Easyjet A320 near Newcastle on Nov 28th 2016, fumes and smoke in cockpit
Last Update: September 14, 2017 / 14:20:50 GMT/Zulu time
A replacement A320-200 registration G-EZWM reached Hamburg with a delay of 4 hours.
The airline reported the aircraft diverted due to technical reasons.
The AAIB reported on Dec 8th 2016, that there was an electrical type smell in the cockpit shortly followed by whispy smoke during the climb out of Edinburgh. The occurrence was rated a serious incident and is being investigated by the AAIB.
On Sep 14th 2017 the AAIB released their bulletin releasing following conclusion:
Static inverter failure
The source of the smoke and fumes was traced to the cockpit additional electrical supply static inverter, which had overheated. The manufacturer of the static inverter isolated the fault to a component, capacitor C306, which had not received an individual quality screening prior to fitment. A batch of 2,058 static inverters were af fected.
The incident on G-EZWX was the eleventh failure reported to the aircraft manufacturer which had resulted in the release of smoke and fumes into the cockpit. Of the eleven failures, at least seven had resulted in diversions.
The operator was not aware until after the incident that the manufacturer of the static inverter had published VSB 1830-25-37, nor that the aircraft manufacturer had previously communicated the problem with the static inverters in TFU 24.00.00.114.
This was because the operator was not registered to receive notifications of VSB’s from the manufacturer of the inverter and, like another large UK operator, did not routinely review TFUs.
Following a decision in September 2016, the aircraft manufacturer subsequently issued OIT 999.0096/16 to all operators on 15 December 2016 to “broaden awareness” that the reason for the failure of the static inverter had been identified and had been published to address this.
Both the aircraft manufacturer and the operator intend further safety action, in addition to that which has already been taken.
Emergency interphone communications
Initial communications between the CM and co-pilot using the emergency interphone system failed to be established, as the co-pilot either inadvertently omitted to set up his audio control panel (ACP) to transmit on the cabin interphone channel or did not select the transmit button.
The CM was unable to hear the co-pilot and hung up his handset, which disconnected it from the emergency call. Communication was subsequently established with the CM about three minutes later when the co-pilot selected the forward interphone call option.
The investigation identified that neither information nor training was provided to crew on how to re-establish communications to the cockpit in the event that a cabin handset became disconnected from an emergency interphone call initiated from the cockpit.
Whilst an emergency call is in progress, it is not possible to initiate a call to the cockpit from a handset that has been disconnected. However, by selecting the emer call button on the disconnected handset’s keypad, the handset is reconnected to the emergency call, allowing communications with the cockpit and other cabin crew who are also on the call. The CM was not aware of this feature, but had he been, communications may have been established more quickly. The emergency interphone system is infrequently used, and therefore it is important that crew have a good understanding of its operation in the event of an emergency.
Both the aircraft manufacturer and the operator intend to take safety action to address this issue.
The AAIB reported that the crew became aware of fumes and smoke in the cockpit when the aircraft climbed through FL230. Both crew donned their oxygen masks, at the same time the "Avionics Smoke" indication activated. The captain assumed duties as pilot flying and communication while the first officer performed the checklists. At about that time the cabin became aware of fumes, the captain announced "Attention, crew at all stations", which alerted cabin crew to a potential emergency. The captain transmitted a Mayday Call and had to repeat the call as ATC initially did not understand the call due to the use of the oxygen masks.
About a minute after the first officer, while working the checklist, had selected Avionics Extract and had set the Blower to OVRD the smoke and smell began to dissipate. The first officer then selected interphone emergency call function, a flight attendant picked up the phone but could not hear the first officer, the first officer however heard the flight attendant. At about the time the flight attendant hung up the interphone the AVIONICS SMOKE indication ceased.
The first officer again attempted to contact the cabin, this time using the interphone call function (rather than the emergency function). The flight attendant in the cabin picked up the hand set, pressed and released the EMER button, a two way communication was now established about 3 minutes after the first attempt to contact the cabin.
The landing into Newcastle went without further incident, the engines were shut down. Emergency services inspected the aircraft, fumes were still noticed in the cockpit, the aircraft was electricalled powered down as a precaution.
A static inverter providing additional electrical supply to the cockpit was identified as source of smoke and fumes, when it overheated.
Following a number of static inverter failures the aircraft manufacturer released information in form of "Technical Follow Up" (TFU), which does not require any follow up and therefore was not follwed by the operator.
The AAIB analysed:
Smoke in the cockpit and the emergency use of oxygen by flight crews are considered to be safety issues by ICAO and, in Annex 13 Attachment C, cite them as possible examples of a Serious Incident. Following the G-EZWX event, the operator queried the aircraft manufacturer’s use of a TFU in this instance as it had concerns that the identified mechanism of the ‘capacitor failure due to overheating resulting in a smoke smell event should be classified as a safety issue and hence should have been clearly communicated to the operators.’ The failure of the static inverter on G-EZWX resulted in an unplanned diversion and the flight crew donning oxygen masks. As a consequence of the smoke and fumes released into the cockpit, this particular mode of failure of the static inverter has resulted in a total of seven aircraft diverting.
With respect to the communication problems over the Interphone the AAIB analysed:
It was most likely that the reason the CM had been unable to hear the co-pilot was because the co-pilot had not set his ACP to transmit on the cabin attendant channel, or he had omitted to select the radio transmit switch on his ACP or sidestick whilst speaking into the oxygen mask microphone. This led to the CM hanging up his handset, which disconnected it from the emergency call. The CM was then able to make a passenger announcement from the forward handset.
However, as the emergency interphone call was still active, it would not have been possible for the CM to have initiated an interphone call to either the cockpit or cabin crew at the rear of the aircraft, until the emergency call was cancelled. In the absence of any other action, this would have required the CM to wait for up to two minutes until the emergency call ‘timed out.’ Pressing the emer call button on his handset would have reconnected the CM to the emergency call immediately; however, the CM was not aware that this was required as it was neither documented nor covered in training.
Three minutes after having initially tried to establish communications with the cabin crew, a button press in the cockpit accompanied by a single call chime was recorded on the CVR. The CM removed his handset from its cradle and pressed and released the emer call button on the keypad before speaking into it. Communications were then established between the CM and co-pilot. The single call chime, followed by communications being established with the CM indicates that the co-pilot had selected the forward attendant call button at this time. This call was prioritised over calls initiated from the cabin and it was therefore not necessary for the CM to have selected the emer call function on his handset to connect the call.
This article is published under license from Avherald.com. © of text by Avherald.com.
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