BAW A388 at Johannesburg on Jul 12th 2023, smoke in cockpit and cabin

Last Update: September 4, 2024 / 18:41:50 GMT/Zulu time

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Photo of British Airways G-XLEH, Airbus A380-800 — British Airways G-XLEH, Airbus A380-800 (Photo credit: Lorenzo Giacobbo / Flickr / License: CC by-nd)

Incident Facts

Date of incident
Jul 12, 2023

Classification
Incident

Airline
British Airways

Flight number
BA-56

Departure
Johannesburg, South Africa

Destination
London Heathrow, United Kingdom

Aircraft Registration
G-XLEH

Aircraft Type
Airbus A380-800

ICAO Type Designator
A388

A British Airways Airbus A380-800, registration G-XLEH performing flight BA-56 from Johannesburg (South Africa) to London Heathrow,EN (UK) with 429 passengers and 24 crew, was climbing out of Johannesburg's runway 03L when the crew stopped the climb at about FL280 reporting smoke in the cockpit as well as in the cabin. The airport immediately assigned runway 03L/21R for the emergency and kept the runway sterile. The aircraft returned to Johannesburg for a safe landing on runway 21R about 50 minutes after departure. The aircraft stopped on the runway, the crew shut the engines down and requested emergency services, who had been deployed in full force affecting operation of the airport (fire cover available), to check their aircraft. Emergency services reported everything on the aircraft looked okay. The aircraft was towed to the apron after about 45 minutes.

According to information The Aviation Herald received the occurrence was a "fume event". A number of members of the crew were complaining about dizziness and nausea and were sent to be assessed at a hospital. The aircraft had had a fuel leak about one week prior to that occurrence.

Passengers reported there was a burning odour in the cabin that became stronger and stronger, the crew told them about a hydraulics and landing gear problem.

Another passenger reported later that there had been smoke in the cabin obviously due to a fire/fault in the cabin, the flight crew instructed cabin crew to prepare for immediate landing, hence cabin crew did not attend to passengers. The passenger observed a trail of vapour of the wing tips, obviously the aircraft was dumping fuel. After landing the aircraft remained on the runway for a long time - during that time the people in the cabin began to feel unwell and hot due to lack of oxygen/air conditioning.

The aircraft remained on the ground in Johannesburg for about 30 hours, then departed for the flight again as flight BA-56D and reached London with a delay of about 30:20 hours.

On Jul 21st 2023 South Africa's CAA reported the occurrence was rated a serious incident and is being investigated. The crew declared Mayday, Mayday, Mayday reporting smoke in cockpit and cabin and requested an immediate descent to 10,000 feet.

On Oct 9th 2023 the SACAA released their preliminary report providing the following abstract of the occurrence:

On Wednesday evening, 12 July 2023, an Airbus A380-841 with registration G-XLEH was engaged in flight BA56 from O.R. Tambo International Aerodrome (FAOR), South Africa, to London Heathrow International Aerodrome (EGLL), United Kingdom. Twenty-four (24) crew members and 429 passengers were on-board the aircraft. The aircraft took off from Runway 03L at 1747Z. Approximately 120 nautical miles (nm) to the north of FAOR whilst climbing through 25 170 feet, the crew declared a Mayday due to an acrid burning smell and haze in the cockpit and cabin areas. The crew immediately commenced a descent to 10 000 feet to return to FAOR.

Approximately 47 minutes after take-off, the aircraft landed on Runway 21R. The aircraft came to a stop on the runway and the crew shut down the engines. The Aerodrome Rescue and Firefighting (ARFF) personnel inspected the aircraft for signs of external damage, and none were found. One of the passengers was not feeling well and was attended to by the emergency medical personnel, whilst the remainder of the passengers and the crew were unharmed.

On Sep 4th 2024 the SCAA released their final report concluding the probable causes of the serious incident were:

The acrid smell that entered the cockpit and the cabin areas prompted the crew to declare a Mayday as well as request an air turnback due to the failure of the Air Cycle Machine (ACM) unit 2 that forms part of the Air Generation Unit 1. The fretting observed on the turbine end journal bearing was likely the source of the acrid smell. Failure of other components (fan end journal bearing, thrust bearings, compressor rotor and both turbine rotors) was associated with damage which led to the stoppage of the rotating system.

The SCAA analysed:

Crew

The crew was appropriately rated and qualified to perform the flight. The first officer (FO) was the pilot flying (PF), and the PIC was the pilot monitoring. After the crew experienced the acrid smell in the cockpit, the PIC declared an in-flight emergency (Mayday) and made a request to the ATC to return to the departure aerodrome (FAOR). This action was taken promptly by the crew with the time lapsed from detecting the acrid smell to declaring an emergency being 2 minutes and 41 seconds. It was determined from the CVR voice communication that the crew attempted to identify the origin of the acrid smell. The SCC reported hearing a loud ‘mechanical grinding’ sound coming from the floor level of the main deck. The crew initially thought this could be from the No. 2 engine, which had experienced an oil leak on a recent previous sector. However, it is now known that the noise was likely coming from the ACM unit that had failed; the ACM is located in the belly of the aircraft on the left side when viewed from the aft in the area of seats 11 A and B in business class on the main deck. The PIC requested the relief pilot to check if he could see anything. With the time of flight being at night, the relief pilot could not see any anomaly. In this case, there were no visually detectable symptoms (i.e., sparks/flames that emanated from the engine). By the time the relief pilot went into the cabin, the grinding noise had stopped. At this point the crew had performed the AIR COND / CABIN EQPT ISOL aspects of the QRH SMOKE/FUMES procedure, resulting in Pack 1 being turned off. This would have removed the source of the acrid smell/fumes and the reported grinding noise.

When the initial actions of the QRH SMOKE/FUMES procedure were conducted, the relief pilot asked the PIC if the crew was to don oxygen masks. The PIC remarked: “I think we are okay, please keep an eye on us”. None of the pilots donned their oxygen masks at this point.

The PIC subsequently stated to the investigation: “At no point did I feel any ill effects, so I decided the risk of not going onto oxygen (O2) was worth the extra SA [situational awareness]. We briefed the relief FO to make us get on oxygen if he thought we needed to.”

The relief pilot stated that he later donned his oxygen mask when the aircraft was on final approach following a suggestion from the cabin that the smell was returning. He removed his mask shortly after landing when it became apparent that the smell/fumes had not returned.

While the PIC and PF did not deem it necessary to don their masks when the smell was first detected, they could have donned their oxygen masks at any time during the descent and return to FAOR if the situation in the cockpit had deteriorated. The operator’s training emphasises that the initial actions on the QRH procedure are reversible (i.e. crew can don masks at any time, even if they did not immediately do so; or they can remove masks, if they had them on.) No smoke or fire ECAM warning was triggered in the cockpit by any of the systems during the flight. The PIC executed the required checklist procedure after referencing the QRH (hardcopy) when there was acrid smell in the cockpit. The very first item on the QRH for Smoke/Fumes states “APPLY OXYGEN MASKS (if required) – USE 100% EMER (see QRH procedure on page 22)”, which leaves this item to the discretion of the crew, depending on the conditions in the cockpit at the time. It is generally accepted that the use of flight crew oxygen masks can make communication in and from the cockpit difficult. This may have influenced the primary crew’s decision not to don their respective oxygen masks. When the acrid smell was detected in the cockpit, the PF stated that it was a “strong smell” but did not elaborate further. Smoke was mentioned by the crew in their communication with ATC. From the CVR recording, the amount of smoke/haze in the cockpit and cabin areas was not discussed at any stage during the flight, however, subsequent crew reports described only fumes/an acrid burning smell in the cockpit, but no smoke. There was no photographic or video evidence of the condition, or any requirement for such evidence to be captured by the operator. The relative absence of smoke in the cockpit may have influenced the decision by the primary crew not to don their oxygen masks.

In the Airbus A380 Flight Crew Techniques Manual (Appendix B, page 4) under the heading Abnormal and Emergency Procedures for Fire, eleven (11) different odours and the suspected causes of each are described. This list acts as guidance to help the crew identify the origin of the odours they might encounter in-flight. An acrid smell is first on the list with the suspected causes being listed as: (i) electrical equipment or (ii) an engine oil leak. The smell from the ACM was caused by different components in the unit that rubbed against the casing whilst it was rotating at a speed of approximately 20 000 revolutions per minute (RPM) as presented under sub-heading 1.16.1. It was noted that there is no reference to the ACM units or the failure thereof (of which there are four on the aircraft) in this document, and it was not included under the heading Suspected Causes as a likely cause.

As the aircraft was not at cruise altitude when the acrid smell entered the cockpit/cabin, this might probably have been the reason why the primary crew did not opt to don their oxygen masks. Approximately 2 minutes and 20 seconds after the FO first mentioned the acrid smell, the PIC declared a Mayday and requested to return to FAOR from ATC as well as descend to FL100 (ATC cleared the aircraft to descend to FL105), which was one of the QRH requirements on page 1 of the Smoke/Fumes checklist if smoke/fumes source was not immediately isolated.

At 1 000 ft above ground level (AGL), the PIC took control of the aircraft and performed a normal landing. Once the aircraft was brought to a stop on the runway, the engines were shut down as discussed during the pre-landing briefing. The aircraft was inspected by ARFF personnel before it was towed from the runway to the apron where a normal deplaning procedure was followed; there was no need for an emergency evacuation after landing.

Aircraft

The aircraft was maintained according to the approved maintenance schedule. The ACM unit that failed was installed on the aircraft during manufacture and had not been removed since.

The ACMs are on-condition items and are overhauled when needed. A total of four ACMs were installed in the aircraft, two on each AGU. The failure of the ACM is a rare occurrence as it is not listed in the Airbus A380 Flight Crew Techniques Manual (Appendix B, page 4) under the heading Abnormal and Emergency Procedures for Fire, Suspected Cause. The ACM unit that had failed was not subjected to any maintenance intervention according to the information the AMO supplied to the investigating team.

Air Traffic Control

The crew was in constant communication with the ATC officer at FAOR who accommodated the crew’s request for an immediate descent to FL100 (FL105 was granted). The crew first requested Runway 03L for landing but after ATC had mentioned that Runway 21 was also available, the crew changed their request to Runway 21R, which was the shortest possible route back to the aerodrome and which was in line with their SOPs.

At 18:06:26 the crew requested Runway 03L for landing, which was granted by ATC.

At 18:10:50 ATC informed the crew that Runway 21 was available.

At 18:12:32 the crew requested Runway 21R for landing, which was granted by ATC. At this stage, the aircraft was 80nm from FAOR. The crew continued with approach for Runway 21R.

At 18:34:39 the aircraft landed on Runway 21R.

The ARFF personnel were notified in advance by ATC whilst they awaited the return of the aircraft. After the aircraft landed and the engines and radar were switched off, the ARFF commander communicated with the crew of the SCM on frequency 121.90MHz to advise them that they would inspect the aircraft for damage, of which none was found.