Danish AT72 at Bornholm on Dec 3rd 2016, smoke in cockpit and cabin

Last Update: March 5, 2018 / 14:28:53 GMT/Zulu time

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Incident Facts

Date of incident
Dec 3, 2016

Classification
Incident

Flight number
DX-31

Aircraft Registration
OY-LHA

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

A Danish Air Transport Avions de Transport Regional ATR-72-200, registration OY-LHA performing flight DX-31 from Bornholm to Copenhagen (Denmark) with 14 passengers and 4 crew, was climbing out of Bornholm's runway 29 when the crew reported smoke in cockpit and cabin, stopped the climb at 2500 feet and landed back on runway 11. The aircraft was evacuated.

The airline reported that maintenance inspected the engines (PW124) and found severe internal damage to the #1 engine. The engine was replaced.

On Dec 15th 2016 Denmark's HCL reported that a few minutes after departure from runway 29 smoke appeared in the cockpit that increased in intensity. The crew received a low oil pressure warning for the left hand engine and indication of 30% loss of torque of the left engine. The crew donned their oxygen masks, shut the engine down and declared emergency reporting smoke in cockpit and cabin. The aircraft returned for a landing on runway 11 about 4 minutes later. There were no problems with the flight controls or other technical issues. One flight attendant put on their smoke hood, the other flight attendant attempted to open the bag of the smoke hood without success. A passenger observed abnormal noise, sparks and a flame from the left engine just when the smoke started. The occurrence had been rated a serios incident and is being investigated by the HCL.

On Mar 5th 2018 Denmark's HCL released their final report concluding the probable causes of the serious incident were:

A failure of the no. 2 bearing in the no. 1 engine most likely caused an engine seizure.

Consequently, smoke entered the aircraft through the air conditioning system.

During the serious incident:

- The senior cabin attendant (CA 1) attempted without success to extract her protective breathing equipment (PBE) from the protective bag.

- Neither cabin crew nor passengers heard the passenger address (PA) announcements made by the left hand seated pilot.

The serious incident occurred in dark night and under visual meteorological condition (VMC).

The HCL analysed: "The borescope inspection and the teardown examination of engine no. 1 revealed that failure of the no. 2 bearing most likely caused the engine seizure."

The HCL continued: "Because of the no. 2 bearing failure and the engine seizure, smoke mixed with compressed air was extracted via the LP stage – or via the HP stage and HP valve – into the aircraft pneumatic system. The smoke contaminated air proceeded then via the Bleed valve and the Pack valve to the LH pack. After the smoke contaminated air was processed in the LH pack, it was routed via the air conditioning supply duct to the cockpit and cabin outlets."

The HCL analysed further:

The CA 1 was not able to open the protective bag containing her PBE during the sequence of events despite of the facts that:

- she had completed her annual recurrent Emergency and Safety Equipment training provided by the operator less than one week prior to the time of the event

- one other participant at the training session demonstrated how to open a similar PBE protective bag

- the operator’s approved Operations Manual Part D included specific training requirements for PBE (and fire and smoke) which were consistent with the required European Commission regulations (EU) 290/2012 and 965/2012 and the EASA AMC & GM to Annex III – Part-ORO

- design specifications for the PBE required “The unit shall be capable of being easily donned and activated, after gaining access to the stowed unit within 15 seconds.” which was reflected in TSO-C116 and E/TSO-C116, both referring to AS8047.

The HCL reported that a safety action was taken by the operator: "Due to this serious incident, the operator recognized the PBE opening issue and replaced all their PBE’s similar to the one installed on this serious incident flight (part number 110093-11) with an updated version of the PBE (part number 110093-21). The updated version incorporated a cut in the seam between the rip-tag and the vacuum protective bag, which should enable an easier opening of the PBE protective bag. Additionally, the operator is considering implementing changes to their future PBE training of cabin crews."
Incident Facts

Date of incident
Dec 3, 2016

Classification
Incident

Flight number
DX-31

Aircraft Registration
OY-LHA

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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