Section/division ACCIDENT AND INCIDENT INVESTIGATIONS DIVISION Form Number: CA 12-14 PRELIMINARY INCIDENT REPORT Reference Number : CA18/3/2/1209 Name of Operator Manufacturer : Bombardier Model : CRJ700 Nationality : South African Registration Marks : ZS-NBG Place Date : 11 May 2018 Time : 0618Z : South African Express Airways (Pty) Ltd : East London Airport (FAEL): Eastern Cape All times given in this report are Coordinated Universal Time (UTC) and will be denoted by (Z). South African Standard Time is UTC plus 2 hours. The information provided herein is of a preliminary nature. Readers are advised that new information may become available that may alter this preliminary report prior to the publication of the final report. This report is issued in accordance with Civil Aviation Regulation (CAR) 2011 Part 12.05.1(2)(a) and ICAO Annex 13 Paragraph 7.1 or 7.2, whichever is applicable. 1. The South African Civil Aviation Authority (SACAA) is conducting a safety investigation into a South African flight involving an aircraft with registration mark ZS-NBG, which had an engine incident on 11 May 2018 at East London airport in the Eastern Cape. 2. The investigation is being conducted in accordance with the international protocol set out by the International Civil Aviation Organisation (ICAO) Annex 13. The investigation team includes an investigator-in-charge (IIC) from the Accident and Incident Investigation Division (AIID) of the South African Civil Aviation Authority (SACAA) and an accredited representative from the National Transportation Safety Board (NTSB) in the United States of America (USA). CA 12-14 01 FEBRUARY 2017 Page 1 of 5
Figure 1: View of the engine taken at the site Debris on the bottom of the exhaust frame Figure 2: The exhaust frame where debris was found CA 12-14 01 FEBRUARY 2017 Page 2 of 5
History of flight 2.1 On Friday morning, 11 May 2018 at about 0618Z, a Bombardier aircraft model CRJ700 operated by South African Express Airways with a registration mark ZS- NBG departed from East London Airport (FAEL) in the Eastern Cape. This was a scheduled commercial flight to OR Tambo International Airport (FAOR). On board the aircraft were 3 crew and 62 passengers. The aircraft was flown under instrument flight rules (IFR) in daylight hours and weather conditions were reported to be fine at the time of the incident. 2.2 According to the pilot in command (PIC), the crew started both engines and taxied to the active runway 29. They applied full power, all indications were normal. The PIC was the pilot flying (PF) and the first officer was the pilot monitoring (PM). After getting airborne and during the initial climb all engine parameters were in the normal ranges. At 600 feet above mean sea level (AMSL). the crew engaged auto pilot and selected HDG mode. At about 800 ft. there was a vibration followed by a loud bang.the PIC mentioned that After the initial shock we identified that we had had an engine failure on the number 1 engine. We called for the memory items for engine severe damage, and went through them. Due to the fact that we had already gone through 1500 we only retracted the flaps at an altitude of about 3000 and handed control over to the co-pilot and commenced with the Risk Management Model (RMM). The crew declared PAN PAN PAN and notified FAEL Air Traffic Control (ATC) of the incident and provided them with the number of passengers on board and endurance. The PIC informed the ATC that he was content to receive the vectors while they were sorting out the problem and then took over control of the aircraft. The co-pilot carried out the Quick Reference Handbook (QRH) actions for the engine shutdown and it was decided not to relight the engine, even though the N1 and N2 gauges still showed rotation. The PIC informed the passengers about what had happened. The QRH actions were completed and runway lengths were checked. The aircraft was configured for landing, landed safely, taxied to the bay and shut down the remaining engine. 2.3 None of the crew and passengers sustained injuries during the incident. The damage was limited to the engine high-pressure turbine (HPT) module and the lowpressure turbine (LPT) module rotor blades and stator vanes. CA 12-14 01 FEBRUARY 2017 Page 3 of 5
Findings 3. Although the investigation is ongoing, the following findings have been made: 3.1 The captain, who was the pilot flying, held a valid airline pilot transport licence (ATPL) with aircraft type rating endorsed on it. His aviation medical certificate was valid with a restriction to wear corrective lenses. He had logged a total flying experience estimated at 18417 hours and 79 hours on type in the past 90 days. 3.2 The 1 st officer, who was the pilot monitoring, held a valid airline pilot transport licence (ATPL) with the aircraft type rating endorsed on it. His aviation medical certificate was valid, with no restrictions. He had logged a total flying experience estimated at 6560,0 hours and 119,2 hours on type in the past 90 days. 3.3 The aircraft possessed both a valid certificate of registration (C of R) and certificate of airworthiness (C of A) at the time of the incident. 3.4 The approved maintenance organisation (AMO) that maintained the aircraft held a valid certificate at the time of the incident. The last maintenance inspection (C-CHECK, at 5000-hour intervals) was carried out on 23 March 2017 at a total of 25812 hours, the last annual inspection (at 12-month intervals) was carried out on the 01 July 2017 at a total of 26151 hours and the last mandatory periodic inspection (A-CHECK) was carried out on 08 May 2018 at a total of 28096 hours. 3.5 The aircraft was fitted with a turbofan engine (CF34-8C5B1 model) which was installed on 16 May 2010 (left) at an engine total time of 11514,00 and total engine cycles 8938. The component life status records pertaining to the engine indicated full compliance, with no indication of any component being overflown. At the time of the incident, the engine was still good for 2153 cycles before the next shop visit or overhaul. 3.6 After the incident, a boroscope inspection was carried out by the AMO on 12 May 2018 that revealed damage in the 1 st stage high-pressure turbine (HPT), with rotor blades all fractured off above the mid-span of the airfoils; approximately 25% of the CA 12-14 01 FEBRUARY 2017 Page 4 of 5
upper airfoil was missing. Blistered shroud segments displayed extreme heat and impact damage to the surface. 3.7 Subsequently, on the 2 nd stage high-pressure turbine (HPT) and nozzle guide vanes access was not possible through the S18 boroscope plug due to debris blocking the hole, but viewed through the damaged stage one HPT blades, the stage two nozzle guide vanes seemed to be extensively damaged by the failed HPT blades. Through the limited opening it was noted that several stage two HPT blades had also been separated by the force and impact of the debris from the first stage turbine blades. 3.8 On the low-pressure turbine (LPT) stator vanes and blades, the destruction and debris field in the LPT were noticeable, with complete destruction of all LPT rotor blades and stator vanes. 3.9 The on-site investigation revealed that there was debris of the blades inside the exhaust frame and limited damage to the tips of the stator vanes of the LPT last stage. The rotor blades of the LPT final stage were found still intact, with no signs of damage. Recommendations 4. No safety recommendation has been issued yet. Conclusions 5 The investigation is continuing and the evidence obtained during the course of the investigation phase will be analysed. -End- CA 12-14 01 FEBRUARY 2017 Page 5 of 5