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Sep 12, 2022 42 likes •297 views

Conducting investigations on similar incidents that occurred in different countries A complex organization Arnaud TOUPET Senior Safety Investigator Capt. Nurcahyo Ray UTOMO NTSC Senior Safety Investigator Investigating on similar

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Conducting investigations on similar incidents that occurred in different countries A complex organization

Arnaud TOUPET

Senior Safety Investigator

Capt. Nurcahyo ‘Ray’ UTOMO

NTSC Senior Safety Investigator

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

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A practical case : the investigation on several incidents

involving propeller severe vibrations during flight

Organization of investigations according to ICAO Annex 13
Highlighted Solutions
Possible ways of improvement

Investigating on similar incidents

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

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On 18th September 2013, in Indonesia, ATR 72-212A

equipped with Hamilton Sundstrand Propellers 568F-1

 Severe vibrations on engine #2 propeller during descent  Engine #2 was shut down after landing  Different blade angles

bserved on

ground

Practical case : propeller severe vibrations

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

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Damages :

 One blade was turning freely (blade trunnion pin broken)  Blade angle actuator forward plate found bent

Practical case : propeller severe vibrations

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

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Damages :

 Two engine fittings found broken

Practical case : propeller severe vibrations

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

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According to the Attachment C of the ICAO Annex 13, this
ccurrence was classified as serious incident.
NTSC conducted full investigation and sent notification to

direct involve parties including France BEA as State of Manufacture.

Significant supports received from the BEA.
30 days after the occurrence NTSC issued safety

recommendation to the aircraft operator.

Serious Incident – full investigation

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

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On 4th May 2014, in Trinidad and Tobago, ATR 72-212A

equipped with Hamilton Sundstrand Propellers 568F-1

 Severe vibrations on engine #2 propeller during descent  No findings from maintenance  On 5th May 2015, vibrations after landing  Test runs leading to damages

Practical case : propeller severe vibrations

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

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Propeller governing system description

Practical case : propeller severe vibrations

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

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Damages :

 One blade was turning freely (blade trunnion pin broken)  Blade angle actuator forward plate found bent

Practical case : propeller severe vibrations

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

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NOT A SERIOUS INCIDENT but SIMILAR INCIDENT INVESTIGATION proposed by BEA INVESTIGATION delegated to BEA

Practical case : propeller severe vibrations

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

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On 30th November 2014, in Sweden, ATR 72-212A

equipped with Hamilton Sundstrand Propellers 568F-1

 Severe vibrations on engine #2 propeller during descent  Impossible to read instruments and to walk in cabin  Engine #1 fatheared then engine #2

Practical case : propeller severe vibrations

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

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Damages :

 One blade was turning freely (blade trunnion pin broken)  Blade angle actuator forward plate found bent

Practical case : propeller severe vibrations

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

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Damages :

 A 180°crack Engine rear inlet case

Practical case : propeller severe vibrations

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

INCIDENT but SIMILAR INCIDENT INVESTIGATION by SHK

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Organization of investigations according to ICAO Annex 13

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

State of occurence

Complete or partial delegation to another state

Serious incident

State of Registry State of Operator State of Design State of Manufacture IIC AccReps Operator Advisers Type design

rganization

Final assembly

rganization

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Organization of investigations according to ICAO Annex 13

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Serious incident

Accrep (Reg) Accrep (Ops) AccRep (Design ) AccRep (Man) IIC Adviser (Ops) Adviser (Design) Adviser (Assy)

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Organization of investigations according to ICAO Annex 13

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

France (Man) Indonesia UTAS ATR T&T/France Sweden USA (Man) Airline A T&T (OPS) Airline B Airline C

Serious Incident A Incident B Incident C

EASA FAA Canada (Man) P&W

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Highlighted Solutions Incident Notification

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

France (Man) Indonesia UTAS ATR T&T Sweden USA (Man) Airline A Airline B Airline C

Incident B Incident C Serious Incident A

Canada (Man)

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Highlighted Solutions Information sharing between SIA

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

France (Man) Indonesia T&T/France Sweden USA (Man) UTAS ATR Airline A Airline B Airline C EASA FAA P&W Canada (Man)

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Highlighted Solutions Examination requests and “to do list”

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

France (Man) Indonesia UTAS ATR T&T/France Sweden USA (Man) Canada (Man) P&W

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Highlighted Solutions Update meetings

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

USA (Man) Indonesia T&T France France (Man) Sweden ATR UTAS France/T&T France (Man) UTAS ATR Sweden Indonesia France (Man) ATR Sweden France (Man) UTAS ATR Airline C FAA EASA France/T&T UTAS ATR France (Man) EASA March 2015 Oct 2014 Dec 2014 February 2015 May 2015 P&W

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Highlighted Solutions Safety recommendations

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

France (Man) Indonesia T&T/France Sweden UTAS ATR Airline A Airline B Airline C EASA FAA 1st event (immediate) 3rd event Canada (Man) USA (Man) P&W

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Highlighted Solutions What about the reports and final recos?

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

France (Man) Indonesia T&T/France Sweden USA (Man)

Draft report comment process Final reports Final recos

Canada (Man)

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Possible ways of improvement

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Improve SIA awareness
f an on going investigation
Focal point

(SIA or safety organization)

Super IIC

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Possible ways of improvement

Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Improve confidentiality principles

for information sharing

Harmonization of reports

and recommendations Similar investigations to be considered as a unique big one ?

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www.bea.aero

Conducting investigations on similar incidents that occurred in different countries A complex organization

involving propeller severe vibrations during flight

Investigating on similar incidents

equipped with Hamilton Sundstrand Propellers 568F-1

 Severe vibrations on engine #2 propeller during descent  Engine #2 was shut down after landing  Different blade angles

ground

Practical case : propeller severe vibrations

 One blade was turning freely (blade trunnion pin broken)  Blade angle actuator forward plate found bent

Practical case : propeller severe vibrations

 Two engine fittings found broken

Practical case : propeller severe vibrations

direct involve parties including France BEA as State of Manufacture.

recommendation to the aircraft operator.

Serious Incident – full investigation

equipped with Hamilton Sundstrand Propellers 568F-1

 Severe vibrations on engine #2 propeller during descent  No findings from maintenance  On 5th May 2015, vibrations after landing  Test runs leading to damages

Practical case : propeller severe vibrations

Propeller governing system description

Practical case : propeller severe vibrations

 One blade was turning freely (blade trunnion pin broken)  Blade angle actuator forward plate found bent

Practical case : propeller severe vibrations

NOT A SERIOUS INCIDENT but SIMILAR INCIDENT INVESTIGATION proposed by BEA INVESTIGATION delegated to BEA

Practical case : propeller severe vibrations

equipped with Hamilton Sundstrand Propellers 568F-1

 Severe vibrations on engine #2 propeller during descent  Impossible to read instruments and to walk in cabin  Engine #1 fatheared then engine #2

Practical case : propeller severe vibrations

 One blade was turning freely (blade trunnion pin broken)  Blade angle actuator forward plate found bent

Practical case : propeller severe vibrations

 A 180°crack Engine rear inlet case

Practical case : propeller severe vibrations

INCIDENT but SIMILAR INCIDENT INVESTIGATION by SHK

Organization of investigations according to ICAO Annex 13

Serious incident

Organization of investigations according to ICAO Annex 13

Serious incident

Organization of investigations according to ICAO Annex 13

Highlighted Solutions Incident Notification

Highlighted Solutions Information sharing between SIA

Highlighted Solutions Examination requests and “to do list”

Highlighted Solutions Update meetings

Highlighted Solutions Safety recommendations

Highlighted Solutions What about the reports and final recos?

Draft report comment process Final reports Final recos

Possible ways of improvement

(SIA or safety organization)

Possible ways of improvement

for information sharing

and recommendations Similar investigations to be considered as a unique big one ?

Thank you for your attention