Miniliner F27 at Paris on Sep 20th 2011, engine fire
Last Update: September 24, 2012 / 15:18:06 GMT/Zulu time
The French BEA released their final report in French concluding the probable cause of the serious incident were:
The incomplete re-assembly of the three way socket of the engine fire suppression system.
Contributing factors were:
- the maintenance manual of Rolls Royce did not detail the operations necessary to replace combustion chamber #3
- the work card #169 procedure to replace the combustion chamber #3 did not show the disassembly and reassembly of the three way socket.
- the tip of the three way socket was not referenced in the part catalogue
Examination of the engine after landing showed that an unknown object was present in the combustion chamber #4 and a perforation of the flame tube, however, no further damage was found. The object was positioned in the air flow of fresh air arriving from the compressor and thus disrupted the local air flow of the combustion chamber. The disrupted air flow led to turbulence and overheating and perforation of the flame tube.
No other malfunction was identified that could have contributed to the failure scenario.
Documentation of the aircraft revealed that the right hand engine had undergone maintenance on Sep 16th 2011, the technician had replaced combustion chamber #3 just above combustion chamber #4 due to a faulty ignition. The maintenance manual shows the generic procedure to remove a combustion chamber, however, without showing the surrounding of each specific combustion chamber. During the replacement work the technician felt he had to remove the three way socket seeing no way to otherwise remove the chamber from its cramped position. During re-installation he referenced the part catalogue to identify the tip.
However, during removal of the socket most likely the fitting had dropped unnoticed by the technician and entered the combustion chamber #4 below coming to rest at the lowest point of the chamber #4.
Upon reinstallation the technician felt something was missing from the socket and again checked with the part catalog, there was no indication of anything amiss from the catalog however.
Following subsequent engine start the fallen fitting was pushed around and finally got locked into a position affecting the inflow of fresh air from the compressor.
The maintenance documentation was modified as result of the incident and investigation.
This article is published under license from Avherald.com. © of text by Avherald.com.
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