fredag 7. juni 2019

DC-3 - Alvorlig hendelse i fjor - Rapport akkurat ute - ASN

Date:14-AUG-2018
Time:17:54
Type:Silhouette image of generic DC3 model; specific model in this crash may look slightly different
Douglas DC-3C
Owner/operator:Flygande Veteraner
Registration:SE-CFP
C/n / msn:13883
Fatalities:Fatalities: 0 / Occupants: 5
Other fatalities:0
Aircraft damage:Substantial
Category:Serious incident
Location:near Linköping City Airport (LPI/ESSL) -    Sweden
Phase:Take off
Nature:Ferry/positioning
Departure airport:Linköping-Saab Airport (LPI/ESSL)
Destination airport:Västerås-Hasslo Airport (VST/ESOW)
Investigating agency: SHK Sweden
Narrative:
The aircraft stranded at Groningen Airport, the Netherlands on Friday 13 July when a loss of oil pressure was noted when starting up engine no.1. It turned out that this was caused by some internal engines that necessitated an engine change. This was accomplished and the aircraft took off on August 14, bound for Sweden. 
It was flown without remark to Linköping. When the aircraft took off again towards Stockholm/Västerås Airport, the fire warning for the left engine was activated. 
The crew feathered the engine and activated the fire extinguishing system, but this had limited effect. The crew informed air traffic control of the fire, carried out a visual approach, which was aborted with a go-around, and then landed on the opposite runway. The brakes gave no effect during the landing roll. The running engine was turned off, the aircraft left the runway and stopped on the strip. 
The aircraft was evacuated and the airport rescue services extinguished the engine fire. There were no injuries sustained. However, there was substantial damage on the aircraft’s left engine nacelle and its accessory compartment. 
The investigation of the wreckage revealed that three screws were missing on the exhaust collector. This led to parts of the exhaust system coming loose and to the exhaust flow causing a fire in the left engine, igniting oil residue and melting parts of the engine cowling. Several hydraulic lines melted and subsequently leaked oil, which added combustible to the fire. The control valve of the cowl flaps was not closed according to the emergency checklist. 
The engine change in Groningen deviated from the operator service manual, as it was carried out without a work order. 
The operator has taken measures to ensure, among other things, that a work order is used in specially planned maintenance. 
The incident was caused by the engine change being carried out without following the operator’s established procedures for specially planned maintenance. 
The following factors contributed to the extent of the fire: 
- The design of the existing hydraulic system, which does not allow the hydraulic oil to be isolated from engine zone 2. 
- The failure to close the control valve of the cowl flaps (item “trail-off” in the engine fire emergency checklist). 





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