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Accident description
Last updated: 23 October 2017
Status:Final
Date:Tuesday 13 April 2010
Time:13:43
Type:Silhouette image of generic A333 model; specific model in this crash may look slightly different
Airbus A330-342
Operator:Cathay Pacific Airways
Registration: B-HLL
C/n / msn: 244
First flight: 1998-11-04 (11 years 5 months)
Total airframe hrs:33378
Cycles:12590
Engines: 2 Rolls-Royce Trent 772-60
Crew:Fatalities: 0 / Occupants: 13
Passengers:Fatalities: 0 / Occupants: 309
Total:Fatalities: 0 / Occupants: 322
Airplane damage: Minor
Airplane fate: Repaired
Location:Hong Kong-Chek Lap Kok International Airport (HKG) (   Hong Kong)
Phase: Landing (LDG)
Nature:International Scheduled Passenger
Departure airport:Surabaya-Juanda Airport (SUB/WARR), Indonesia
Destination airport:Hong Kong-Chek Lap Kok International Airport (HKG/VHHH), Hong Kong
Flightnumber: 780
Narrative:
Cathay Pacific Airways flight CPA780, an Airbus A330, was scheduled to operate from Surabaya, Indonesia to Hong Kong. The crew had carried out the sector from Hong Kong to Surabaya on the previous day. The accident aircraft stayed overnight at Surabaya Airport and was parked at Stand 8.
The accident aircraft uplifted 24,400 kilogram (kg) of fuel and was prepared for departure. The flight was airborne at 08:24 local time. During the climb, the flight crew noticed some abnormal Engine Pressure Ratio (EPR) fluctuations on No. 2 engine, with a range of approximately 0.015 around EPR target. No. 1 engine also had abnormal EPR fluctuations but within a narrower range.
At 08:58, shortly after levelling off at FL390, an ECAM message "ENG 2 CTL SYS FAULT" was annunciated. ECAM information "ENG 2 SLOW RESPONSE" was shown for crew awareness. After consulting with a maintenance engineer, it was decided to continue since all engine parameters were considered normal other than the EPR fluctuations.
Almost two hours into the flight, the same ECAM message appeared, with an additional information message "AVOID RAPID THR CHANGES". The engine anti-ice was selected on for both engines, but this had not effect. The crew then again contacted a maintenance engineer, who told them that he had seen these EPR fluctuations before and that the Fuel Metering Unit (FMU) of engine no. 2 would be replaced after landing.
Nearing the destination, the crew began to prepare for a runway 07L arrival. According to recent weather information, significant windshear was forecast for both runway 07L and 07R.
At 13:19 hrs local time during the descent to a cleared level of FL230, ECAM messages "ENG 1 CTL SYS FAULT" and "ENG 2 STALL" were annunciated within a short period of time. According to the Commander, a light "pop" sound was heard and some "ozone" and "burning" smell was detected shortly before the ECAM message "ENG 2 STALL". At that time the flight was at about 110 nautical miles southeast of Hong Kong, and was descending through FL300 with a Calibrated Air Speed (CAS) of 295 kt. Vertical mode "Open Descent" was selected. The flight crew completed the necessary ECAM actions and set No. 2 thrust lever accordingly to IDLE position. ECAM information "ENG 1 SLOW RESPONSE" and "AVOID RAPID THRUST CHANGES" were also annunciated. No. 1 thrust lever was advanced to Maximum Continuous Thrust (MCT) position as per the "SINGLE ENGINE OPERATIONS" strategy stated in the Quick Reference Handbook (QRH). However No. 1 engine N1 only temporary increased to about 57% N1 and then dropped back to about 37% N1 at 13:21 hrs.
At 13:21 hrs, the flight crew declared "PAN PAN" to Hong Kong Radar and advised that No. 2 engine was operating at idle thrust. The crew made the request to shorten the track for a priority landing. Hong Kong Radar then cleared the flight to proceed directly to waypoint "LIMES".
At about 13:26 hrs, the Commander took control of the aircraft as the PF in accordance with Cathay standard operating procedures for one engine inoperative and the co-pilot became the Pilot Monitoring.
At 13:30 hrs, when the aircraft was approximately 45 nm southeast from Hong Kong and was about to level off at 8,000 ft AMSL, ECAM message "ENG 1 STALL" was annunciated. The CAS at that moment was about 295 kt. ECAM actions were carried out by the flight crew and No. 1 thrust lever was put to IDLE position accordingly. Autothrust (A/THR) was disengaged and both engine master switches remained at the "ON" position. With both thrust levers at IDLE position, the Commander then tested the controllability of the engines by moving the thrust levers one at a time. There were no thrust changes corresponding to the engine lever movements initially. At 13:32 hrs, ECAM messages "ENG 1 STALL" was annunciated again.
At 13:32 hrs, the crew declared "MAYDAY" and advised Hong Kong Approach of the double engine stall situation. CPA780 was then cleared to descend to 3,000 ft AMSL. At that time, the aircraft was still in Instrument Meteorological Conditions (IMC) and the CAS was at about 233 kt and reducing. At around the same time, the Commander disconnected the Autopilot and the Flight Directors (FD) and flew the aircraft manually. The altitude increased from 6,760 ft to 7,164 ft AMSL with the CAS reducing and the aircraft started to descend again when the CAS decreased to about 200 kt.
When the aircraft was on base leg during the approach, the flight crew reported that they were flying in VMC.
The crew moved the thrust levers to check the engine control but there was no direct response from the engines. The No. 1 engine speed eventually increased to about 74% N1 with the No. 1 thrust lever in the CLB (climb) detent position. The No. 2 engine speed remained at sub-idle about 17% N1, with the No. 2 thrust lever at the IDLE position.
At 13:37 hrs, the ATC made both runways 07L and 07R available for CPA780. During the descent and approach, there were a number of other ECAM warning messages announced in the cockpit which were not relevant to the engine control problem.
The flight crew carried out the "ENG ALL ENG FLAMEOUT - FUEL REMAINING" checklist in the QRH for No. 2 engine in an attempt to clear the thrust control fault of that engine. As per the checklist, the Ram Air Turbine (RAT) was deployed manually, APU bleed was selected "ON" and No. 2 engine MASTER switch was set to "OFF" then "ON" at 13:38 hrs. However, No. 2 engine remained at a sub-idle speed of 17% N1.
At 13:38 hrs, Flap CONF 1 was selected. At 13:39 hrs, when CPA780 was at 5,524 ft AMSL, a CAS at 219 kt and a distance of nine nm from the airport, the Commander tried to decrease the speed by retarding the No. 1 thrust lever. However, there was no corresponding decrease in No. 1 engine speed. Eventually, No. 1 thrust lever was left at the IDLE position and No. 1 engine speed remained at 74% N1.
At 13:40 hrs, Hong Kong Approach cleared CPA780 for a visual approach for Runway 07L. Flight crew deployed the speedbrakes when the aircraft was at 5,216 ft AMSL descending with a CAS of 234 kt at around 8 nm from the runway. Flight crew selected landing gear down shortly afterwards.
The Commander aimed to fly the aircraft at a CAS as close as possible to the Minimum Selectable Speed (VLS), which was 158 kt at that time. The aircraft went through the runway extended centreline and recaptured the centreline from the north in order to manage altitude and airspeed.
At around 13:41 hrs, with the Maximum Allowable Speed (Vmax) at 240 kt and actual CAS at 244 kt, an overspeed warning was generated by the onboard system. A short while later Hong Kong Approach cleared CPA780 to land on runway 07L and advised that the current surface wind was 150 degrees at 13 kt. Flight crew stowed the speedbrakes when the aircraft was at 984 ft AMSL and armed the ground spoilers at 816 ft AMSL.
At 13:42 hrs, when CPA780 was still at flap CONF 1, with a CAS of 227 kt and a vertical speed of 1,216 ft per min at an altitude of 732 ft AMSL and at about two nm to touchdown, the warning "Too Low Terrain" was generated by the Enhanced Ground Proximity Warning System (EGPWS). Flap CONF 2 was selected at around one nm to touchdown with a CAS of 234 kt and at an altitude of 548 ft AMSL. A flashing "F RELIEF" message was displayed at Engine Warning Display (EWD) as the TE flap was extended to 8-degree position instead of the commanded 14-degree position. With a Vmax of 205 kt, another overspeed warning was generated shortly after Flap 2 selection. The "Too Low Terrain" warning changed to "Pull Up" warning briefly at 176 ft AMSL and back to "Too Low Terrain" within a very short timeframe. The EGPWS warning stopped at 24 ft above the ground.
During the final approach, No. 1 engine speed decreased to about 70% N1 at touchdown, with the No. 1 thrust lever at IDLE position. No. 2 engine speed remained at about 17% N1 throughout the final approach and landing.
CPA780 touched down on runway 07L at 13:43 hrs at a position between abeam Taxiways A4 and A5 and with a distance of around 680 metres (m) from the beginning of the runway threshold at a ground speed of 231 kt. The landing weight was approximately 173,600 kg. The landing wind was 143 degrees at 14 kt. Immediately after both main gears touched down on the runway, the right main gear bounced and the aircraft became airborne again briefly. The aircraft then rolled left seven degrees and pitched down to -2.5 degrees at the second touchdown during which, the lower cowling of No. 1 engine contacted the runway surface. Spoilers deployed automatically. Both engine thrust reversers were selected by the Commander. Only No. 1 engine thrust reverser was deployed successfully and ECAM message "ENG 2 REV FAULT" was annunciated. Maximum manual braking was applied. As required by the company procedure for the purpose of drawing the PFs attention in the status of the deceleration devices, the co-pilot called out "no spoilers, no REV green, no DECEL" during the landing roll.
The aircraft came to a complete stop on the runway at a position just passed Taxiway A10, with its nose wheel at about 309 m from the end of Runway 07L. The total distance for stopping the aircraft from the initial touchdown was approximately 2,630 m.
The crew shut down the engines and requested the tower controller to check for a possible wheel fire. There was no sign of fire. An emergency evacuation was then ordered just after 13:45.
One passenger sustained serious injuries in the evacuation while 56 passengers and six crew members sustained minor injuries.

Probable Cause:

Causes:
The accident was caused by fuel contamination. The contaminated fuel, which contained SAP spheres, uplifted at WARR subsequently caused the loss of thrust control on both engines of the aircraft during approach to VHHH.

The following chain of events and circumstances had led to the uplift of contaminated fuel to CPA780:
i. The re-commissioning of the hydrant refuelling system after the hydrant extension work in WARR had not completely removed all contaminants in the affected hydrant refuelling circuit. Salt water remained in the affected hydrant refuelling circuit.
ii. The re-commissioning of the hydrant refuelling system after the hydrant extension work in WARR was not properly coordinated which led to the premature resumption of the hydrant refuelling operations while the hydrant system still contained contaminant.
iii. The refuelling operation in WARR, in particular low flow-rate refuelling, DP recording and monitoring, did not fully comply with the international fuel industry latest guidance.
iv. A number of unscheduled filter monitors replacements after the premature resumption of hydrant refuelling operation were not investigated by the fuel supplier and hydrant operator at WARR.
v. The unusual vibration observed during the refuelling of CPA780 was not stopped immediately and properly investigated by the fuel supplier personnel.

The investigation also identified the following deficiencies and contributing factors that may cause possible fuel contamination:
i. There were no established international civil aviation requirements for oversight and quality control on aviation fuel supply at airports.
ii. There were no established international civil aviation requirements for refuel operational procedures and associated training for aviation fuel supply personnel.
iii. The manual monitoring of DP changes in a fuelling dispenser during refuelling was not effective.

Classification:
Fuel contamination
Forced landing on runway

Follow-up / safety actions

CAD HK issued 4 Safety Recommendations

Show all AD's and Safety Recommendations

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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Surabaya-Juanda Airport to Hong Kong-Chek Lap Kok International Airport as the crow flies is 3289 km (2056 miles).

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