ASN logo
ASN Wikibase Occurrence # 179599
Last updated: 4 October 2019
This information is added by users of ASN. Neither ASN nor the Flight Safety Foundation are responsible for the completeness or correctness of this information. If you feel this information is incomplete or incorrect, you can submit corrected information.

Date:09-SEP-2012
Time:06:49
Type:Silhouette image of generic DH8C model; specific model in this crash may look slightly different
de Havilland Canada DHC-8-315Q Dash 8
Owner/operator:Abu Dhabi Aviation
Registration: A6-ADB
C/n / msn: 650
Fatalities:Fatalities: 0 / Occupants: 49
Other fatalities:0
Aircraft damage: Minor
Category:Incident
Location:near Abu Dhabi -   United Arab Emirates
Phase: En route
Nature:Domestic Scheduled Passenger
Departure airport:Abu Dhabi International Airport (OMAA)
Destination airport:Das Island Airport (OMAS)
Investigating agency: GCAA UAE
Narrative:
The DHC-8-315Q aircraft, registration A6-ADB, operated by Abu Dhabi Aviation, departed from Abu Dhabi International Airport (OMAA) at
06:45 LT on a scheduled 35-minute passenger flight, to Das Island Airport (OMAS) with 49 persons on-board. After several minutes in flight, and before reaching 5,000 feet, a passenger informed the cabin crew member about signs of paint blisters on the right hand engine inboard panel, as seen through the cabin window.
The passenger's observation was confirmed by the co-pilot who informed the captain of a possible engine fire. A PAN was declared and Abu Dhabi air traffic control (ATC) gave an immediate clearance for landing. Cockpit indications were normal but the crew decided to return to the airport due to the possibility of an engine fire. Unknown to the crew and passengers, the same condition also existed on the left hand engine.
The aircraft landed uneventfully and the airport fire service confirmed that there was no sign of fire. No injury was reported among the passengers or crew members.

Causes:
The Air Accident Investigation Sector determines that the cause, of this incident, which resulted in an 'in-flight turn back', was due to the omission to reinstall the left engine igniters on both of the aircraftís engines following maintenance work. The maintenance error occurred as result of a number of contributing factors.

The Contributing factors to the event were:
(a) Unrecorded maintenance work performed on the Aircraft by the Operatorís maintenance personnel.
(b) Introduction of an engine wash without a maintenance task card.
(c) Engineer signed off work on the aircraft without verifying that the work had been performed.
(d) Mechanics performed unsupervised work.
(e) Mechanics performed engine motoring without the Operatorís approval.
(f) Work was performed on the aircraft without maintenance task card.
(g) Engine washes were not considered a critical task by the Operator.
(h) Performing similar tasks on both engines during the same maintenance visit.
(i) Not carrying out an engine run after the engine washes were performed
(j) Not performing a system check of the engine ignition system after engine wash normalization.
(k) Not attaching a telltale streamer to indicate that parts have been removed and are in a concealed area.
(l) Operatorís quality oversight, as unrecorded work was being performed regularly prior to the Incident.
(m) Mechanics not signing for work performed, following engine washes.
(n) The removal, in 2009, of the engine wash card which was requiring a signature by the mechanic, before the engineer signoff.
(o) The effect of fatigue on the decision making process of the Engineer due to his shift pattern of working an average of 8.5 hours a day for 32 days with 2 staggered days off.
(p) The Engineer, in addition to supervising the shift work, was required to enter data into the Operatorís electronic system.
(q) Application of the Operatorís human factors training, as unrecorded work was a practice associated with engine washes.
(r) The Operatorís SMS implementation, since there were GCAA audit findings between 2009 and 2012.
(s) Lack of guidance provided by the GCAA, and the Operator, of the effect of shift duty times, and management of the risk associated with fatigue.

Sources:

Accident investigation:
cover
  
Investigating agency: GCAA UAE
Status: Investigation completed
Duration:
Download report: Final report


Revision history:

Date/timeContributorUpdates
16-Sep-2015 09:24 harro Added

Corrections or additions? ... Edit this accident description