak in the MFOHE. The deadline for incorporating the SB was determined using the CAAM. The actions called for by the SB was not performed on the occurrence engine as the SB was issued after the engine’s last maintenance.

• In the course of the investigation, the engine and MFOHE manufacturers have identified that diffusion bonding can potentially cause any tube in the MFOHE to crack.

• The flight crew did not execute the steps in the FUEL DISAGREE checklist correctly.

• The flight crew depended on the fire commander as their sole information source when deciding whether an evacuation was needed. Several other resources which could have aided them in making their decision were not utilised.

Safety Recommendations:

• GE Aviation, as the engine manufacturer and holder of the engine type certificate, to review the need to accelerate the implementation of the recommendations in its main fuel oil heat exchanger Service Bulletin of December 2014, to prevent another fire or other hazardous incident from arising as a result of fuel leakage into the engine oil system. The information provided herein is of an interim nature. Readers are advised that new information may become available that may alter this interim statement prior to the publication of the Final report

• The Boeing Company, as the aircraft manufacturer, to review the need for operational procedures in the event a flight crew encounters a similar fuel leak situation in flight.

• US Federal Aviation Administration

– to require the Boeing Company to review the need for operational procedures in the event a flight crew encounters a similar fuel leak situation in flight; and

– to require GE Aviation to review the need to accelerate the implementation of the recommendations in its main fuel oil heat exchanger Service Bulletin of December 2014.

SAFETY RECOMMENDATIONS A safety recommendation is for the purpose of preventive action and shall

in no case create a presumption of blame or liability.

Further to the four safety recommendations that have been made on 25 July 2016 (see paragraph 4.1), it is recommended that:

• 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.

• The airline operator ensure that its pilots are able to correctly perform the actions called for in the emergency and non-normal checklists.

• The engine manufacturer conduct in-depth studies to understand if cracks may develop in the crimped areas of other tubes over time.

• The F A A consider requiring the engine manufacturer to conduct further in- depth studies to better understand if there can be other ways the MFOHE can fail over the expected operating lifespan.

• The engine manufacturer evaluate the need to periodically inspect the internal components of the MFOHE.

• The F A A consider requiring the engine manufacturer to evaluate the need to periodically inspect the internal components of the MFOHE.

• The aircraft manufacturer review the use of combustible gas detector as the preferred means of fuel detection during engine oil servicing instead of relying on maintenance personnel’s sense of smell to detect fuel odour.

• The F A A consider requiring the aircraft manufacturer review the use of combustible gas detector as the preferred means of fuel detection during engine oil servicing instead of relying on maintenance personnel’s sense of smell to detect fuel odour.

• The airline operator consider the detection of fuel during engine oil servicing by using combustible gas detector as the preferred method, instead of relying on maintenance personnel’s sense of smell to detect fuel odour.

• The CAAS consider requiring Singapore’s airline operators to use combustible gas detector to detect the presence of fuel in their maintenance activities, instead of relying on their maintenance personnel’s sense of smell to detect fuel odour.

• The FAA to review its airworthiness control system to ensure that corrective actions can be implemented expeditiously to prevent the recurrence of unsafe conditions.

• The aircraft manufacturer evaluate the need for providing guidance on how to perform fuel leak check with the engines operated at unequal thrust.

• The FAA to consider requiring the aircraft manufacturer evaluate the need for providing guidance on how to perform fuel leak check with the engines operated at unequal thrust.

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