MAP AT72 at Manaus and Itaituba on Sep 16th 2019, engine failure in flight, other engine fails after touch down
Last Update: February 18, 2024 / 12:45:45 GMT/Zulu time
Incident Facts
Date of incident
Sep 16, 2019
Classification
Incident
Airline
Map Linhas Aereas
Flight number
PAM-5913
Departure
Itaituba, Brazil
Destination
Manaus, Brazil
Aircraft Registration
PR-MPY
Aircraft Type
ATR ATR-72-200
ICAO Type Designator
AT72
Brazil's CENIPA reported the crew was able to restart the right hand engine and taxied the aircraft to the apron. There were no injuries and no damage to the aircraft. The occurrence, classified as "out of fuel" and rated a serious incident, is being investigated by CENIPA (editorial note: the initial note does not say anything about fuel remaining on board).
On Oct 2nd 2019 The Aviation Herald received information from a source in Itaituba, that no usable fuel was left in the tanks of the aircraft when the aircraft stopped on the apron.
Brazil's CENIPA released their final report concluding the probable causes of the serious incident were:
Contributing factors
Attention – undetermined.
Due to the multiple tasks performed by the pilots while on the ground in SBIH, there was possibly a reduction in their process of attention, which may have caused lapses related to automatic processes, and distractions concerning the amount of fuel required for starting operations in SBIH, since the PIC signed the flight dispatch, which contained the minimum fuel requirements.
Crew Resource Management – a contributor.
There was inefficiency in the utilization of the human resources available for the operation of the aircraft, due to an inappropriate management of the tasks assigned to each pilot, considering their inobservance of the minimum fuel required for starting operations in SBIH.
Aircraft maintenance – a contributor.
After the occurrence of the serious incident, and upon completion of the aircraft repair work, the fuel quantity indicator of the PR-MPY resumed proper operation anew, evidencing that the FQI components had problems that interfered directly with the fuel system indication. Thus, one verified the non-conformity of the maintenance services previously performed on the aircraft, independently of having been preventive or corrective, since the PR-MPY had remained with a system failure that contributed to the serious incident.
Support personnel – undetermined.
The fact that there was no support staff at SBIH to perform post-flight, pre-flight and refueling tasks may have strongly increased the pilots’ workload, which may have resulted in possible distraction as to the need of refueling the aircraft.
Organizational processes – undetermined.
One cannot rule out the possible contribution of the company's organizational support, since, despite the fact that MAP Linhas Aéreas Ltda. possessed its own team of mechanics, it was actually Manaus Aerotáxi the company responsible for the maintenance of the aircraft, since MAP Linhas Aéreas Ltda did not have certification for the provision of maintenance services. Such state of circumstances may have led to failures in the supervision or, even, in the design of organizational processes important for the preservation of safety.
Managerial oversight – a contributor.
In view of the various non-conformities observed in the components of the fuel indication system after the occurrence, one inferred that there were failures in the monitoring and oversight of the maintenance services of the operating company.
CENIPA analysed:
At the take-off from the municipality of Itaituba for the flight to Manaus, the weather conditions at the departure aerodrome were consistent with VFR flights.
While en route, with the aircraft maintaining FL180, the crewmembers received information that the destination aerodrome was closed, due to an aircraft accident, which would make it impossible to land upon arrival in SBEG.
In order to increase their en-route time, in an attempt to prevent holding close to Manaus, the aircraft reduce speed. At the same time, the cruise-flight level changed from FL180 to FL160, with the purpose of preventing the occurrence of icing.
Even with the reduction in speed, upon arriving in Manaus, the airfield was still unavailable for operations, with holdings taking approximately 25 minutes. As there was no forecast for SBEG to resume operations, the crew, in coordination with the airline office, decided to return to SBIH, which was, at that moment, 28 NM closer than the planned alternate aerodrome of SBTF, besides being operating VFR.
The FQI indicators showed that there would be 1,200 kg of QAV-1, enough fuel to proceed to any of the aerodromes.
The crew reported that, while they were cruising at FL 190 on the way back to Itaituba, the FUEL light illuminated on the Crew Alerting Panel for the first time. Then, that light went out without identification of any associated light. However, the data obtained from the QAR showed that the first illumination of the MC and of the FUEL light, indicating low level of fuel, occurred still during a turn performed while holding in SBEG. In total, the Master Caution light illuminated on five occasions, all of them associated with low levels of fuel.
The FQI had a Low Level Light (LO LVL) for each tank. It would illuminate if the total quantity of fuel in a tank dropped below 160 kg.
Because of the alert on the CAP concerning the fuel system, the crew performed a profile of descent, seeking to minimize the flight time, and proceed as quickly as possible for the landing. They were still on the final approach when the engine no.1 shut down.
After landing, they maneuvering on the runway to return to the apron when the engine no. 2 of the aircraft shut down. The crew successfully restarted the right-hand engine of the aircraft in order to clear the runway and proceed to the parking area, where the passengers and crew disembarked.
The crew reported that it was only after the start-up of the engine no. 2 that the first light on the LO LVL of the right-hand side of the FQI illuminated, with an indicated amount of 180 kg of fuel. On the left-hand side, the indicated amount was 230 kg. Thus, in such condition, the Fuel-Level Magnetic Indicators (located under the wings) indicated zero fuel after being measured.
The discrepancy between the mass of fuel indicated in the FQI and the measurement of the Fuel-Level Magnetic Indicators led one to investigate the reasons why the engines had shut down.
At a first moment, on 18 September 2019, the PR-MPY received 2,537 liters of QAV1, which represented a weight of 1,935.73 kg (2,537 liters x 0.763), after verification of the respective density (weight to volume ratio).
After this refueling, the data available in the FQI indicated 1,190 kg on the left-hand wing tank and 1,200 kg on the right-hand wing tank, i.e. a total of 2,390 kg.
On the other hand, the Fuel-Level Magnetic Indicators showed that the left-hand wing tank had 1,350 liters of fuel, and the right-hand one had 1,550 liters, which represented a weight of 1,039.5 kg on the left-hand wing tank, and 1,193.5 kg on the right-hand wing tank, considering the density of 0.77, i.e. a total of 2,233 kg.
That was a difference of 157 kg between the indications of the FQI and of the FuelLevel Magnetic Indicators.
After authorized by ANAC, the aircraft was ferried to SBEG, where tests of higher accuracy found several non-conformities after transference of fuel between the wings for verification of the behavior of the fuel-quantity indication system, as follows
- with the FQI of the left-hand wing tank indicating 310 kg, the Fuel-Level Magnetic Indicators of that wing indicated zero fuel;
- even after removing all the remaining fuel (75 liters) from the left-hand wing tank by means of a drain located near the wing root, the FQI of left-hand wing tank indicated a quantity of 230 kg of QAV-1;
- the low fuel-level indication in the FQI of the right-hand wing tank illuminated when the data shown on the instrument was 170 kg; and
- even when there was no drainable fuel on the left-hand wing tank any longer, the light that would indicate the low fuel-level condition did not illuminate in the respective FQI, evidencing that the alert was inoperative.
These findings corroborate the information that, after the incident, only one of the LO LVL amber lights was on when the aircraft was in the parking area of Itaituba, even with the markings of the Fuel-Level Magnetic Indicators showing zero kg of fuel.
Such differences led the commission to start a research aimed at determining the origin of the failure in the indication, and of the difference existing between the mass of fuel indicated in the FQI and the actual quantity of fuel in the tanks of the aircraft.
Subsequently, as per the JIC 28-42-72 FUT 10000, all six fuel-probes of the tanks were subject to functional tests. The results indicated that the number-3 fuel probes of both wings (P/N 768-100, S/N 1358 and S/N 516, respectively) were out of parameters and requiring replacement. Similarly, the P/N 798-078-2 Harness (Cabling) of the number-3 fuel probe on the right wing was out of parameters and in need of replacement.
Due to lack of indication of low fuel-level in the FQI of the left-hand wing tank, the number-1 fuel probe (P/N 766-983-1 S/N 1647) of the referred wing was replaced.
After replacement of the three right-hand side fuel probes and damaged Harness (which had several protection wires broken), the FQI resumed showing correct “zero-fuel” indications, besides turning on the LO LVL amber lights, indicative of low fuel-level. Upon completion of the repairs, the fuel quantity indication of the PR-MPY restarted its normal operation, confirming that these components had defects that had directly interfered with the PR-MPY fuel system indication.
...
Therefore, even though the aircraft took off from SBIH with a quantity of aviation kerosene that fell 94 kg short of the quantity specified in the planning, that fact in isolation would not be enough to cause the engine of the aircraft to shut down in flight, had the information on the fuel available to the pilots been reliable and effective, with real FQI indication of the actual mass of QAV-1 available for the flight.
The discrepancy was such that the QAR reading indicated that the plane had 1,500 kg of fuel when it took off from SBIH towards SBEG. According to the numbers entered by the PIC in the logbook, this amount would be 2,022 kg, that is, a difference of 522 kg.
That difference between the indicated and the actual fuel could only be verified on the ground after the flight, when the crew had information of at least 410 kg of fuel in the tanks, an amount that was in fact unreal, as verified by the measurements of the under-wing FuelLevel Magnetic Indicators, which showed zero fuel.
Despite the survey carried out in the history of the aircraft's fueling information, it was not possible to identify the moment at which the information provided by the FQI diverted from the real expression of the mass of fuel contained in the left- and right-hand wing tanks of the aircraft.
Incident Facts
Date of incident
Sep 16, 2019
Classification
Incident
Airline
Map Linhas Aereas
Flight number
PAM-5913
Departure
Itaituba, Brazil
Destination
Manaus, Brazil
Aircraft Registration
PR-MPY
Aircraft Type
ATR ATR-72-200
ICAO Type Designator
AT72
This article is published under license from Avherald.com. © of text by Avherald.com.
Article source
You can read 2 more free articles without a subscription.
Subscribe now and continue reading without any limits!
Read unlimited articles and receive our daily update briefing. Gain better insights into what is happening in commercial aviation safety.
Send tip
Support AeroInside by sending a small tip amount.
Related articles
MAP AT72 at Manaus on Jun 14th 2019, smoke in cabin
A MAP Linhas Aereas Avions de Transport Regional ATR-72-200, registration PR-MPY performing a flight from Manaus,AM to Tupinambaran,AM (Brazil), was…
MAP AT42 at Manaus on Jun 15th 2019, emergency return ends in gear up landing
A MAP Linhas Aereas Avions de Transport Regional ATR-42-300, registration PR-MPN performing flight PAM-5914 from Manaus,AM to Carauari,AM (Brazil)…
Map AT42 near Belem on Jul 4th 2017, dropped panel in flight
A Map Linhas Aereas Avions de Transport Regional ATR-42-300, registration PR-MPN performing flight PAM-5952 from Altamira,PA to Belem,PA (Brazil)…
Newest articles
Fleet type match
Bonza B38M at Sunshine Coast on Apr 23rd 2024, fumes in cockpit
A Bonza Airline Boeing 737-8 MAX, registration VH-UJK performing flight AB-570 from Avalon,VI to Sunshine Coast,QL (Australia), was on approach to…
Link SF34 at Sydney on Oct 24th 2022, too low of final ILS approach
A Link Airways Saab 340B on behalf of Virgin Australia, registration VH-VEQ performing flight VA-669 from Canberra,AC to Sydney,NS (Australia), was…
Subscribe today
Are you researching aviation incidents? Get access to AeroInside Insights, unlimited read access and receive the daily newsletter.
Pick your plan and subscribePartner
A new way to document and demonstrate airworthiness compliance and aircraft value. Find out more.
ELITE Simulation Solutions is a leading global provider of Flight Simulation Training Devices, IFR training software as well as flight controls and related services. Find out more.
Your regulation partner, specialists in aviation safety and compliance; providing training, auditing, and consultancy services. Find out more.
AeroInside Blog
Popular aircraft
Airbus A320Boeing 737-800
Boeing 737-800 MAX
Popular airlines
American AirlinesUnited
Delta
Air Canada
Lufthansa
British Airways