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ASN Wikibase Occurrence # 228978
Last updated: 12 September 2019
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Date:12-OCT-2018
Time:01:55 UTC
Type:Silhouette image of generic B734 model; specific model in this crash may look slightly different
Boeing 737-4Q8 (SF)
Owner/operator:West Atlantic UK
Registration: G-JMCR
C/n / msn: 25372/2280
Fatalities:Fatalities: 0 / Occupants: 2
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:en-route to East Midlands Airport -   United Kingdom
Phase: En route
Nature:Cargo
Departure airport:Amsterdam-Schiphol International Airport (AMS/EHAM)
Destination airport:East Midlands Airport (EMA/EGNX)
Investigating agency: AAIB
Narrative:
The crew reported for work at Leipzig Halle Airport, Germany, on the evening of 11 October 2018. They were rostered to operate a three-sector day from Leipzig to Amsterdam Schiphol Airport, then to East Midlands Airport and finally to Aberdeen Airport.
On arrival at the aircraft, the crew met with the pilots who had flown the aircraft into Leipzig and briefly discussed that the aircraft was operating with an Acceptable Deferred Defects (ADD) for an inoperative Gen 1.
The aircraft was permitted to operate under Minimum Equipment List (MEL) 24-1b providing the APU, and its generator, were run during the flight. In this condition the No 1 electrical system was powered by the APU generator and the No 2 system by the engine-driven generator on the right engine (Gen 2).
At 22:43 UTC, the aircraft departed from Leipzig and the flight was without incident until the landing at Amsterdam when the co-pilotís flight instruments, which are powered by the No 2 electrical system, intermittently blanked and several electrical warning lights on the overhead panel illuminated intermittently. The crew were unable to determine the cause of the problem and concluded that Gen 2 had failed, leaving the APU generator providing the only electrical power to the AC busses. They attempted to select the APU generator to provide power to the No 2 electrical system, but it would not connect. The aircraft was taxied to the parking stand and shut down.
The crew were aware that the MEL did not allow the aircraft to dispatch with only a single generator functioning and, therefore, the crew contacted the operatorís Line Maintenance Control (LMC) who arranged for an engineer in Amsterdam to attend the aircraft. After around 30 minutes, the engineer arrived at the aircraft and was briefed by the commander. He was seen to open the cowlings on the right engine in order to examine Gen 2; he also checked the relevant circuit breakers and Panel M238 on the sidewall of the cockpit. The engineer informed the crew that he had reset a circuit breaker and was confident that this was the cause of the problem but would require the right engine to be run in order to ensure that the engine generator was working correctly. The engine run was performed satisfactorily and the generator on the right engine and the No 2 electrical system worked normally. The engineer cleared the entry in the aircraft technical log and as part of their pre-flight preparation the crew discussed the actions they might take in the event they lost the remaining engine generator. The aircraft departed Amsterdam with the original ADD for an inoperative Gen 1.
The flight was without incident until the aircraft was approximately 60 nm from East Midlands, with the co-pilot as PF, when during the descent the autopilot disconnected, the co-pilotís screens lost power and his flight instruments failed. The commander took control and disconnected the autothrottle as he was flying the aircraft manually. Numerous lights on the overhead panel and system annunciation panels illuminated and flashed, and multiple aural warnings were generated by the Terrain Avoiding Warning System (TAWS). As both crew members were visual with the runway, the commander instructed the co-pilot to make a PAN call and ask for vectors straight onto the ILS at East Midlands. During the next 20 minutes, and until the aircraft landed, the flight instruments on the co-pilotís side came on and off numerous times.
The commander manually flew an ILS approach onto Runway 27. The aircraft controls, flaps and gear worked normally although the distracting flashing warning lights and aural callouts continued throughout the approach. On landing, numerous aircraft systems failed including the autobrakes (although manual braking remained available), half the exterior lights and the commanderís speed indications on his electronic attitude display indicator. On reaching the stand, the crew were unable to connect the electrical ground power to the aircraft system.
While the flaps were retracted, the flap indication showed them still deployed. No electrical power was available to the cargo door, cargo bay and multiple items on the flight deck.

AAIB Conclusion
This serious incident was caused by the incorrect racking of GCU 2 which moved forward in flight initially causing an intermittent and then total disconnection of the electrical connector. The aircraft was not designed to operate with the GCU disconnected and the crew were presented with an unusual situation that was not covered in the QRH.
The activities surrounding the management of the faults on G-JMCR during the previous 12 days, and the actions of the crew in handling the emergency, indicates a weakness in the operatorís policies and procedures for the management of risk. Engineers were not always given sufficient time to investigate the faults, with the result that fault finding was often repeated and not finished. Work at a number of locations was not recorded as having been carried out in the aircraft documentation. The aircraft was dispatched from its main operation base with an ADD and flew through a number of locations where it could have been cleared, which was contrary to the procedures in the Operation Manual.
Communication between LMC, the commander and the Part 145 organisation at Amsterdam was ineffective in highlighting the underling technical problems on the aircraft.
The engineer was unaware of the full history of the faults and the concerns that LMC conveyed to the commander that there was a ďserious electrical fault on the aircraftĒ. The engineer was tasked with resetting the generators and spent less than 30 minutes at the aircraft. Despite the ongoing concerns with the electrical systems previously raised by a number of engineers and crews, and the unusual set of failures that occurred during the landing at Amsterdam, LMC did not carry out any form of risk assessment or ensure a deeper investigation was carried out before the aircraft departed Amsterdam. While the commander had the ultimate decision on accepting the aircraft, he was new to the company and may have relied on the advice of the engineers without being aware that the engineer had only been tasked with resetting the generators.
The operator had previously identified that there was a need to restructure LMC, introduce the post of Defect Controller and provide staff with further training to improve their competency.

Sources:

AAIB

Accident investigation:
cover
  
Investigating agency: AAIB
Status: Investigation completed
Duration: 11 months
Download report: Final report


Revision history:

Date/timeContributorUpdates
12-Sep-2019 19:57 harro Added

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