Icelandair B752 near London on Jun 4th 2009, engine problem

Last Update: May 31, 2013 / 13:54:50 GMT/Zulu time

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Incident Facts

Date of incident
Jun 4, 2009

Classification
Incident

Cause
Engine problem

Airline
Icelandair

Aircraft Type
Boeing 757-200

ICAO Type Designator
B752

Iceland's Rannsoknarnefnd flugslysa (RNF, Air Accident Investigation Board) released their final report concluding the probable cause of the incident was:

The operator’s engine maintenance program had an omission, where the low pressure fuel pump did not have a task assigned to it, requiring soft life maintenance when the engine was removed for shop visit.

- The low pressure fuel pump installed on engine #1 had never undergone its recommended maintenance.

- The low pressure fuel pump installed on engine #1 failed due to internal wear.

The RNF reported the first officer (32, ATPL, 3,807 hours total, 2,112 hours on type) was pilot flying, the captain (39, ATPL, 6,844 hours total, 4,408 hours on type) was pilot monitoring. The aircraft had just been handed over from Paris Center to London Center and was climbing through FL320 about 85 nm southsoutheast of London Gatwick Airport, when the flight crew noticed white smoke entering the cockpit and donned their oxygen masks, the first officer upon rapidly further intensifying smoke also donned his smoke goggles while the captain abandoned attempts to put his goggles on after two failed attempts concluding he had more important to do. The captain assumed role as pilot flying while the first officer began to read the relevant checklist, smoke or fire or fumes checklist. 17 seconds after the smoke was noticed the crew notified London ATC about smoke on the flight deck, a few seconds later three loud bangs were heard from the left hand engine (RB211), that supposedly surged at this time. The captain, barely able to see the instrument panel, leaned forward to check the engine displays and found the left hand engine was showing irregular parameters in addition to rising EGT, the first officer was unable to see the EICAS at all. 46 seconds after the smoke was first detected the captain shut down engine #1 by moving the fuel lever to cutoff position. The captain was ready to pull the fire handle and discharge the fire agent suspecting the engine was on fire, however, no engine fire indication occurred, hence the captain did not proceed with the fire drill. Shortly after the engine was shut down, the smoke started to dissipate.

At the time of the engine shut down the autothrust system had disconnected, the aircraft started yawing and rolling, the captain felt the autopilot was struggeling flying the aircraft, so that the captain disengaged the autopilot and flew the aircraft manually for most of the remainder of the flight (the autopilot was briefly re-engaged for about 20 seconds 10 minutes after the smoke had been detected).

Two minutes after the smoke was detected the crew requested diversion to London Gatwick airport and was cleared to descend for a landing on Gatwick's runway 26L.

A passenger told cabin crew that there was smoke in the cabin, the flight attendant looked up and saw a wall of smoke rolling through the cabin, that seemed to originate from the area near the wings and subsequently distributed evenly throughout the cabin. The flight attendant informed the flight deck, all flight attendants fetched their fire extinguishers, donned oxygen masks and looked for possible sources of fire and smoke.

The left hand air conditioning system had shut down together with the left hand engine, due to the shut down the right hand air conditioning system was prevented to go into high flow mode and thus was not able to maintain cabin pressure, the cabin altitude began to rise as result. When the aircraft descended through FL200 the cabin altitude horn sounded, the first officer determined that they were descending quickly enough so that no release of the oxygen masks would be necessary. About 4 minutes later the cabin altitude horn stopped after the aircraft had descended below FL100.

11 minutes after the smoke was detected the smoke had dissipated sufficiently that the flight crew removed their oxygen masks. 19 minutes after the smoke appeared the aircraft touched down on Gatwick's runway 26L for a safe landing. Emergency services checked the left hand engine for any fire, no trace of fire was detected, then the aircraft was cleared to taxi to the apron. At the stand all aircraft doors were opened to release the smoke, the passengers disembarked normally via stairs through the right hand doors upon request by fire services who still were on stand by for the left hand engine problem.

Some passengers and crew suffered from minor eye irritation and minor respiration problems as result of the smoke.

After the aircraft had arrived at the stand, fluid was seen leaking from the left hand engine, the fluid was identified to be fuel. The engine was opened and extensive smell of fuel and a fuel leak in the area of both magnetic chip detector plugs were detected.

The engine was removed and sent for analysis.

The left hand engine had accumulated 63,434 hours in 17,811 flight cycles since new. It had been last overhauled in 2005 when a cracked high pressure turbine blade was replaced and had been installed on TF-FIJ in 2006.

The magnetic chip detectors contained a large amount of metallic debris, which could not be clearly identified though it was suspected to originate from a locking nut, a stepped sleeve, a carbon face seal and from a cup washer.

The low pressure fuel pump was found with internal damage including the self-locking nut, abutment sleeve, cup washer, carbon face seals, face seal springs, stepped sleeve and retaining pin, it was likely the material found in the magnetic chip detector originated from these parts. Tear down analysis of the pump identified the carbon seal insert in the seal assembly between pump and high speed gearbox had broken.

The RNF analysed that it was difficult to follow emergency procedures due to the rapid development of smoke. Following the engine shut down the rudder pedal was moved into the wrong direction, which explains the autopilot had difficulty to control the aircraft. The captain stated that the difficulty to read the instruments may have caused this initial reaction. The captain was simulator instructor for pilot training and thus was very familiar with the simulator smoke drill training.

ATC had ensured the aircraft was on a discrete frequency without other traffic on frequency, the crew voiced appreciation of the support provided by ATC.

Icelandair's computerized maintenance tracking system had no tasks assigned to the low pressure fuel pump and instead had assigned an engine maintenance program, which required maintenance after 12,000 hours. The engine manufacturer however had required a full overhaul of the low pressure fuel pump after exceeding 20,000 hours. Maintenance undertaken in 2002 therefore missed the manufacturer's requirement to replace the fuel pump and again in 2005. It was likely a previous chip detector indication in 2008 were first indications of the low pressure fuel pump failure.

Following the failure of the low pressure fuel pump and resulting fuel leak, that also intruded the engine oil path, it is likely that the fuel/oil mixture entered the engine compressor contaminating the air before the bleed air outlet resulting in smoke penetrating the aircraft cockpit and cabin.

When the fuel/oil mixture went further down the gas path inside the engine it is believed to disrupt the operation of the engine sufficiently to cause the engine surges observed.

Six safety recommendations were released as result of the investigation.
Incident Facts

Date of incident
Jun 4, 2009

Classification
Incident

Cause
Engine problem

Airline
Icelandair

Aircraft Type
Boeing 757-200

ICAO Type Designator
B752

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