Slide 1Air AccidentsInvestigationBranch

Boeing 777 G-YMMMBoeing 777 G-YMMM

London HeathrowLondon Heathrow

17 Jan ’0817 Jan ’08

BRIEFING TO IASCC 9 September 2010BRIEFING TO IASCC 9 September 2010

Slide 2Air AccidentsInvestigationBranch

LHR - BEI – LHRFuel 79,000 kg (No 3 Jet Fuel, PRC)

3 flt - 13 cabin - 136 pax

Uneventful flight ( Min temps: SAT -76ºC; TAT -45ºC; Fuel -34ºC )

TOD predicted fuel 10,000 kg

Slide 3Air AccidentsInvestigationBranch

Thrust Levers

EPR actual and commandFMV (QAR)

Fuel Flow

1,600 ft agl to TD4 sec grid spacing

Slide 4Air AccidentsInvestigationBranch

PALT

Min Fuel Temp in cruise -34 deg C

TAT

Accident Flight Track from FDR

Takeoff fuel temp was -2 deg C

Fuel temp at 590 ft agl was -22 deg C

FDR Data

Slide 5Air AccidentsInvestigationBranch

Accident Site

Slide 6Air AccidentsInvestigationBranch

Aircraft examination

• No pre-existing defects found with electrical, hydraulic, autoflight, navigation systems or flying controls

• HIRF/EMI eliminated by testing – the power levels required to affect the EEC would have affected the electrical, navigation and communications system first.

Slide 7Air AccidentsInvestigationBranch

Fuel system description

Slide 8Air AccidentsInvestigationBranch

Reconstruction of Left Wing Fuel System

Engine

Centre tank

Main tank

Strut pipes

Slide 9Air AccidentsInvestigationBranch

Engine - HP pump cavitation marks

• Fuel Pump 0019 (LH Engine)– Built Oct ’99, Never overhauled– A/C Boost pump debris on Impellor– Abnormal cavitation markings on

bearing thrust faces and HP housing at discharge window

Slide 10Air AccidentsInvestigationBranch

Types of water in fuel

• Dissolved water– Molecule of water attached to a hydrocarbon

molecule. As temperature drops becomes entrained water.

• Undissolved water– Entrained water, often referred to as

suspended.• Suspended as tiny droplets in the fuel settles to form

free water.

– Free water• Visible water that collects on bottom of tanks.

Slide 11Air AccidentsInvestigationBranch

Water ice in fuel• Only entrained and free water form

ice.• Ice crystals form at -1 to -3 Deg C.

– Density similar to fuel, so float in fuel.• Critical Icing Temperature ~ -8 Deg C.

– When ice crystals start to stick to their surroundings.

• -18 Deg C– Crystals adhere to each other and

become larger.• Below -20 Deg C little is known about

the properties of the ice.

Slide 12Air AccidentsInvestigationBranch

Fuel testing

• Fuel was of good quality.• Fuel freezing point was -57 Deg C.• Compared with 1,245 batches of Jet

A-1 tested in UK during 2007.– Distillation range average.– Freezing point slightly below average.

Slide 13Air AccidentsInvestigationBranch

Estimated water content in fuel during accident flight

• Dissolved water, 3 ltr (40ppm).• Undissolved water (entrained and free),

maximum of 2 ltr (30 ppm).• This Water would have been evenly spread

across the fuel system at the start of the flight.• Water also introduced through the vent system

during the flight, approximately 0.14 ltr.• Plus any water remaining from previous flights.

Slide 14Air AccidentsInvestigationBranch

Testing by Boeing• Beaker Test

– Small scale test in climatic chamber.– Used simulated fuel system components.– Establish how ice might accumulate and

restrict flow.

• Fuel rig testing– Actual components from B777.– Establish if ice could build up in the system and

restrict the flow.– Use fuel preconditioned with water or inject

water directly into boost pump inlet.

Slide 15Air AccidentsInvestigationBranch

Beaker Tests

Slide 16Air AccidentsInvestigationBranch

Significant temperatures

Water ice forms (-1 to -3C, 31 to 27F)

Sticky range (-8 to -20C, 23 to -4F)

Ice starts to adhere to metal (-9C, 16F)

Ice at most stickiness (-12C, 10F)

Ice adheres strongly to metal surfaces (-17C, 0F)

Ice takes on a more crystalline appearance below -20C, (-4F)

Ice lacks the properties to bridge orifices (-25C, -23F)

Spontaneous formation of ice crystals from super cooled water (-24C, -11F)

Lowest temperature super cooled water can exist in aviation fuel (-51C, -60F)

0C

-50C

Slide 17Air AccidentsInvestigationBranch

Spar Valve

Boost Pump

FOHE

Sight Glass

Inlet Screen

Flexible Hose

Sight Glass

LP/HP Pump

Boeing Proprietary

Layout of fuel Components on the Boeing Fuel Rig

Slide 18Air AccidentsInvestigationBranch

FOHE fitted to fuel rig

Slide 19Air AccidentsInvestigationBranch

Ice collecting on pump inlet screen

Slide 20Air AccidentsInvestigationBranch

Icing of FOHE

Slide 21Air AccidentsInvestigationBranch

Aircraft fuel pipes

Strut pipes

LP pump

Fuel pipes in main tank

Slide 22Air AccidentsInvestigationBranch

Fuels Lab Test #156Tube Inspections (Cont.)

Slide 23Air AccidentsInvestigationBranch

Findings of rig test

• Ice can accrete on the inside of fuel pipes and on inlet screens.– Thickness depend on fuel temp and flow.

• It is possible to restrict the flow through the FOHE with cold fuel and low levels of water simulating a sudden release of ice.

• Blocks of ice unlikely to have caused restriction.

• Problems with repeatability of some of the results.

Slide 24Air AccidentsInvestigationBranch

Data Mining"the extraction of previously

unknown, and potentially useful information from significant

quantities of data“

Slide 25Air AccidentsInvestigationBranch

Facts from the accident flight

• Fuel temperature at takeoff -2 degC

• Minimum fuel temperature in the cruise -34 degC

• Minimum TAT in the cruise -45 degC

• Fuel temperature on final approach -22 degC

Slide 26Air AccidentsInvestigationBranch

BA/United/Cathay ~60,000 flights (Apr06 to Mar 08)

Minimum fuel temperature, -12 deg C and below

G-YMMM -34 Fuel-45 TAT

Fuel Temp

TAT

Slide 27Air AccidentsInvestigationBranch

The accident flight WAS NOT unique with respect to fuel temperatures

experienced during takeoff, cruise or approach phases

Slide 28Air AccidentsInvestigationBranch

Through the complementary use of data mining and laboratory tests, efforts were focused on the activity of two

parameters:

Fuel Flow and Fuel Temperature

The following slide identifies the combination of Fuel Flow and Fuel

Temperature parameters which were unique to the accident flight

Slide 29Air AccidentsInvestigationBranch

1.Fuel Temperature at take off below 0°C and remaining below 0°C during all phases of flight

2.Max Fuel Flow in cruise less than 10,000 pph3.Fuel Temperature during approach less than -15°C 4.Max Fuel Flow greater than 10,000 pph during

approach5.Max Fuel Flow during descent less than 10,000 pph

ONLY MMM ACCIDENT FLIGHT MET ALL 5 CRITERIA FROM ~13,000 FLIGHTS.

Slide 30Air AccidentsInvestigationBranch

Investigation Summary

• Engines rolled back due to reduced fuel flow with no increase although FMV opens fully.

• No technical problem with the aircraft or its systems that could explain the event

• Only physical evidence – HP pump cavitation

• Reasons for HP pump cavitation – a restriction of the fuel flow to the pump

Slide 31Air AccidentsInvestigationBranch

Testing showed:

• Ice can accrete on:– Fuel tank surfaces– Boost pump Inlet screen– Pipework – both rigid and flexible– Valves within the fuel system

Slide 32Air AccidentsInvestigationBranch

Testing also showed• The FOHE can become blocked when water

is introduced to cold fuel creating a ‘snowball’

• The effect of the blockage changes at different fuel temperatures & fuel flows (above certain temperatures and below certain fuel flows, the FOHE can successfully melt the ice)

• The system needs to be ~95% blocked to cause the reduced fuel flow

• Ice can accrue within the airframe fuel system and be released, dependent on fuel temperatures and flow rates

Slide 33Air AccidentsInvestigationBranch

Summary• Fuel flow restricted due to ice formed from water

that was naturally occurring in the fuel• The ice accreted over a long period, with low fuel

flows whilst the fuel temperature was in the ‘sticky’ range

• The ice was suddenly released, probably due to demands for higher fuel flow during final approach, but could be due to other factors such as increasing temperatures or turbulence

• The sudden ‘avalanche’ of ice blocked the FOHE, which was unable to melt it

• G-YMMM was always within its certificated operating envelope and there was no evidence of abnormal water quantities in the fuel

• No tests for this threat existed at the time of certification (and will they in the future?)

Slide 34Air AccidentsInvestigationBranch

AAIB Safety Recommendations.These included:

• Interim flight crew procedures to clear accumulated ice at a safe altitude

• Modifying the FOHE to resist this unforeseen threat (already underway by Rolls-Royce)

• Investigating other airframe/engine combinations for vulnerability to this phenomenon

• Changing certification requirements to accommodate the new threat

Slide 35Air AccidentsInvestigationBranch

Safety Recommendation 2009-032 – Issued 12 March 2009

It is recommended that the Federal Aviation Administration and the European Aviation Safety Agency jointly conduct research into ice accumulation and subsequent release mechanisms within aircraft and engine fuel systems.

Slide 36Air AccidentsInvestigationBranch

Questions?