A330/Trent700 Fuel Contamination, Dual Eng

Loss of Thrust Control

Presented by
Christopher McGregor , Head of Accident/Incident Investigation
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.
Rome, 21-24 March 2011 17th Flight Safety Conference
Event description
Technical description
Certification and Fuel Quality
Operational aspects
Conclusion
Content
Page 2
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Event Summary
A330-300, Trent 772
Scheduled flight from Surabaya (Indonesia) to Hong Kong, 13/04/2010
During descent, approach and landing the aircraft encountered a loss
of thrust control event affecting both engines
Engine 1 remained at 70% N1, Engine 2, sub-idle
An emergency landing was made at HKG,
Aircraft landed at a ground speed of approx 240 knots, conf 1.
On landing (bounce), the lower cowling of No. 1engine contacted the
runway surface.
The aircraft stopped 3,300m beyond threshold, on the runway.
During the emergency evacuation there was one serious injury.
Subject to a formal investigation led by the Hong Kong CAD
Rome, 21-24 March 2011 17th Flight Safety Conference
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Event Summary climb, cruise, top of descent
Rome, 21-24 March 2011
EPR Fluctuations
observed by the
flight crew during
climb
01:20
ENG 2 CTL SYS FAULT
ENG SLOW RESPONSE
01:58
FL340
ENG 2 CTL SYS FAULT
AVOID RAPID THR CHANGES
ENG2 STALL
ENG 1 CTL SYS FAULT
05:19 05:30
8000ft
ENG 1 STALL,
ENG 2 dropped to sub-idle and
remained sub-idle for remainder of flight
CAS starts to decrease below target
300kts
A/THR disconnected
TRA2 & TRA1 advanced but
no thrust increase TRA1 set
to climb notch, N1 increased
from 35 to 45% but no
decrease when TRA1 was
set back to idle
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ALT
UTC
UTC
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Descent
5500ft
05:36
TRA1 briefly set to MCT, EPR
actual increases to 1.30 (N1 75%)
and remains stuck at this level.
CAS increases above 200kts
05:40
ENG2 re-start attempt
but remains sub-idle
CONF 1 selected
CAS 212 knts
TRA1 set to idle
CAS stabilises at 220kts
Significant sideslip
ENG1 multiple stalls
Airbrakes fully extended
Landing gears extended at 233kts
Side-stick nose down inputs
CAS 236kts
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ALT
UTC
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Touch down
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05:40
CONF 2 selected at 234kts but
only CONF 1 reached
VFE warning triggered till
touchdown
Above ILS beam
CAS 230 kts
-1600ft/min
Pitch zero
Autobrake armed (low mode)
Ground spoilers armed
05:42
500 ft
Passing 80ft
CAS 241kts (VFE + 35)
-1000ft/min
800 ft
RH crosswind 20kts
Touch down 1,350m from
threshold with 5 of right drift
angle
NLG and RH MLG bounce
Nz +0.30g / +1.80g.
Max manual braking
Full reverse were applied
Reverse #1 deployed
Reverse #2 remained stowed.
The aircraft stopped 3,300m
beyond threshold, on the runway.
3300 m
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ALT
UTC
GPWS triggered
TOO LOW TERRAIN
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Rome, 21-24 March 2011 17th Flight Safety Conference
Event description
Technical description
Certification and Fuel Quality
Operational aspects
Conclusion
Content
Page 7
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.
Rome, 21-24 March 2011 17th Flight Safety Conference
Fuel
FILTER
HMU
HP PUMP
FOHE
LP PUMP
FILTER
HP PUMP
FOHE
LP PUMP
Fuel from aircraft fuel tank
To engine
combustor
FMGEC
(Autothrust)
Throttle Lever
Angle
FADEC
Thrust demand
Aircraft airspeed
Flight mode
Main
metering
valve
A330/Trent 700 Fuel Control
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Contaminants ranged
from 5 to 40 microns
Typical clearance 7
microns
Main metering valve - contaminated
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Microspheres composition
Microsphere composed of salt, water and Super Absorbent
Polymer.
Presence of Salt is Critical
The presence of salt has resulted in a more dense and stable SAP
structure in comparison to known SAP migration
Dried microsphere with
salt on surface
Effect of absorbing water
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Failure to stop refuelling on delta pressure rise:
Monitor elements damaged
Training procedures not applied
Refuelling continued after pressure rise
Failure to follow Hydrant re-commissioning procs.
Hydrant lines not flushed through fully
Salt water contamination left in system
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Fuel Quality Assurance Failures
WATER
SALT
No system for continuing analysis/surveillance
No continuous analysis
No inspection program
No notification of system coming back on line
Oversized Hydrant Dispenser Filter Monitors
System optimised for 4 to 8 times typical refuel rates
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HK CAD Recommendations
7.1 Recommendation 2010-1
The J uanda Surabaya Airport Development Taskforce) should,
......conduct an extensive review of the re-commissioning procedures of
hydrant refuel system in accordance with the best practice in aviation
fuel industry.
7.2 Recommendation 2010-2
The J uanda Surabaya Airport Development Taskforce should ensure
the re-commissioning procedures are completed before resuming the
hydrant refuelling operation for Stands No. 1 to 10 at WARR.
Rome, 21-24 March 2011 17th Flight Safety Conference
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AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.
Rome, 21-24 March 2011 17th Flight Safety Conference
Event description
Technical description
Certification and Fuel Quality
Operational aspects
Conclusion
Content
Page 13
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Engine certification J AR-E E670
Industry standard MIL-E-5007 debris
Largely hard particulates
Majority 0-5micron
Deliberately biased to cover debris size likely to be
generated (a/c, pipelines etc)
Engine cert defines quantity and size of contaminant
to be tested.
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Engine certification
Requirements (filtered)
500 hours at 0.5gm/4500lt= 196gm total debris
Requirement (unfiltered)
Must be able to complete half the longest flight at a rate of
4.5gm/4500lt after filter blockage warning= 31.5gm total
debris
Nominal engine filter capability 40
microns max capability 10
microns.
The filters (engine 1 and 2 did not
go into bypass) hence no filter clog
indication.
Rome, 21-24 March 2011 17th Flight Safety Conference
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Fuel Quality Control
Industry standards and guidelines exist,
SIL28-094, (ASTM D 1655, DEF STAN 91-91)
Aviation Fuel Quality Requirements for Jointly
Operated Systems (AFQRJOS)
International Fuel Quality Pool (IFQP) Standard,
Joint Inspection Group (JIG)
SAE 6401 Storage, Handling and Distribution of Jet
Fuels at Airports (issue imminent), ...etc
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EASA: Part M, subpart C, AMC M.A.301-1c
....consumable fluids, gases, etc. uplifted prior to flight are
of the correct specification, free from contamination and
correctly recorded.
Globally, self regulation has assured fuel quality and development of
harmonised international standards
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Available technology to improve jet fuel quality
Rome, 21-24 March 2011
Pressure sensing
In line, real time, automatic
operation
Particle counters
In-line full flow design
No sampling errors
Near-real time information
Distinguishes/quantifies both
solid particles and free water
Automatic operation
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Way Forward
Following Airbus and Operator request, IATA have agreed to take
the lead and develop an oversite proposal to ICAO:
Workgroups:
Supply group: (All aspects from Refinery to Airport Storage)
Storage group: (Airport Storage and Hydrant Systems)
Provision group: (Vehicles, Pressure control and Into-plane)
Proposals to be submitted mid 2011.
Engine manufacturers requested to review FMU designs.
Airbus have commissioned a laboratory to reproduce microsphere
contamination to ensure effective testing of future FMU designs.
Rome, 21-24 March 2011 17th Flight Safety Conference
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AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.
Rome, 21-24 March 2011 17th Flight Safety Conference
Event description
Technical description
Certification and Fuel Quality
Operational aspects
Conclusion
Content
Page 19
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.
Operational considerations new development
Rome, 21-24 March 2011 17th Flight Safety Conference
ENG 1(2) CTL SYS FAULT
AVOID RAPID THRUST CHANGE Or ENG 1(2) SLOW RESPONSE
With rapid and continuous EPR fluctuation indications on BOTH ENG
Apply the following paper procedure:
- A/THR.............................................................................OFF
If EPR fluctuations on both engines stop:
- ECAM PROC..................................................... APPLY
- A/THR..........................................................KEEP OFF
If EPR fluctuations on both engines continue:
- FUEL CONTAMINATION PROC.......................APPLY
Page 20
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.
Operational considerations new development
Rome, 21-24 March 2011 17th Flight Safety Conference
ENG 1 CTL SYS FAULT
ENG 2 CTL SYS FAULT
AVOID RAPID THRUST CHANGE Or ENG 1(2) SLOW RESPONSE
Apply the following paper procedure:
- A/THR.............................................................................OFF
- FUEL CONTAMINATION PROC...............................APPLY
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Operational considerations new development
Rome, 21-24 March 2011 17th Flight Safety Conference
FUEL Contamination procedure (under review)
A fuel contamination may result, in the worst case, in a loss of
engine thrust control.
Aim: Maintaining the thrust on one engine and Minimizing the
thrust changes on the other, in order to prevent contaminant from
blocking the mechanical devices of engine thrust regulation.
LAND ASAP
A/THR..................................................................KEEP OFF
MAN THR............................................. SET and MAINTAIN
Page 22
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.
Rome, 21-24 March 2011 17th Flight Safety Conference
Event description
Technical description
Certification and Fuel Quality
Operational aspects
Conclusion
Content
Page 23
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.
Conclusions
Fuel contamination traced to refuel dispenser
On-ground technology available to improve level of protection at point
of refuel.
IATA Fuel Working Groups formed. Oversight recommendations to
ICAO, mid 2011
Manufacturers engaged in further research and development,
New operational guidance to assist flight crews
Rome, 21-24 March 2011 17th Flight Safety Conference
Continue to enforce established fuel quality procedures
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