Delta B763 at Edinburgh on Feb 10th 2023, engine shut down in flight
Last Update: July 18, 2024 / 09:47:48 GMT/Zulu time
Incident Facts
Date of incident
Feb 10, 2023
Classification
Incident
Airline
Delta Airlines
Flight number
DL-209
Departure
Edinburgh, United Kingdom
Destination
New York JFK, United States
Aircraft Registration
N197DN
Aircraft Type
Boeing 767-300
ICAO Type Designator
B763
The aircraft remained in Prestwick until Feb 22nd 2023, then positioned to Atlanta,GA (USA) and remained on the ground in Atlanta before returning to service on Mar 3rd 2023.
The AAIB reported later the aircraft suffered a fuel leak following an inflight engine fire and diverted to Preswick. The AAIB have opened an investigation.
On Feb 9th 2024 the AAIB reported in a brief interim statement: "The aircraft suffered a contained engine failure on takeoff from Edinburgh Airport and experienced airframe vibration and engine indications resulting in the aircraft diverting to Prestwick Airport. Once on stand, fuel was seen coming from the right wing and the passengers were rapidly disembarked. The investigation has been focused on understanding the effect of engine vibration which led to the fuel leak. The investigation is ongoing, and the final report is expected to be published in early 2024."
On Jul 18th 2024 the AAIB released their final bulletin concluding the probable causes of the serious incident were:
During the early stages of the event flight a high-pressure turbine blade fractured through fatigue cracking. The fatigue crack was initiated by a possible combination of hot corrosion and pitting from external contamination. The detached blade caused damage to a further five blades resulting in an engine imbalance. A drain tube in the right fuel tank fractured, probably as a result of the vibrations transmitted from the out of balance engine. This resulted in fuel escaping from the right fuel tank out of a wing drain hole and igniting in flight. The flight crew landed the aircraft promptly at Prestwick. They were unaware of any flames, or the right engine running down, until after landing.
The fuel coming from the wing was noticed by the ground crew as the aircraft parked near the terminal buildings. The wind was blowing the fuel towards the hot brakes and there was a risk of a fuel fire. The passengers were rapidly disembarked, and actions were taken to contain and stop the fuel leak.
As a result of the vibration-driven fatigue fracture of the drain tube, the aircraft manufacturer has launched a project to identify potential reliability improvements to the design while the Federal Aviation Administration reviews the manufacturer’s finding that the risk of a catastrophic outcome from a failed drain tube is not elevated. This project is ongoing and so a Safety Recommendation has been made to the Federal Aviation Administration to ensure the aircraft continues to meet the certification requirements for large transport aircraft.
The AAIB analysed:
Introduction
A high-pressure turbine blade fractured in the right engine, probably during takeoff, which damaged a further five blades, but the engine was still capable of producing thrust.
A passenger recorded a video of flames coming from below the wing, however the fire extinguished before the landing. Extensive CCTV recordings of the landing and taxi, and eyewitness accounts, did not indicate the presence of fire whilst on the ground. As the aircraft arrived on stand the AFS noticed the fuel coming from the wing and put provisions in place to capture the fuel and prevent it igniting on the hot engine or brakes. Thus, there was the potential for a more significant event to have occurred. The crew actions and the engineering aspects are analysed below.
Initial crew actions
Flight deck indications of a failure began during the airborne acceleration segment of the takeoff with the autothrottle disconnecting and right engine EEC mode alerts, neither of which were resolved using the applicable QRH procedure. While considering the effect of those on continuing the flight, reports of abnormal vibration in the cabin raised the commander’s awareness of a bigger, yet unidentified, problem. That, combined with abnormal EGT indications, prompted his decision to divert, probably realising such indications would preclude an overwater crossing anyway. While the extent to which crew members perceived the vibration varied, the commander, appearing aware it could vary with altitude and airspeed, preferred landing promptly. As no urgent assistance was required, declaring an emergency with ATC was probably not necessary.
The flight crew managed the overweight landing according to the associated QRH guidance; they used the longest runway nearby, with flaps 25, autoland, maximum autobrake, and requested AFS attendance on arrival.
Engine management and procedural implications for the approach
Vibration became evident in the flight deck during the base leg, especially when flaps 1 was set. More than one QRH procedure, along with other guidance, was applicable. The ‘Engine fire or engine severe damage or separation’ procedure directed engine shutdown, while the ‘Engine limit or surge or stall’ procedure contained options to shut down the engine or operate it at reduced thrust settings (depending on specified engine indications). The flight crew’s actions aligned with aspects of the ‘Engine limit or surge or stall’ procedure and, consistent with other aspects of QRH and FCTM guidance, they considered whether an ‘actual shutdown’ was necessary. Aside from the ‘Engine EEC mode’ procedure, they did not appear to reference the QRH manual itself.
The relief pilot made several references to engine failure considerations but the commander, appearing keen to land, preferred continuing with the approach, and operating the engine at reduced thrust. Supporting that decision, the relief pilot continued making effective suggestions to encompass single engine operating aspects. The ‘Engine limit or surge or stall’ QRH procedure specified using the single engine landing flaps setting. Although the commander briefed the single engine go-around, he continued with the overweight flaps setting for the approach. He might have assessed landing performance as the more immediate threat and wished to avoid the distraction of re-setting speeds, while he perceived time pressure to continue with the approach. The right engine subsequently running down was not apparent to the crew until after landing, therefore did not feature in those decisions.
The arrival and disembarkation
The ATCO ensured a full emergency response because of the intended overweight landing, and there were indications the flight crew were under pressure. After the flight crew declared an onboard ‘yellow’ emergency, the cabin crew had limited time to make landing preparations, and the short period of flames seen from the cabin was not reported to the flight crew. Such a report may not have significantly changed the approach and landing but might have caused the AFS to inspect the aircraft immediately after landing and/or keep it away from the terminal building.
Because the right wing’s fuel leak was discovered after parking, the commander could make the pragmatic decision of deplaning the passengers quickly using the normal (left) exits, without baggage. The fuel leak’s proximity to hot brakes from an overweight landing increased urgency. However, prompt actions by airport staff and assertive cabin crew passenger management helped fulfil a ‘rapid disembarkation’. Had the fuel leak been discovered before parking; or had the stairs been delayed to the stand and/or the fuel been leaking from the left wing, an evacuation (using relevant exits), with the inherent risk of injuries, may have been necessary.
Other crew resource management aspects
The commander’s openness to input, combined with assertive communications by the relief pilot and cabin crew, manifested some effective information sharing while the copilot focussed on the flying task. However, high workload for all the crew during the last ten minutes of the flight, along with natural limitations of communicating using interphone, might have impeded certain cabin information reaching the flight crew. The flight crew remained unaware of the flames which had been seen from the cabin during the approach.
The commander exhibited natural signs of stress during the event. The insidious, complex, and dynamic nature of the failure might have increased the potential for plan continuation bias, as the commander felt time pressured to land the aircraft. Consequently, some decision making, for example, in relation to engine operating considerations for the approach, appeared more intuitive, rather than structured, in nature.
Delaying commencing the approach, for example, after the vibration became evident while at 6,000 ft amsl, could have allowed time for the flight crew to reference the QRH together; agree on engine operation and aircraft configuration for the landing and go-around; and make additional communications with the cabin. Nevertheless, the affected engine ran down, the flames curtailed, and the aircraft landed promptly.
Aircraft Registration Data
Incident Facts
Date of incident
Feb 10, 2023
Classification
Incident
Airline
Delta Airlines
Flight number
DL-209
Departure
Edinburgh, United Kingdom
Destination
New York JFK, United States
Aircraft Registration
N197DN
Aircraft Type
Boeing 767-300
ICAO Type Designator
B763
This article is published under license from Avherald.com. © of text by Avherald.com.
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