Swiftair AT72 at Madrid on Jun 24th 2013, engine shut down in flight

Last Update: October 9, 2015 / 19:14:38 GMT/Zulu time

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Incident Facts

Date of incident
Jun 24, 2013

Classification
Incident

Airline
Swiftair

Flight number
UX-7306

Departure
Madrid, Spain

Destination
Vigo, Spain

Aircraft Registration
EC-KKQ

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

A Swiftair Avion de Transport Regional ATR-72-500 on behalf of Air Europa, registration EC-KKQ performing flight UX-7306 from Madrid,SP to Vigo,SP (Spain) with 69 passengers and 4 crew, was climbing out of Madrid's runway 36L when the left hand engine (PW127) failed and needed to be shut down. The crew decided they could not accept runway 32L and landed the aircraft safely on runway 36L about 11 minutes after departure.

A replacement aircraft reached Vigo with a delay of 90 minutes.

Passengers reported the aircraft was shaking violently shortly after becoming airborne until the left hand engine was shut down. On final approach they overflew another runway just before touch down.

On Jun 27th 2013 Spain's CIAIAC reported that the crew received a #1 engine fire indication during the initial climb, worked the relevant checklists to shut the engine down and discharge the fire suppression system. The aircraft was vectored for a return to runway 32L, the crew however declared emergency and requested runway 36L, which was only used for takeoffs at the time. The aircraft landed safely on runway 36L after aircraft lined up and awaiting takeoff from 36L had been moved off the runway, the passengers disembarked normally. The CIAIAC have opened an investigation into the occurrence.

On Oct 9th 2015 the CIAIAC released their final report in Spanish concluding the probable cause of the incident was:

the detachment of a stage 2 turbine blade of the left hand engine. The vibration ration caused by this failure probably resulted in the rupture of an oil pipe distributing oil directly towards the hot sections of the engine causing a fire.

Improper Crew Resource Management and non-adherence to standard procedures by the crew resulted in an unintentional approach to an active runway which was exclusively used for takeoffs.

The CIAIAC reported that shortly after takeoff the crew received a fire indication for the left hand engine, shut the engine down and activated the fire suppression. The crew subsequently informed ATC about an engine problem informing ATC they would maintain 3500 feet MSL and needed to return to Madrid. The aircraft was cleared for an approach to runway 32L.

The fire indication did not extinguish despite completion of the relevant checklists however, the crew declared emergency, a short time later the fire indication ceased however after having been active for 2:26 minutes. The crew turned to align with runway 36L and declared their intention to land on that runway indicating they would not be able to go around. The controller immediately ensured the runway was vacated and cleared UX-7306 to land on runway 36L.

The CIAIAC annotated that the maneouver to land on runway 36L has high significance as there was no approach path designed for runway 36L and the approach path leads over villages and unusual installations.

A visual examination of the engine showed substantial damage to the last stage of turbine blades, evidence of overheated wires and pipes and oil stains. No damage was observed to the engine inlet and first stages of compressor blades, hence a foreign object damage was ruled out.

The crew consisted of the captain (44, ATPL, 8,330 hours total, no hours on type provided), a first officer (33, ATPL, 3,140 hours total, 655 hours on type) and the operator's chief pilot occyuping the observer's seat.

The CIAIAC analysed that during taxi and departure the crew engaged in discussion of logistical issues of the airline, personal matters and training issues with the chief pilot.

During the departure roll the left hand engine's Inter Turbine Temperature rose beyond the maximum limit of 765 degrees C before the aircraft reached V1, however, neither captain nor first officer noticed the parameter exceedance, the chief pilot did detect the indication outside permitted values but did not comment. The takeoff was continued rather than the correct decision to reject takeoff.

In response to the fire indication the crew initially delayed thrust lever actions until they were sure which engine the fire indication was for, then the left power lever was reduced to idle, the resulting thrust assymetry caused the autopilot to disconnect. The captain took manual control of the aircraft, and although the aircraft had already been cleaned up, asked whether they were already above acceleration altitude.

In the meantime the first officer, rather than putting the condition lever of the failed engine into feather, radioed ATC about the emergency, then moved the condition leaver into the feather position. The action however was incomplete, as the fuel cut off was not operated. The captain subsequently pulled the left fire handle but did not engage the fire agent, the chief pilot pointed the omission out about 30 seconds later. A hasty announcement to the passengers was made, the crew noticed that the fire indication was still active, the captain now called for the fire drill (which so far had not happened). 19 seconds after the fire drill was completed the fire indication ceased after having been active for 2 minutes and 26 seconds.

The CIAIAC continued analyses that the crew did not distribute tasks according to their roles with the captain as pilot flying taking control of the aircraft and radio and the first officer as pilot monitoring work the related checklists.

The captain subsequently indicated the intention to land on runway 32L. The first officer talking to ATC received an instruction to turn onto a heading of 140 degrees to join the downwind for runway 32L, the commander initated the turn however continued until a heading of 005 and aligned with the extended runway center line of runway 36L. The first officer reported they were on final to runway 32L.

An Iberia Airbus A319 had just lined up runway 36L.

At this point the captain realized they were on final approach to runway 36L and urgently requested the first officer to obtain landing clearance on 36L.

The CIAIAC analysed that the urgency of carrying out the landing as soon as possible, due to the long period of time the fire indication remained active, led to the loss of situational awareness by the captain which resulted in erroneous distribution of tasks, incorrect execution of memory items, incorrect execution of checklists and setting priority of communication over aircraft control and navigation.

Given the nature of the emergency it would have been prudent after the fire indication extinguished that the crew assessed their options, entered a long downwind to work the single engine checklist and before landing checklist to set the aircraft up optimally for the approach and landing.

The tower controllers, once responsible for runway 32L, the other responsible for runway 36L, were taken in surprise by the maneouvering of the aircraft. Once they had recognized the aircraft was not on final approach to runway 32L but on approach to runway 36L all departures from runway 36L were halted and the A319, already lined up for departure, was instructed to taxi off the runway. The controller subsequently cleared the Swiftair for landing on 36L.

The cause of the engine failure was identified as #30 blade fracture, which cracked as result of fatigue contributed to by corrosion aggravated by the presence of Sulphur. The failed blade caused damage to other engine components and resulted in vibrations which caused the #6 bearing vent pipes to fracture and spray oil onto hot parts of the engine resulting in a fire.
Incident Facts

Date of incident
Jun 24, 2013

Classification
Incident

Airline
Swiftair

Flight number
UX-7306

Departure
Madrid, Spain

Destination
Vigo, Spain

Aircraft Registration
EC-KKQ

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

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