Atlas B748 at Miami on Jan 18th 2024, engine fire

Last Update: October 17, 2024 / 10:19:31 GMT/Zulu time

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Incident Facts

Date of incident
Jan 18, 2024

Classification
Incident

Cause
Engine fire

Airline
Atlas Air

Flight number
5Y-95

Departure
Miami, United States

Destination
San Juan, Puerto Rico

Aircraft Registration
N859GT

Aircraft Type
Boeing 747-8

ICAO Type Designator
B748

An Atlas Air Boeing 747-8 Freighter, registration N859GT performing flight 5Y-95 from Miami,FL (USA) to San Juan (Puerto Rico) with 5 crew on board, was climbing through about 2000 feet out of Miami's runway 09 when the crew declared Mayday reporting a #2 engine (GEnx, inboard left hand) fire, the #2 engine emitted streaks of flames and sparks in regular intervals. The aircraft stopped the climb at 3000 feet and returned to Miami for a safe landing on runway 09 about 15 minutes after departure. The aircraft vacated the runway and stopped on taxiway T8 for checks by emergency services, following the checks the aircraft taxied to the apron.

The FAA reported: "AIRCRAFT DEPARTED, EXPERIENCED #2 ENGINE FAILURE AND RETURNED TO LAND, POST FLIGHT INSPECTION REVEALED A SOFTBALL SIZE HOLE ABOVE #2 ENGINE, MIAMI, FL."

The NTSB opened an investigation, Boeing and General Electric stated they are supporting the NTSB in their investigation.

On Feb 9th 2024 the NTSB released their preliminary report summarizing the sequence of events:

The flight crew reported that, after departure and while passing through about 3,000 ft mean sea level (msl) they received an “OVHT ENG 2” followed by a “FIRE ENG 2” warning message on their engine indicating and crew alerting system (EICAS) display. Simultaneously, the fire warning light illuminated, and the fire bell sounded. The captain declared a mayday with air traffic control (ATC) and the flight was cleared back to MIA via radar vectors for a landing on runway 9. The electronic non-normal (NNC) checklist was completed, and the number 2 engine was shutdown by the flight crew. One fire bottle was discharged, and the fire warning light subsequently extinguished. Following an uneventful landing, the airplane was met by firefighting personnel and the airplane was cleared to taxi under its own power to parking.

A post-incident inspection of the General Electric (GE) GEnx-2B67 engine revealed burn through of the thrust reverser fan duct fixed inner wall (see figure 1). The engine cases were intact and there was no evidence of an uncontained engine failure. The combustor diffuser nozzle (CDN) case port M borescope plug was not secured in the case and was found loose in the engine cowling. The burn through observed on the thrust reverser wall was directly above the open CDN port M. The engine low pressure spool (N1) and high pressure spool (N2) manually rotated smoothly. A borescope inspection through CDN port M was performed and no combustor damage was visible. A preliminary review of quick access recorder (QAR), flight data recorder (FDR), and continuous engine operating data (CEOD) showed no evidence of engine failure or surge/stall.

A review of the aircraft’s maintenance records revealed that on January 14, 2024, the aircraft underwent an “ENG 2 COMBUSTION SECTION- BORESCOPE NOZZLE- INSPECT” performed by a third-party vendor that required the removal of the port M borescope plug (see figure 2 for location of port M). The maintenance work card provided instructions on how to properly reinstall the borescope plugs to ensure the locking feature was properly engaged. The work card was initialed by the technician performing the work and an inspector, indicating this task had been completed in accordance with the maintenance manual procedure.

On Oct 17th 2024 the NTSB released their final report and investigation docket concluding the probable cause of the incident was:

Maintenance personnel’s improper installation and inspection of the port M borescope plug, which resulted in an engine fire.

The NTSB analysed:

During the airplane’s initial climb after departure, the flight crew received engine overheat and fire warning indications for the No. 2 engine. The engine was subsequently shut down, one fire bottle was discharged, and the engine fire light extinguished. After declaring a mayday, the flight returned to the airport and made an uneventful landing.

A review of the airplane’s maintenance records revealed that, 4 days before the flight, the airplane had undergone a borescope inspection of the No. 2 engine performed by a third-party vendor. The inspection required the removal of the port M borescope plug. The maintenance work card provided instructions for properly reinstalling the borescope plug to ensure that the locking feature was properly engaged. By initialing the work card, the technician who performed the work and the inspector who reviewed the work indicated that this task had been completed in accordance with the maintenance manual procedure.

A postincident inspection of the No. 2 engine revealed that the engine cases were intact with no evidence of an uncontained engine failure. The inspection also revealed burn through of the thrust reverser fan duct fixed inner wall located directly over the combustor diffuser nozzle (CDN) port M borescope plug. The CDN case port M borescope plug was not secured in the engine case and was found loose in the engine cowling. The open CDN port allowed hot gases to escape from the engine, which caused thermal damage to the thrust reverser.

A postincident inspection of the port M borescope plug revealed no anomalies to the plug’s material composition, dimensions, threads or locking components. The plug was threaded into an exemplar engine without binding or stiffness and locked as designed. Although the work card had been initialed by a technician and an inspector, it is likely that the port M borescope plug was not properly secured and inspected according to maintenance manual procedures and that the improperly secured plug resulted in the engine fire.
Aircraft Registration Data
Registration mark
N859GT
Country of Registration
United States
Date of Registration
Lhq pjnlpbk Ajb Subscribe to unlock
Manufacturer
BOEING
Aircraft Model / Type
747-87UF
Number of Seats
Iee Subscribe to unlock
ICAO Aircraft Type
B748
Year of Manufacture
Femj Subscribe to unlock
Serial Number
Nqn l Subscribe to unlock
Aircraft Address / Mode S Code (HEX)
Accpch Subscribe to unlock
Engine Count
H Subscribe to unlock
Engine Manufacturer
Cl Subscribe to unlock
Engine Model
CAqfpAgjl Subscribe to unlock
Engine Type
QfphipgAi Subscribe to unlock
Pounds of Thrust
Feqcg Subscribe to unlock
Main Owner
NdgdcnffgpAgffdncnpjpejgdhfl cAbcAedbmiikncpAgiAqA dpfmmkhlAhcffmkmecdndeklqdAdqcmjkmgAmkcgnhkn Subscribe to unlock
Incident Facts

Date of incident
Jan 18, 2024

Classification
Incident

Cause
Engine fire

Airline
Atlas Air

Flight number
5Y-95

Departure
Miami, United States

Destination
San Juan, Puerto Rico

Aircraft Registration
N859GT

Aircraft Type
Boeing 747-8

ICAO Type Designator
B748

This article is published under license from Avherald.com. © of text by Avherald.com.
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