Blue1 RJ85 near Helsinki on Dec 17th 2009, fuel system malfunction
Last Update: October 31, 2012 / 16:38:47 GMT/Zulu time
Incident Facts
Date of incident
Dec 17, 2009
Classification
Incident
Aircraft Type
AVRO RJ-85 Avroliner
ICAO Type Designator
RJ85
The most probable cause for the incident was frozen water in the fuel system. This ob-structed the transfer of fuel from the wing tanks to the engines' feed tanks. As a result, the fuel level in three out of the four feed tanks began to drop.
Another factor was the detail that the flight crew ignored the item on the warning check-list which commands the pilots to land as soon as possible.
Contributing factors included the flight crew's action and decision-making style which demonstrated poor airmanship.
The layout of the emergency checklist concerning the failure is complex and verbose.
The aircraft had arrived into Vaasa from Helsinki, ambient temperature at Vaasa was -24 degrees C. While on the ground the APU was used causing a slight fuel imbalance between the tanks.
The captain (36, ATPL, 6,111 hours total, 2,585 hours on type) was pilot flying, the first officer (37, 3,320 hours total, 2,354 hours on type) was pilot monitoring for the sector to Helsinki. Following departure from Vaasa the captain used the fuel cross feed to even out the slight fuel imbalance. Climbing through FL200 out of Vaasa, about 11 minutes into the flight, the crew received a "R FEED TANK LO LEVEL" warning indicating the fuel quantity in one of the right hand feed tanks had dropped below 272kg and began to process the relevant checklist up to the point, where it read "land as soon as possible". At that time the aircraft was 42nm north of Tampere Airport, the first officer mentioned their only option was to land in Tampere, the captain however did not respond. Instead, the climb to cruise level continued for another 10 minutes until the aircraft levelled off at cruise level, the captain subsequently reduced thrust on the right inboard engine in order to conserve fuel in the engine's feed tank. At that time the crew noticed the quantity in the right hand outboard engine's feed tank was reducing as well. The crew estimated the remaining flight time to Helsinki at 16 minutes with the quantities in the right hand feed tanks sufficient for 23 minutes at maximum cruise thrust.
2 minutes later the crew received a "L FEED TANK LO LEVEL" warning due to the left outboard fuel feed tank quantity reducing. The captain thus requested the shortest available approach to Helsinki and a priority landing into Helsinki, at that time the right inner feed tank reached its minimum quantity of 150kg remaining. Tampere area control center handed the aircraft off to Helsinki Approach, where the crew reported the issues with the fuel feed tanks again and requested the shortest approach and priority, Helsinki Approach declared an emergency for the aircraft.
The crew subsequently worked the regular approach check list, then read the remainder of fuel feed failure checklist which demanded landing at 24 degrees of flaps in order to keep the pitch angle as low as possible in order to support gravity fuel feed. Although the runway's reported friction values were sufficient for a landing with flaps at 24 degrees, the captain decided to use the normal 33 degrees flap setting for the landing.
During the approach the "FEED TANK LO LEVEL" began to intermittently clear and show up again. The aircraft landed safely on Vantaa Airport's runway 04L about 40 minutes after departure from Vaasa, a total 2500 kg of fuel was remaining.
The SIAF analysed: "The investigation commission believes that the cockpit culture on the occurrence flight manifested a very low cockpit authority gradient. The result was that, from time to time, the cockpit was bereft of leadership, and good airmanship did not fully materialise."
The SIAF analysed that the fuel feed failure checklist is very complex and verbose with a lot of text which "hides" important information such as a full engine feed tank permitting to run the engine at 23 minutes of maximum cruise thrust, or at the top of descent to descend, approach, go around and make another approach and full stop landing. The crew must not rely on any other fuel available on board as some valves may not be operative without indication on the flight deck. The checklist subsequently read "land as soon as possible" if the checklist actions did not clear the indication or "monitor fuel" if the checklist actions cleared the fault indication.
The SIAF further stated that the checklist does not specify when the 23 minutes begin to run down. When the crew read the relevant point of the checklist, they were already 12 minutes after the first indication.
The SIAF analysed that the aircraft had been drained of water in the fuel tanks the night before the flight while the aircraft was inside a hangar. Following the occurrence flight maintenance tested the electrical fuel boost pumps and detected that the pumps did not transfer any fuel to the feed tanks. The aircraft was therefore towed to the warm hangar and drained of water. Another test of the electrical boost pumps showed normal function and transfer of fuel to the feed tanks. The aircraft manufacturer states that daily water drains are an effective measure to prevent freezing related fuel feed anomalies. 45 fuel feed freezing related events had been recorded between 2005 and 2010, mainly between October and April (winter time).
Incident Facts
Date of incident
Dec 17, 2009
Classification
Incident
Aircraft Type
AVRO RJ-85 Avroliner
ICAO Type Designator
RJ85
This article is published under license from Avherald.com. © of text by Avherald.com.
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