Investigation report submitted to SHC: Technical fault led to 2016 ATR crash

KARACHI: An investigation report on the 2016 ATR aircraft crash blamed some technical fault which triggered a chain of events that ended up in the crash of the ATR. The final investigation report by the Aircraft Accident Investigation Board (AAIB) was submitted to the Sindh High Court (SHC) on Thursday.

The court had directed the AAIB chief last month to come up on November 19 with the final investigation report of the 2016 ATR aircraft crash. The report said that the dislodging/fracture of one PT-1 blade of Engine No 1 triggered a chain of events.

Unusual combination of fractured/dislodged PT-1 blade with two latent factors caused off design performance of the aircraft and resulted in the accident, the report said.

It pointed out that the dislodging/fracture of PT-1 blade of Engine No 1 occurred after omission from the EMM (Non-Compliance of SB-21878) by PIA during an unscheduled maintenance performed on the engine in November 2016, in which the PT-1 blades had fulfilled the criteria for replacement, but were not replaced.

"Fracture/dislodging of PT-1 blade in No 1 Engine, after accumulating a flying time slightly more than the soft life of 10,000 hrs (ie at about 10004.1 + 93 hrs) due to a known quality issue," it indicated.

The report recommended to PIA to ensure replacement of PT-1 blades as per schedule given in EMM Chapter 5 in letter and spirit on the entire fleet of ATR aircraft (in the light of the First Immediate Safety Recommendation) and ensure recycling of all the Qty-48 OSGs (currently held with PIA) from an OEM's certified MRO facility to verify and confirm that no other OSG is having any internal pre-existing anomaly (in the light of the Second Immediate Safety Recommendation).

It also suggested that PIA is to ensure strict compliance of service information letter (SIL-568F-796) issued by Collins Aerospace to maintain proper cleanliness and FOD prevention during engine and propeller storage and maintenance and should undertake improvements (and ensure continued compliance) in all the areas identified in P&WC site survey report of the MRO facility established for the maintenance of PW127 series engines.

It also proposed that the PIA safety management must identify critical performance indicators both in the domains of airworthiness as well as flight operations. The data is to be utilized for establishing trends and weak areas, further leading towards proactive corrective measures and corresponding improvements in SOPs/training programmes.

It called upon PIA to ensure effective utilization of the FDM system, observations noted during the simulator check flights and training sessions to identify and maintain records of operational trends. This mechanism may also include continuous monitoring and must enable requisite/proportionate improvements in relevant SOPs and training program and revamp its CRM training system (in the light of purposes and objectives of relevant ICAO publications and applicable SARPs) and evolve a purposeful internal assessment mechanism to gauge the effectiveness of CRM training.

Copyright Business Recorder, 2020