Kasai B733 near Kisangani on Nov 17th 2013, engine shut down in flight

Last Update: February 4, 2015 / 16:33:17 GMT/Zulu time

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Incident Facts

Date of incident
Nov 17, 2013

Classification
Incident

Airline
Air Kasai

Flight number
751

Aircraft Registration
9Q-CGD

Aircraft Type
Boeing 737-300

ICAO Type Designator
B733

An Air Kasai Boeing 737-300, registration 9Q-CGD performing flight 751 from Kinshasa to Kisangani (DR Congo) with 120 passengers and 7 crew, was enroute about one hour into the flight when the left hand engine (CFM56) emitted strange loud noises which settled again, the flight was continued. The loud noises repeated about half an hour later prompting the crew to shut the left engine down, the aircraft continued to Kisangani for a safe landing about 2 hours after departure from Kinshasa.

The French BEA reported in their weekly bulletin that Authorities of the Democratic Republic of Congo (DR Congo) rated the engine failure a serious incident and opened an investigation.

Passengers reported the left hand engine was emitting very loud strange noises about one hour into the two hour flight, the noise disappeared again and the crew calmed everybody down, however, about 30 minutes later the noises reappeared in about same intensity. The engine was shut down and the aircraft made a hard landing in Kisangani.

According to ATDB Air Kasai leased the Boeing 737-300 MSN 23788 in from Gomair in October 2013.

On Feb 4th 2015 DR Congo's Bureau Permanent d’Enquêtes d’Accidents et Incidents d’Aviation (BPEA) released their final report via the French BEA concluding the probable causes of the serious incident were:

According to the flight data recorder the left hand engine surged and recovered, evident by transient drop in N1 that stabilized again. However, the EGT and fuel flow of the engine gradually increased indicating a degraded performance of the engine. 30 minutes after the first surge the engine surged again and did not recover causing autothrottle to disconnect. The crew eventually shut the engine down. It is probable that loss of material contributed to the deteriorating airflow inside the engine, e.g. increased space between blade tips and the casing of the engine, mechanical degradation of the engine blades.

The investigation concluded the cause of the serious incident was a latent technical factor.

The BPEA reported that the aircraft was enroute at FL330 with autopilot and autothrottle engaged when at 08:35Z the left hand engine "pumped" for a first time but recovered, N1 temporarily dropped but stabilized again, autothrottle and autopilot remained connected. EGT and fuel flow were slightly increased and stabilized again.

At 09:05Z the engine surged again, this time the engine did not recover, as result autothrottle disconnected. The engine was reduced to idle, N1 and N2 stabilized, EGT and fuel flow gradually increased.

At 09:09Z, while descending through FL310, the crew established first radio contact with Kisangani, at 09:21Z the left hand engine was shut down as engine vibrations rapidly increased from 4 to 5. The aircraft continued for a safe landing on runway 31 of Kisangani at 09:52Z.

The BPEA analysed that the engine had sustained foreign object damage on Nov 10th 2013 at Kisangani, according to the crew an inspection of the engine had been done, however, the BPEA stated, no documents indicating that examination or the results thereof were available. On Nov 12th 2013 the left hand engine ingested a bird on departure from Kisangani, no inspection was carried out as all engine parameters remained normal.

The left hand engine had accumulated 41,868 flight hours in 28,237 cycles and was due for the next work shop at 42,118 flight hours/28,487 cycles.

The cockpit voice recorder was overwritten by the time it was shut down.

The BPEA complained that the airline's maintenance is "poorly run" stating that no technical documentation of the aircraft was available, no documents detailing the engine oil and fuel quantities were available, incomplete recording of engine parameters, no safety management, no reporting system, no daily maintenance released before first flight of the day, non-approved GPS in use, no subscriptions to Airworthiness Directives and Service Bulletins, no training or retraining of crews, no documented release of the aircraft to service following the foreign object damages.
Incident Facts

Date of incident
Nov 17, 2013

Classification
Incident

Airline
Air Kasai

Flight number
751

Aircraft Registration
9Q-CGD

Aircraft Type
Boeing 737-300

ICAO Type Designator
B733

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