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Mensaje: <blockquote data-quote="cosmiccomet74" data-source="post: 3707540" data-attributes="member: 4858">Un accidente que sucedio en el 2010 debido a contaminación de combustible donde cargan combustible en Indonesia con destino a Hong Kong.[URL unfurl="true"]https://avherald.com/h?article=42a1000b/0003[/URL]Accident: Cathay A333 at Hong Kong on Apr 13th 2010, engine stuck at high thrust<table style='width: 100%'><tr><td>By Simon Hradecky, created Wednesday, Sep 4th 2013 15:40Z, last updated Wednesday, Sep 4th 2013 15:40Z Hong Kong's Civil Aviation Department (CAD) released their <a href="http://www.cad.gov.hk/reports/2%20Final%20Report%20-%20CX%20780%202013%2007%20web%20access%20compliant.pdf" target="_blank">final report</a> concluding the probable cause of the accident was: The accident was caused by fuel contamination. The contaminated fuel, which contained SAP (Super Absorbent Polymer) spheres, uplifted at WARR (Surabaya) subsequently caused the loss of thrust control on both engines of the aircraft during approach to VHHH (Hong Kong). The following chain of events and circumstances had led to the uplift of contaminated fuel to CPA780: - The re-commissioning of the hydrant refuelling system after the hydrant extension work in WARR had not completely removed all contaminants in the affected hydrant refuelling circuit. Salt water remained in the affected hydrant refuelling circuit. - The re-commissioning of the hydrant refuelling system after the hydrant extension work in WARR was not properly coordinated which led to the premature resumption of the hydrant refuelling operations while the hydrant system still contained contaminant. - The refuelling operation in WARR, in particular low flow-rate refuelling, DP recording and monitoring, did not fully comply with the international fuel industry latest guidance. - A number of unscheduled filter monitors replacements after the premature resumption of hydrant refuelling operation were not investigated by the fuel supplier and hydrant operator at WARR. - The unusual vibration observed during the refuelling of CPA780 was not stopped immediately and properly investigated by the fuel supplier personnel. The investigation also identified the following deficiencies and contributing factors that may cause possible fuel contamination: - There were no established international civil aviation requirements for oversight and quality control on aviation fuel supply at airports. - There were no established international civil aviation requirements for refuel operational procedures and associated training for aviation fuel supply personnel. - The manual monitoring of DP changes in a fuelling dispenser during refuelling was not effective. The CAD analyzed that following the indication that both engines had stalled about 45nm from the aerodrome the aircraft was left with insufficient power to reach Hong Kong Airport until the crew worked the all engines flame out checklist, which resulted in the left hand engine's thrust to increase sufficiently to be able to reach Hong Kong. The CAD wrote: "On descent to FL230 at 0519 hrs, the flight crew received the ECAM messages of “ENG 1 CTL SYS FAULT” and “ENG 2 STALL” within a short period of time. The flight crew handled the abnormal situation in accordance with the Airbus and the company procedures for the A330 aircraft. The crew appropriately declared a “PAN” call to ATC and also briefed the cabin crew of the situation. The abnormal landing to VHHH was planned in accordance with the company procedures. At 0530 hrs, when the aircraft was approximately 45 nm southeast of VHHH, the ECAM message “ENG 1 STALL” annunciated. This became an emergency situation and the workload in the cockpit had understandably increased significantly. The crew again handled the emergency situation in accordance with the Airbus and the company procedures for the A330. They also appropriately declared a “MAYDAY” to ATC. Owing to the control problem of the engine thrust and the limited power produced by the engines during descent, the flight crew had attempted to clear the faults from No. 2 engine by conducting the “ALL ENG FLAME OUT – FUEL REMAINING” checklist. This crew action is considered reasonable under the circumstances as that checklist provides the necessary procedures for restarting the engine(s) and also provides information on configuring the aircraft for an emergency landing should the engines fail. After the N1 of No. 1 engine had increased, it became apparent to the flight crew that CPA780 could reach VHHH for an emergency landing." The CAD went on to write: "During the visual approach to Runway 07L, the Commander manoeuvred the aircraft in order to manage altitude and airspeed. It was not until the aircraft on the final descent for landing that the Commander realised they could not reduce the thrust on the number 1 engine. The speed was not controllable and from that point, there was no time for the crew to consider other strategy nor procedure to cope with such emergency situation. The Commander operated the aircraft as close as possible to VLS for landing at whatever configuration they could achieve. High drag devices such as speedbrakes and landing gears were deployed. However, due to the high thrust from the No. 1 engine, it was clear to the Commander that they would be landing at high speed, and he manoeuvred the aircraft visually as required to achieve a touchdown as close as possible to the normal touchdown zone. The crew did not inform ATC of the abnormal high speed landing, very likely due to high workload and limited time available. At the time of the landing there was a crosswind of about 13 kt from the right. The aircraft touched down at about 231 kt (the configuration full approach speed with landing weight of 173,600 kg was 135 kt), and at a position between abeam Taxiways A4 and A5 and with a distance of around 680 metres from the beginning of the runway threshold, and bounced. The aircraft rolled left to seven degrees and pitched down to -2.5 degrees at second touchdown. Eventually the lower cowling of No. 1 engine contacted the runway surface. The very high speed landing combined with the strong wind could have led to the bounce of the aircraft after landing. This, combined with the necessary directional control of the aircraft, could have subsequently caused the lower cowling of No. 1 engine contacting the runway. Although the autobrake remained at “LO” (i.e. the lowest autobrake setting) due to time constraint and workload, the Commander applied full manual braking force after the touchdown. As a result of the high landing speed and abnormal landing configurations, the aircraft came to a stop near the runway centreline in the vicinity of the threshold area of the opposite Runway 25R, about 309m from the end of the landing Runway 07L. Landing distance for such abnormal configurations and speed was not provided, nor was it required to be provided, by the Airbus or the CPA documentations. The heat generated from the high energy braking also caused the thermal relief plug to deflate three of the left main gear tyres and two of the right main gear tyres, and the subsequent hot brakes and fire observed by the AFC." The CAD further analysed that after bringing the aircraft to a stop the crew worked the evacuation checklist until the point where the decision whether to commence evacuation or not was to be made. The crew inquired with tower whether fire or smoke was visible, the tower replied in the negative and instructed the crew to switch to the fire chief's frequency, the fire chief subsequently reported fire and smoke from one of the aircraft wheels. Upon that information the commander decided to go ahead with the evacuation. The CAD annotated: "This decision of evacuation was considered reasonable." The CAD praised the crew: "The crew, as a whole, had demonstrated good crew resource management throughout the flight." The CAD was not satisfied with the performance of Hong Kong ATC stating: "At 0532 hrs, CPA780 called “MAYDAY” and advised HK Approach of the dual engine stall situation. Under the circumstance where a twin-engine aircraft encountered dual engine stall, ATC would, according to standing instructions, upgrade the emergency category to a Full Emergency. However, on this occasion ATC did not upgrade the emergency category. The investigation tried to establish why a “MAYDAY” call associated with a dual engine stall situation had not triggered ATC upgrading the Local Standby to a Full Emergency." and further down commented: "Nevertheless, given the limited time of 11 minutes available from the moment CPA780 declared “MAYDAY” to the time it landed at the airport, there is no evidence suggesting a different emergency category declared by ATC during the accident would have any bearing on the emergency resources attending to CPA780 and the subsequent emergency evacuation." The CAD analysed with respect to the contaminated fuel, that after finding of SAP spheres in the fuel further checks at the fuel metering unit, variable stator vanes control unit and main metering valve found stiction of SAP spheres in the fuel metering unit and variable stator vanes control unit and accumulation of SAP spheres at the main metering valves of both fuel metering units that seized both valves. The CAD analyzed that during the uplift of 24,400kg of fuel the fuelling hose vibrated a number of times, which was abnormal. SAP spheres were found in the filters, hose and dispensers of the fuelling vehicle used to uplift the fuel to the aircraft. The CAD commented: "It was apparent that the contaminated fuel had been supplied to the aircraft." The CAD analyzed that with Surabaya being located close to the seashore it was quite likely that water puddles at the aerodrome contained salt and stated with respect to the ongoing upgrade work on the aerodrome's fuel distribution system: "When there was shortfall in adherence to the tie-in procedures, such salt water could have entered the main distribution pipe of the fuel hydrant circuit." The CAD continued that theoretic considerations verified by a practical test had indicated the possibility that salt water in the fuel could compromise the fuel monitoring system permitting the uplift of fuel despite the presence of contamination: "When the SAP was fully activated with the salt water left inside the fuel hydrant system, the performance of filter monitors was compromised and could not completely shut down the flow. This allowed continuous refuelling through the filter monitors. With such degraded performance of the filter monitors, fuel contamination was not detected by the dispenser operator unless the fuel flow was so restricted that warrant a filter change." 13 immediate safety actions were taken by Surabaya Airport, DGAC Indonesia, CAD and Cathay Pacific, the investigation released four more safety recommendations, two to the airport authority of Surabaya with respect to fuel distribution system and two to ICAO to introduce monitoring of fuel quality, fuel uplift procedures and personnel training at aerodromes as well as the introduction of devices which would stop the uplift of fuel "when the differential pressure across the equipment filtration system is outside the equipment designed value or range." </td></tr></table><hr />By Simon Hradecky, created Sunday, Nov 1st 2020 17:55Z, last updated Sunday, Nov 1st 2020 17:58Z<table style='width: 100%'><tr><td>In October 2020 the European Aviation Safety Agency (EASA) released their <a href="https://ad.easa.europa.eu/blob/EASA_SIB_2018_10_R1.pdf/SIB_2018-10R1_1" target="_blank">Safety Information Bulletin SIB 2018-10R1</a> addressing the events on board of B-HLL of April 2010 as well as at least 7 other similiar events known since 2010. The EASA argues: There have been several events of engine power fluctuations or other occurrences as described in the reference publications that were caused by deposits of Super Absorbent Polymers (SAP) in the aircraft/engine fuel system. These problems are assumed to be caused by a migration of SAP out of filtration devices (filter monitors) that are used in the fuel supply chain to the aircraft. Aircraft and engine type certificate holders consider the presence of SAP in fuel to be a potential flight safety issue and cannot endorse a level of SAP that is acceptable in fuel. The aim of this SIB is to enhance awareness of aircraft and aerodrome operators of the risks associated with SAP in jet fuel, to inform about on-going industry actions on the matter and to provide recommendations for the purpose of mitigating the associated risks. At this time EASA does not regard the issue a safety issue, that would warrant an airworthiness directive or similiar measures. EASA bases the Safety Information Bulletin on findings by the Joint Investigation Group (JIG) about fuel filter monitors of Dec 11th 2017, the findings by IATA's special interest group, a FAA Safety Information Bulletin of Oct 9th 2020 as well as further JIG findings up to Oct 9th 2020.</td></tr></table><hr />By Simon Hradecky, created Thursday, Jan 20th 2011 17:39Z, last updated Thursday, Jan 20th 2011 17:39Z<table style='width: 100%'><tr><td>Hongkong's Civil Aviation Department (CAD) said in their <a href="http://www.cad.gov.hk/reports/Accident%20Bulletin%201-2011.pdf" target="_blank">third preliminary report</a> that the spheres found seizing both engines' variable stator vane controllers were identified to mainly consist of sodium polyacrylate "consistent with the super absorbent polymer (SAP) material used in the filter monitors on a fuelling dispenser". These spheres were present in the hose end strainer of Surabaya's fuel dispenser JUA06 used for refueling B-HLL before the accident flight. The investigation is still working to determine how those spheres were created and how they entered the aircraft. Following the extension work it was noted that between April 10th and April 15th four fuel dispensers had unscheduled fuel filter monitor replacements due to high differential pressure readings of the monitor vessel, which is indicative of a filter monitor clogging. Further tests have been conducted on Surabaya's airport fuel supply system. A fuel sample taking from the supply for stands 5 to 10 showed sodium chloride and water in the sample, the source of the contamination could not be determined however. Another Airbus A330-300 registration B-HLM performing flight CX-780 departing Surabaya on April 12th 2010 had been refueled by dispenser JUA06. During the flight the crew experienced engine #1 (Trent 700, outer left) parameter fluctuations however without associated ECAM messages. The #1 FMU (fuel metering unit) was replaced following the flight. In the light of the accident flight the following day the FMU of B-HLM was also examined and showed contamination with spheres consistent with those found on the accident aircraft. Those spheres were also found in the low pressure fuel filter of the #1 engine of B-HLM. One of the fuel dispensers at Surabaya, monitoring and pressure differential (Photo: CAD): <img src="https://avherald.com/img/cathay_a333_b-hll_hongkong_100413_2.jpg" alt="One of the fuel dispensers at Surabaya, monitoring and pressure differential (Photo: CAD)" class="fr-fic fr-dii fr-draggable " style="" /></td></tr></table><hr />By Simon Hradecky, created Wednesday, Aug 11th 2010 10:16Z, last updated Wednesday, Sep 4th 2013 15:59Z<table style='width: 100%'><tr><td>In a new <a href="http://www.cad.gov.hk/reports/AB-03-2010e.pdf" target="_blank">preliminary report</a> Hong Kong's Civil Aviation Department (CAD) said, that the engine fuel components, relevant fuel samples and monitor filters in the vessel of the dispenser refueling the aircraft in Surabaya were collected and sent to the UK for analysis. Flight data and cockpit voice recorders were read out. An examination of the engine fuel components showed, that the main metering valves (MMV) of the fuel metering units (FMU) were seized, the left at a position consistent with the 70% N1 of the left hand engine, the right hand at a position consistent with the 17% N1 achieved by the right hand engine. The right hand engine's variable stator vane controller (VSVC) was also found seized. Fine spherical particles (spheres) were found in the FMU, VSVC and variable stator vane actuator (VSVA) of both engines. No fault has been observed to any component other than those associated with the contamination by spheres. The spheres could not be generated from within the airframe or engine systems under normal operating conditions and environment. The fuel samples also showed contaminations with such spheres. The monitor fuel filters from the dispenser also showed traces of such spheres, spheres were also found in fuel samples taken downstream of the monitor filters. The spheres appeared similiar to those found on the aircraft. The exact nature of the spheres is still under investigation. The flight data recorders and quick access recorders as well as aircraft monitoring system showed no abnormal commands sent from the electronic engine control or autothrust system. The abnormal engine condition therefore is believed to be the result of the contamination with spheres leading to the seizure of the MMVs. The aircraft had loaded 24400 kg of fuel from Surabaya's hydrant refuelling at stand 8, which was part of a circuit refuelling stands 1 to 10. Prior to the event there had been extensive work on that circuit as part of the Surabaya Airport extension project. The refueling circuit was isolated for the investigation. Inspection of the refuelling circuit revealed, that some of the re-commissioning procedures were not in line with guidelines and practises commonly used in the aviation industry. The re-commissioning had not been completed when B-HLL and other aircraft were already being refueled from that circuit. On Aug 16th Indonesia's NTSC contested the findings of the CAD stating, that those statements only represent the Hong Kong side of things. Many Indonesian Aircraft have been refuelled from that circuit and have not suffered any problems. A new investigation is to be carried out by the NTSC to verify the quality of the fuel supplied at the Surabaya Airport. </td></tr></table><hr />By Simon Hradecky, created Thursday, May 6th 2010 11:20Z, last updated Thursday, May 6th 2010 11:20Z<table style='width: 100%'><tr><td>Hong Kong's Civil Aviation Department (CAD) have released their <a href="http://www.cad.gov.hk/reports/AB-01-2010e.pdf" target="_blank">preliminary report</a> saying, that the airplane had no observations in the maintenance logs regarding fuel system and engines prior to the accident flight. The airplane took at at 198700 kg takeoff weight, thereof 33400 kg of fuel. During the climb the crew noticed an EPR fluctuation of the right hand engine, the left engine also showed fluctuations however within a narrower range. After levelling off at FL390 the crew received an ECAM message "ENG 2 CTL SYS FAULT", the according checklists were executed and the crew contacted their maintenance department. As all parameters of the engines were normal except the slight EPR fluctuations, it was decided to continue the flight. 100 minutes later the "ENG 2 CTL SYS FAULT" message reappeared, all parameters still remained normal, crew consulted maintenance again and it was decided to carry on. During the descent towards Hong Kong while descending through FL230 the crew received two ECAM messages: "ENG 1 CTL SYS FAULT" and "ENG 2 STALL" within a short period of time. The flight crew advanced the number 1 lever to the max continuous thrust position and pulled the number 2 lever to idle. The crew requested a priority landing and track shortening, air traffic control facilitated the request and sent the airport's emergency services on stand by. 11 minutes later while descending through 8000 feet the crew received an "ENG 1 STALL" ECAM message and declared emergency and actioned the according checklists. The captain attempted to move both thrust levers, during these movements the engine #1 increased thrust to 74% N1 while engine #2 remained at 17% N1 (below idle). The captain flew a visual approach for runway 07L, with both thrust levers at idle the left hand engine #1 showed an N1 of 74% and the right hand engine 17% N1. The left hand engine reduced to 70% N1 during touch down. The airplane touched down at 230 KIAS at a landing weight of 173600 kg, during touch down the left hand engine's underside of the cowling briefly touched the runway. Spoilers deployed automatically, the left hand reverser was deployed, the captain applied maximum manual braking. When the airplane stopped the left hand engine was still running at 76-79% N1. Both engines were shut down, 5 main gear tyres deflated. Emergency services reported smoke and fire from the main gear prompting the crew to initiate an emergency evacuation via the slides, while emergency services sprayed the main gear to battle the fire and cool the brakes down. The CAD does not expect the investigation to conclude in less than a year.</td></tr></table><hr />By Simon Hradecky, created Tuesday, Apr 13th 2010 11:00Z, last updated Saturday, Apr 24th 2010 13:26Z<table style='width: 100%'><tr><td><table style='width: 100%'><tr><td><table style='width: 100%'><tr><td><img src="https://avherald.com/img/cathay_a333_b-hll_hongkong_100413_1.jpg" alt="B-HLL being evacuated (Photo: AP)" class="fr-fic fr-dii fr-draggable fr-fil" style="" /> </td></tr><tr><td>B-HLL being evacuated (Photo: AP) </td></tr></table> A Cathay Pacific Airbus A330-300, registration B-HLL performing flight CX-780 from Surabaya (Indonesia) to Hong Kong (China) with 309 passengers and 13 crew, was on approach to Hong Kong, when the crew reported a left hand engine (Trent 772) failure and declared emergency. During roll out on the northern runway 07L brakes overheated resulting in a small fire and 6 main gear tyres deflating. The occupants of the airplane evacuated after standstill. 7 people received injuries in the evacuation. The airline reported, that 5 people were taken to a hospital. The runway was closed for about 2.5 hours. Hong Kong's Civil Aviation Authority said, that one engine had been shut down countering rumours in Hong Kong, that the airplane may have lost both engines on short final. Cathay Pacific reported on Apr 13th, that the airplane touched down on one engine (in response to media reports in Hong Kong, that the second engine had failed on short final 10 minutes after the first was shut down). In an <a href="http://www.cathaypacific.com/cpa/en_INTL/aboutus/pressroomdetails?refID=b4d6b987a8bf7210VgnVCM62000007d21c39____" target="_blank">updated press release</a> on Apr 14th Cathay Pacific said, that the left hand engine was delivering 70% N1 stuck at that level, while the right hand engine was delivering idle thrust throughout the approach. The excess thrust delivered by the left hand engine forced a higher than normal approach speed without the usual flap settings. The airplane touched down at 230 KIAS (usual approach speed 135 KIAS), the high speed overheating the brakes and leading to the deflated tyres (all 4 on the left, 2 on the right hand main gear). After landing the crew was informed about smoke and flames at the undercarriage and initiated the evacuation as a reaction to that information. Aviation sources in Hong Kong said on Apr 13th, that both engines got stuck at a setting of about 70% N1 delivering high power. The crew shut the left hand engine down to reduce excess thrust and performed an emergency landing with the other engine still operating at 70% N1. Touch down speed is reported at around 200 KIAS causing the brakes to overheat. Airbus reported later, that both engines were stalled and thrust control was lost for both engines. The right hand engine was delivering thrust below flight idle, the left hand engine thrust above flight idle. The crew received ECAM stall messages for both engines, those messages being usually associated with engine compressor surges. During landing the engine #1 (left hand) cowling scraped the runway. Cathay detailed further, that the aircraft experienced minor EPR oscillations shortly before reaching Top of Climb on departure out of Surabaya. These oscillation had an according indication of fuel flow, an ECAM message was produced for engine #2 (right hand). The crew consulted Cathay's dispatch and it was decided that the EPR oscillations did not warrant a diversion. On initial descent, when the airplane was descending through FL310, the right hand engine experienced a surge and stalled, the engine remained below flight idle for the remainder of the flight. When the airplane levelled off at an intermediate altitude in the latter part of the approach, thrust control over the left hand engine was gradually lost resulting in an uncontrolled thrust increase to 70% N1. The airplane was able to maintain speed and altitude. The crew conducted an ILS approach with flaps reaching stage 1 (selected were flaps 2) and an approach speed of 230 KIAS, the airspeed reduced to 220 KIAS during flare and touch down. Reverse thrust was successfully selected, the crew managed to stop the airplane about 1000 feet before the end of runway 07L (before the threshold runway 25R). Both engines were shut down after the airplane came to a stop, rescue services advised of tyre deflation and presence of smoke and fire around the wheels. An investigation has been initiated that also includes fuel system fault and fuel contamination.</td></tr></table> Metars: VHHH 130800Z 17014KT 9999 FEW008 SCT018 28/24 Q1012 BECMG 09015KT VHHH 130730Z 16018KT 9999 FEW008 SCT018 29/24 Q1012 NOSIG VHHH 130700Z 16017KT 9999 FEW008 SCT018 29/24 Q1012 NOSIG VHHH 130630Z 16018KT 9999 FEW008 SCT020 29/24 Q1012 WS R07R NOSIG VHHH 130600Z 14017KT 110V170 9999 FEW008 SCT020 29/24 Q1012 NOSIG VHHH 130530Z 15019KT 120V190 9999 FEW008 SCT020 29/24 Q1012 NOSIG VHHH 130500Z 15017KT 9999 FEW008 SCT020 29/24 Q1013 NOSIG VHHH 130430Z 15015KT 9999 FEW006 SCT018 29/24 Q1013 NOSIG VHHH 130400Z 15015KT 130V190 9999 FEW005 SCT018 29/24 Q1014 NOSIG VHHH 130330Z 16015KT 130V210 9999 FEW005 SCT018 29/24 Q1014 WS R07L NOSIG VHHH 130300Z 16014KT 140V210 9999 FEW005 SCT018 29/24 Q1014 WS R07L NOSIG VHHH 130230Z 16014KT 9999 FEW005 SCT018 29/24 Q1014 NOSIG </td></tr></table></blockquote>

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