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Attributes | |
ACN | 398789 |
Time | |
Date | 199803 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : koa |
State Reference | HI |
Altitude | msl bound lower : 900 msl bound upper : 900 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tower : koa |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial other other |
Route In Use | departure other enroute : pacific |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : instrument pilot : atp pilot : commercial |
Experience | flight time last 90 days : 117 flight time total : 13000 flight time type : 6800 |
ASRS Report | 398789 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : declared emergency other |
Consequence | other Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | other |
Narrative:
After takeoff and gear retraction, with maximum power (2.01 EPR), flaps 5 degrees at 800-900 ft MSL, we experienced a loud bang from #1 engine followed by sudden loss of power. EPR rolled back from 2.01 to approximately 1.50. Engine and aircraft vibrated severely until throttle was reduced. We declared an emergency, climbed to 3000 ft MSL and stayed in the traffic pattern. The engine continued to run at idle with moderate vibration. We completed qrm checklists, briefed the cabin crew and returned for uneventful landing. After landing, we inspected the engine and it was obvious catastrophic failure was caused by failure of high speed components. Tear down of engine later discovered failure of T1. This is the second catastrophic engine failure I have experienced in a B737 at this company in last 13 months. Both occurred at 2ND segment climb. The cause of the first catastrophic engine failure was the same, failure of T3 and T4 -- reported to ASRS in feb 1997. I have flown helicopters and GA aircraft for 26 yrs. I have had 3 complete engine failures, 1 in a piper chieftain, 2 in a B737, none in helicopters. What's wrong with this picture? Callback conversation with reporter revealed the following information: reporter stated that this was his 2ND B737 engine failure since feb 1997. The engine involved is a jt-8D-9A series that was purchased from a 'third world' country. Reporter claims that these engines that were purchased in a large order were defective or 'bad' engines. The airline canceled the purchase inspection requirements and placed the engines into service without a major, minor or acceptance inspection. The 'bad' quote was from the airline's engine manager who is currently out on 'stress disability.' the reporting captain alleged that on the weekend of his event there were 2 other engine shutdowns on his airline, one with engine oil loss and one with an in-flight engine fire warning indication that required a 2 bottle application of the fire extinguisher. The indication on that one was apparently false. He cited 4 turbine failures in a 13 month period from feb 1997 to now. The reporter is very unhappy with the airline maintenance policy. The company has 3 degrees of ratings so far as aircraft stability goes. These are the reporter's ratings. By stability he was referring to the aircraft's center of gravity being in the norm or neared the aft end of the aircraft's allowable center of gravity or mean average chord (mac). The convertible cargo aircraft are the most stable, the standard aircraft are average but two of the aircraft (purchased from a foreign carrier) are very marginal, being very close to the aft end of the allowable 'mac.' both of his engine failures occurred on these 'sister' aircraft. The first one in 1997 had a tail heavy feeling and failed to perform as expected, actually losing altitude at 500 ft AGL until he over boosted the remaining engine. The aircraft was very tail heavy and did not fly like the simulator. These 2 aircraft were 'demoded' from hush kitting and had aft airstairs added for weight and balance. Since then 10 additional seats were added and the aircraft now has to either have a nose ballast added or lead weights placed in the forward cargo compartment to counter-balance the added seats. The airline has tinkered around with the passenger weights and fuel loads in order to try to resolve this issue. The company and the pilot's union have either ignored him or failed to pass on any relative information as to 'fixes.' the airline had an unofficial, unwritten, law of a 1 to 15 ratio of 1ST class passenger to coach passenger and would upgrade on a 'balance or ballast' basis. This worked until the paying 1ST class passenger and frequent traveler coach passenger complained (unknowingly as to the reason) of this apparently unfair practice. The airline had recently changed their maintenance contractor to another more reliable airline service and are attempting to get the aircraft to ETOPS standards. This is a concern when viewing the past engine performances as experienced by the reporter.
Original NASA ASRS Text
Title: A B737-200 RETURNS LANDS AT KOA DUE TO CATASTROPHIC ENG FAILURE. POSTFLT INSPECTION REVEALED A FAILURE OF THE T1 1ST STAGE COMPRESSOR WITH SUBSEQUENT ENG DAMAGE AND FAILURE.
Narrative: AFTER TKOF AND GEAR RETRACTION, WITH MAX PWR (2.01 EPR), FLAPS 5 DEGS AT 800-900 FT MSL, WE EXPERIENCED A LOUD BANG FROM #1 ENG FOLLOWED BY SUDDEN LOSS OF PWR. EPR ROLLED BACK FROM 2.01 TO APPROX 1.50. ENG AND ACFT VIBRATED SEVERELY UNTIL THROTTLE WAS REDUCED. WE DECLARED AN EMER, CLBED TO 3000 FT MSL AND STAYED IN THE TFC PATTERN. THE ENG CONTINUED TO RUN AT IDLE WITH MODERATE VIBRATION. WE COMPLETED QRM CHKLISTS, BRIEFED THE CABIN CREW AND RETURNED FOR UNEVENTFUL LNDG. AFTER LNDG, WE INSPECTED THE ENG AND IT WAS OBVIOUS CATASTROPHIC FAILURE WAS CAUSED BY FAILURE OF HIGH SPD COMPONENTS. TEAR DOWN OF ENG LATER DISCOVERED FAILURE OF T1. THIS IS THE SECOND CATASTROPHIC ENG FAILURE I HAVE EXPERIENCED IN A B737 AT THIS COMPANY IN LAST 13 MONTHS. BOTH OCCURRED AT 2ND SEGMENT CLB. THE CAUSE OF THE FIRST CATASTROPHIC ENG FAILURE WAS THE SAME, FAILURE OF T3 AND T4 -- RPTED TO ASRS IN FEB 1997. I HAVE FLOWN HELIS AND GA ACFT FOR 26 YRS. I HAVE HAD 3 COMPLETE ENG FAILURES, 1 IN A PIPER CHIEFTAIN, 2 IN A B737, NONE IN HELIS. WHAT'S WRONG WITH THIS PICTURE? CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THIS WAS HIS 2ND B737 ENG FAILURE SINCE FEB 1997. THE ENG INVOLVED IS A JT-8D-9A SERIES THAT WAS PURCHASED FROM A 'THIRD WORLD' COUNTRY. RPTR CLAIMS THAT THESE ENGS THAT WERE PURCHASED IN A LARGE ORDER WERE DEFECTIVE OR 'BAD' ENGS. THE AIRLINE CANCELED THE PURCHASE INSPECTION REQUIREMENTS AND PLACED THE ENGS INTO SVC WITHOUT A MAJOR, MINOR OR ACCEPTANCE INSPECTION. THE 'BAD' QUOTE WAS FROM THE AIRLINE'S ENG MGR WHO IS CURRENTLY OUT ON 'STRESS DISABILITY.' THE RPTING CAPT ALLEGED THAT ON THE WEEKEND OF HIS EVENT THERE WERE 2 OTHER ENG SHUTDOWNS ON HIS AIRLINE, ONE WITH ENG OIL LOSS AND ONE WITH AN INFLT ENG FIRE WARNING INDICATION THAT REQUIRED A 2 BOTTLE APPLICATION OF THE FIRE EXTINGUISHER. THE INDICATION ON THAT ONE WAS APPARENTLY FALSE. HE CITED 4 TURBINE FAILURES IN A 13 MONTH PERIOD FROM FEB 1997 TO NOW. THE RPTR IS VERY UNHAPPY WITH THE AIRLINE MAINT POLICY. THE COMPANY HAS 3 DEGS OF RATINGS SO FAR AS ACFT STABILITY GOES. THESE ARE THE RPTR'S RATINGS. BY STABILITY HE WAS REFERRING TO THE ACFT'S CTR OF GRAVITY BEING IN THE NORM OR NEARED THE AFT END OF THE ACFT'S ALLOWABLE CTR OF GRAVITY OR MEAN AVERAGE CHORD (MAC). THE CONVERTIBLE CARGO ACFT ARE THE MOST STABLE, THE STANDARD ACFT ARE AVERAGE BUT TWO OF THE ACFT (PURCHASED FROM A FOREIGN CARRIER) ARE VERY MARGINAL, BEING VERY CLOSE TO THE AFT END OF THE ALLOWABLE 'MAC.' BOTH OF HIS ENG FAILURES OCCURRED ON THESE 'SISTER' ACFT. THE FIRST ONE IN 1997 HAD A TAIL HVY FEELING AND FAILED TO PERFORM AS EXPECTED, ACTUALLY LOSING ALT AT 500 FT AGL UNTIL HE OVER BOOSTED THE REMAINING ENG. THE ACFT WAS VERY TAIL HVY AND DID NOT FLY LIKE THE SIMULATOR. THESE 2 ACFT WERE 'DEMODED' FROM HUSH KITTING AND HAD AFT AIRSTAIRS ADDED FOR WT AND BAL. SINCE THEN 10 ADDITIONAL SEATS WERE ADDED AND THE ACFT NOW HAS TO EITHER HAVE A NOSE BALLAST ADDED OR LEAD WTS PLACED IN THE FORWARD CARGO COMPARTMENT TO COUNTER-BAL THE ADDED SEATS. THE AIRLINE HAS TINKERED AROUND WITH THE PAX WTS AND FUEL LOADS IN ORDER TO TRY TO RESOLVE THIS ISSUE. THE COMPANY AND THE PLT'S UNION HAVE EITHER IGNORED HIM OR FAILED TO PASS ON ANY RELATIVE INFO AS TO 'FIXES.' THE AIRLINE HAD AN UNOFFICIAL, UNWRITTEN, LAW OF A 1 TO 15 RATIO OF 1ST CLASS PAX TO COACH PAX AND WOULD UPGRADE ON A 'BALANCE OR BALLAST' BASIS. THIS WORKED UNTIL THE PAYING 1ST CLASS PAX AND FREQUENT TRAVELER COACH PAX COMPLAINED (UNKNOWINGLY AS TO THE REASON) OF THIS APPARENTLY UNFAIR PRACTICE. THE AIRLINE HAD RECENTLY CHANGED THEIR MAINT CONTRACTOR TO ANOTHER MORE RELIABLE AIRLINE SVC AND ARE ATTEMPTING TO GET THE ACFT TO ETOPS STANDARDS. THIS IS A CONCERN WHEN VIEWING THE PAST ENG PERFORMANCES AS EXPERIENCED BY THE RPTR.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.