ASN Wikibase Occurrence # 145469
Last updated: 28 February 2017
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Narrative:A Transasia ATR-72-500, registration B-22810, performing flight GE-515 from Taipei-Sung Shan Airport (TSA/RCSS) to Makung Airport (MZG/RCQC) with 72 passengers, was climbing through 5000 feet out of Taipei's Sung Shan Airport about 11 minutes into the flight when the crew received oil fluctuations for the #1 engine (PW127, left hand) followed by a fire indication (caused by a Power Turbine Stage 1 blade failure which resulted in fracture of the scavenge and vent tubes and an oil leak which became the trigger and source for the engine fire). The crew shut the engine down, activated the fire suppression system and returned to Sung Shan for a safe landing about 40 minutes after departure.
ATR 72-500 (72-212A)
|C/n / msn:|| 642|
|Fatalities:||Fatalities: 0 / Occupants: 72|
|Airplane damage:|| Minor|
|Location:||4km E Taipei-Sung Shan Airport -
|Phase:|| En route|
|Nature:||Domestic Scheduled Passenger|
|Departure airport:||Taipei-Sung Shan Airport (TSA/RCSS)|
|Destination airport:||Makung Airport (MZG/RCQC)|
Findings related to Risks include maintenance related, flight operations and Air Traffic Control (ATC):
Maintenance related finding include the no. 2 engine throttle did not reach the rated torque output of target value and meet the requirement of the flight operation in the occurrence.
Flight Operations related findings include the flight crew did not initiate ENG Fire memory items immediately prior to request air-turn-back, did not prioritize the tasks and flight management which increased the work load and influence the aircraft operation; the flight crew neither mention the aircraft was under single engine operation nor announce the emergency situation during the air-turn-back, therefore the controller was unable to acknowledge the situation, unfavorable for controllerís judgment, planning and assistance; the aircraft did not capture the ILS due to the flight crew did not Arm App Mode immediately, set the correct course and turn left heading to 45 degrees, the deviation was 1.273 dots and the aircraft was passing through the course; the flight crew altered the default altitude to 3,800 ft and cancelled AFCS ALT HOLD MODE of 2,800 ft and continue descending without receiving any updated clearance or GS MODE activation, the aircraft might deviated from the assigned attitude and closed to the ground obstacle; the flight crew did not climb immediately and obtain maximum obstacle separation as ATR72 EGPWS Enhanced Mode warning and recovery procedures required, led the aircraft emitted stall warning and temporary abnormal condition; the TransAsia Airways (TNA) ATR FCTM of EGPWS Mode 2 warning procedure was pitch the aircraft up to 25 degrees, this procedure might led the aircraft to stall condition due to the aircraft might be under low speed, different configuration, engine failure and other abnormal condition; the aircraft might have different configuration and need to maintain maximum climb speed when encountering EGPWS warning, the manufacture ATR-72 FCOM EGPWSs Mode 2 warning recovery procedure might need further explanation from the manufacture prior to flight crew initiate the procedure.
ATC related risk findings include when the approach control controller instructed GE 515 to intercept the final approach course, the aircraft was higher than the glide path; the approach controlís Air Situation Display (ASD) no longer displayed the Air Traffic Management System (ATMS) warning of the aircraft after the approach control handed over to control tower, the approach control was unable to initiate the potential safety risk reminder to the tower.
There are 5 other findings in the report.
Regarding to the recommendations related to the subject issue of 1st stage PT blade failures on PW100 engines caused by the micro-porosity problem, P&WC is in the process of reviewing the life limitation for 1st stage PT blades installed on the higher-powered PW100 engines. Maintenance Manual revisions to this effect are targeted to be released in the 2nd quarter of 2013. AD CF-2013-02, mandating compliance with P&WC SB 21823, requiring one time inspection of all PT blades been made between 2005 and 2008 period, in accordance with the enhanced X-ray inspection method introduced in March 2008, P&WC is also in the process of reviewing the inspection records of all 1st PT blades since the enhanced method was introduced to identify any quality escape due to human error. P&WC will release a new SB by the 2nd quarter 2013 to re-inspect all suspect blades post 2008. The ASC has incorporated the above information into the safety action taken accordingly.
A total of 17 safety recommendations issued to P&WC, ATR, TNA and CAA.
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