Vliegtuigongeval op 31 MAR 1998 met British Aerospace BAe-748-378 Srs. 2B G-OJEM

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Status:	Accident investigation report completed and information captured
Datum:	dinsdag 31 maart 1998
Tijd:	00:31
Type:	British Aerospace BAe-748-378 Srs. 2B
Luchtvaartmaatschappij:	Emerald Airways
Registratie:	G-OJEM
Constructienummer:	1791
Bouwjaar:	1982-04-01 (16 years )
Aantal vlieguren:	18352
Aantal vluchten:	19122
Motoren:	2 Rolls-Royce Dart 535-2
Bemanning:	slachtoffers: 0 / inzittenden: 4
Passagiers:	slachtoffers: 0 / inzittenden: 40
Totaal:	slachtoffers: 0 / inzittenden: 44
Schade:	Afgeschreven
Gevolgen:	Written off (damaged beyond repair)
Plaats:	London-Stansted Airport (STN) ( Verenigd Koninkrijk)
Fase:	Start (TOF)
Soort vlucht:	Binnenlandse charter
Vliegveld van vertrek:	London-Stansted Airport (STN/EGSS), Verenigd Koninkrijk
Vliegveld van aankomst:	Leeds/Bradford Airport (LBA/EGNM), Verenigd Koninkrijk

Beschrijving:
The HS-748 was cleared for a runway 23 takeoff at 23:29. The first officer was the handling pilot and the takeoff was to be made with full dry power; the water methanol system was selected to standby. At an airspeed of 111 kt the Commander called 'vee one, rotate', the first officer moved the control column rearwards and the aircraft became airborne. Less than five seconds after the 'rotate' call, at an airspeed of 115 kt and a height of between 30 feet and 100 feet agl, the no. 2 engine suffered a catastrophic failure resulting in a sudden loss of power and an immediate substantial nacelle fire. The aircraft yawed 11deg to the right of the runway heading. The Commander took over control and the crew were told by the senior cabin attendant that the right engine was on fire. Engine power was reduced and the aircraft yawed 14.5° to the left of runway heading. Four seconds later, the sound of the engine fire warning bell was recorded. The aircraft was in the air for a total period of 27 seconds before it touched down.
The aircraft ran off the end of the runway at 62 kt., crossed the perimeter track and came to rest with the collapse of the nose landing gear.

Probable Cause:

CAUSAL FACTORS:
"1. Significant reduction in the fatigue strength of the HP turbine disc due to surface corrosion.
2. Inadequate control of the fit between engine turbine assembly seal members, possibly influenced by inadequate turbine clamping bolt fit, causing sufficient reduction in the natural frequency of an HP turbine disc vibratory mode to allow its excitation within the normal operating speed range and consequent excessive stressing of the disc.
3. Fuel leakage from the engine bay fuel system, resulting in a major nacelle fire.
4. Failure to identify the turbine assembly seal member fit and HP turbine disc corrosion as possible contributors to disc fatigue damage after previous similar failures."

Accident investigation:

Investigating agency:	AAIB
Status:	Investigation completed
Duration:	3 years and 8 months
Accident number:	AAIB AAR 3/01
Download report:	Final report

Veiligheidsmaatregelen

AAIB issued 19 Safety Recommendations

Issued: 01-DEC-2001	To: Emerald Airways	2001-10
The operator ensures that the colour coding of the anchorages for the HS748 emergency escape slides are readily interpretable and are consistent with the descriptions in the aircraft operating and maintenance manuals.
Issued: 01-DEC-2001	To: CAA	2001-11
The CAA require the HS748 to be provided with an easily deploy able and effective means of descent from both fuselage rear doors in an emergency evacuation situation with any landing gear configuration.
Issued: 01-DEC-2001	To: CAA	2001-12
The CAA review the escape systems fitted to other UK public transport aircraft certificated to an earlier standard and require similar action where doubts exist as to their effectiveness. 4.6.
Issued: 01-DEC-2001	To: CAA	2001-13
The manufacturer and the CAA reassess the crashworthiness of the aircraft electrical system in the event of nose landing gear overload failure and take measures aimed at ensuring that safety-critical services remain operable in such a case. These services should include LP fuel cocks and engine bay fire extinguishers.
Issued: 01-DEC-2001	To: CAA	2001-14
The CAA require the aircraft manufacturer to consider measures aimed at ensuring that the LP fuel heater assembly in the HS748 engine bay can tolerate the displacements likely to result from a major failure of the engine rotating assembly without releasing fuel.
Issued: 01-DEC-2001	To: CAA	2001-15
The CAA review, in the light of advances in communication technology, its response to and reconsider Safety Recommendation 4.14, Aircraft Accident Report 8/88.
Issued: 01-DEC-2001	To: Rolls-Royce	2001-16
The engine manufacturer undertake further research with the aim of determining the causes of in-service deviation from the installation setting of Dart engine fuel burner flow and developing means of preventing variation beyond acceptable limits.
Issued: 01-DEC-2001	To: Rolls-Royce	2001-17
The engine manufacturer include a requirement in the Engine Overhaul Manual for an as-received burner flow check for the Dart engine at all maintenance shop visits. The Manual should also include requirements for any turbine disc action necessitated by the flow check results that fully reflect the latest knowledge on the possible effects of burner flow deviation on the discs.
Issued: 01-DEC-2001	To: CAA	2001-18
The CAA review and revise as necessary the requirements for the recording of maintenance actions with the aim of ensuring that information essential to the further operation and maintenance of the aircraft is readily available.
Issued: 01-DEC-2001	To: CAA	2001-19
The CAA require the engine manufacturer to designate repair schemes in such a way that the standard that has been used on any particular occasion is readily apparent.
Issued: 01-DEC-2001	To: CAA;Rolls-Royce	2001-20
The engine manufacturer and the CAA reassess the susceptibility of the three-stage Dart turbine to HCF failure and ensure that effective action aimed at preventing recurrence has been taken.
Issued: 01-DEC-2001	To: CAA;Rolls-Royce	2001-21
The CAA and the engine manufacturer consider the need for further improvement to their systems intended to ensure effective action to prevent recurrence following potentially catastrophic in-service failures of UK type-certificated equipment used on public transport aircraft.
Issued: 01-DEC-2001	To: CAA	2001-22
The CAA review the adequacy of their current procedures to ensure that aircraft being entered into th~ UK Register have DFDR installations that satisfy the requirements of applicable performance specifications.
Issued: 01-DEC-2001	To: CAA	2001-23
The CAA provide adequate guidance material on the subject DFDR installations to all personnel responsible for the surveying and regulation of such installations.
Issued: 01-DEC-2001	To: CAA	2001-24
The CAA, in conjunction with operators, review the DFDR installation of aircraft on the UK Register which are fitted with the type PV1584 DFDR to determine compliance with the applicable minimum performance standards.
Issued: 01-DEC-2001	To: CAA	2001-25
The CAA should require that, during a mandatory DFDR installation calibration, a range of expected data values should be stipulated for every point of a transducer\'s travel that is tested. These range values should be stated in either the calibration test procedure or the appropriate test results sheet.
Issued: 01-DEC-2001	To: CAA	2001-26
The CAA should require that, during a mandatory readout of a DFDR, a section of the read out data should be examined to determine that all parameters have been recorded in accordance with the repetition rate specified in the data frame layout and conversion document pertinent to the DFDR installation being assessed.
Issued: 01-DEC-2001	To: CAA	2001-8
The CAA require modification of the PA/Interphone system on HS 748 aircraft at the rear cabin attendant position to render the handset and its controls accessible to an attendant strapped into the aft cabin crew seat.
Issued: 01-DEC-2001	To: CAA	2001-9
The manufacturer revise and the CAA approve an amendment to the HS748 Flight Manual to emphasise the importance of LP fuel cock closure as a priority action in the event of an engine bay fire. The CAA should consider whether similar measures are necessary for other aircraft types.

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Foto's

accident date: 31-03-1998
type: BAe-748-378 Srs. 2B
registration: G-OJEM

accident date: 31-03-1998
type: Hawker Siddeley HS-748-378 Srs.2B
registration: G-OJEM

Kaart

Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen London-Stansted Airport en Leeds/Bradford Airport bedraagt 252 km (158 miles).

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.

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