|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Locale Reference||airport : zzzz.airport|
|Altitude||agl single value : 0|
|Operator||common carrier : air carrier|
|Make Model Name||MD-11|
|Operating Under FAR Part||Part 121|
|Flight Phase||descent : approach|
ground : takeoff roll
|Affiliation||company : air carrier|
|Function||flight crew : relief pilot|
|Experience||flight time last 90 days : 90|
flight time total : 4600
flight time type : 550
|Affiliation||company : air carrier|
|Function||maintenance : technician|
|Anomaly||aircraft equipment problem : critical|
maintenance problem : improper maintenance
maintenance problem : improper documentation
non adherence : published procedure
non adherence : far
non adherence : company policies
|Independent Detector||aircraft equipment other aircraft equipment : engine instruments|
other flight crewa
|Resolutory Action||flight crew : declared emergency|
flight crew : landed in emergency condition
flight crew : rejected takeoff
|Problem Areas||Maintenance Human Performance|
On ILS; just after selecting flaps 28 degrees; the aircraft began shuddering like the flaps were at 50 degrees; but about 2 times as hard. Captain queried to what we were feeling. Thinking the confign change was the cause of the situation; we checked the confign page and the flaps were at 28 degrees as selected. I scanned left to the ead at that point and saw that the N1 and N2 were rolling back on the #2 engine and announced we were losing #2. The captain chose to place the #2 throttle lever to idle. Then the #2 engine egt hi level 2 caution illuminated around 1600 ft and the procedure was completed between the first officer and international relief officer. Full confign was obtained and a decision to continue to land was made. Just below 1000 ft; the ead started to display yellow X's on N2 first and then the entire stack of tapes for engine #2. I called possible severe damage on the #2 engine. The decision at that point was that the vibration and subsequent engine failure was due to severe damage and the fire handle was pulled and a bottle discharged. An emergency was declared prior to landing stating the loss of an engine. The landing and rollout were unremarkable. We exited the runway directly in front of the fire station and stopped to allow them to view the #2 engine to verify we did not have any fire/smoke or damage. Then we continued to the blocks. We remained at the aircraft for the next 3 hours. Maintenance in these hours inspected the fan blades and turbine of N1; replaced the bottle that was discharged and stepped through a checklist for the egt hi caution that was displayed. A request to turn the engine was presented and the captain and first officer completed checklists; started #2; and shutdown the engine. The engine started and ran with what appeared normal numbers with exception of a fluctuating evm on N1 variable between 0.8 and 1.4. Now; this was at idle thrust. Then maintenance said that the aircraft is signed off and a borescope would be deferred. The crew was then taken to the hotel for crew rest. The plan was to fly out the following day. The captain and crew did not want to take the aircraft without a high power engine turn and a borescope with the severity of the shutdown in-flight that evening. The next day maintenance determined they would complete a borescope and engine turn. The steps were completed for the borescope and the engine high power turn. Crew arrived at the aircraft 2 days later around XA00 local time. A maintenance man was the first person I came across. I queried to how the higher power turn went and if we were good to fly. He stated that they had difficulties with the APU and subsequently MEL'ed the APU. When asked why; he stated compressor stalls. He also stated that at the conclusion of securing the APU while turning the #2 engine; there were no further compressor stalls. After reviewing the logbook of all signoffs; including borescope; high power engine turns; and inspections; the crew readied the aircraft for flight. Normal checklist were completed for before start. We started the #3 engine in the blocks due to the APU being MEL'ed and then pushed back for other starts and taxi. All engines started normally. The aircraft was taxied to runway xxl for departure and all indications to this point were normal. We were cleared for takeoff; rolled into position and began the takeoff roll. Immediately as power was pushed forward; international relief officer noted #2 was not responding properly. With increased throttle position; #1 and #3 responded correctly and #2 engine N1 and N2 actually rolled backwards with an increase of egt. The takeoff roll was aborted under 30 KTS. We taxied back to the blocks and turned the aircraft over to maintenance. After some discussions with maintenance; the maintenance crew at the aircraft asked if we could taxi the aircraft to the run-up area to show them what had occurred. We agreed and after downloading all cargo; maintenance cleared the MEL on the APU and we got the aircraft ready for taxi. We started the aircraft once pushed back and all 3 engines started normally. With brakes held; the captain showed the maintainer by pushing the #2 engine throttle up; the N1 and N2 rolled backwards and the egt began to climb. Throttle was returned to idle and the indications slowly rolled back to an idle thrust setting. The maintainer; who had another maintenance person on the phone during the turn; said they are right; it doesn't work. The captain taxied the aircraft back and shutdown the aircraft. It is of my opinion that the maintenance performed on this aircraft was not thoroughly executed and improperly diagnosed. The crew did the best to explain that we had a severely damaged engine; but the maintenance procedures performed did not initially find any damage. It was the captain standing by his initial feelings that this aircraft engine had significant problems that the high power and borescope were even accomplished. The aircraft logbook sign-off that states a high power turn had been accomplished is very questionable.
Original NASA ASRS Text
Title: A MD11 IRO REPORTS A NUMBER 2 ENGINE MALFUNCTION ON APPROACH. THE ENGINE WAS SHUTDOWN AND THE NEXT TAKEOFF WAS ABORTED BECAUSE #2 ENG WAS NOT RESPONDING PROPERLY.
Narrative: ON ILS; JUST AFTER SELECTING FLAPS 28 DEGS; THE ACFT BEGAN SHUDDERING LIKE THE FLAPS WERE AT 50 DEGS; BUT ABOUT 2 TIMES AS HARD. CAPT QUERIED TO WHAT WE WERE FEELING. THINKING THE CONFIGN CHANGE WAS THE CAUSE OF THE SITUATION; WE CHKED THE CONFIGN PAGE AND THE FLAPS WERE AT 28 DEGS AS SELECTED. I SCANNED L TO THE EAD AT THAT POINT AND SAW THAT THE N1 AND N2 WERE ROLLING BACK ON THE #2 ENG AND ANNOUNCED WE WERE LOSING #2. THE CAPT CHOSE TO PLACE THE #2 THROTTLE LEVER TO IDLE. THEN THE #2 ENG EGT HI LEVEL 2 CAUTION ILLUMINATED AROUND 1600 FT AND THE PROC WAS COMPLETED BTWN THE FO AND IRO. FULL CONFIGN WAS OBTAINED AND A DECISION TO CONTINUE TO LAND WAS MADE. JUST BELOW 1000 FT; THE EAD STARTED TO DISPLAY YELLOW X'S ON N2 FIRST AND THEN THE ENTIRE STACK OF TAPES FOR ENG #2. I CALLED POSSIBLE SEVERE DAMAGE ON THE #2 ENG. THE DECISION AT THAT POINT WAS THAT THE VIBRATION AND SUBSEQUENT ENG FAILURE WAS DUE TO SEVERE DAMAGE AND THE FIRE HANDLE WAS PULLED AND A BOTTLE DISCHARGED. AN EMER WAS DECLARED PRIOR TO LNDG STATING THE LOSS OF AN ENG. THE LNDG AND ROLLOUT WERE UNREMARKABLE. WE EXITED THE RWY DIRECTLY IN FRONT OF THE FIRE STATION AND STOPPED TO ALLOW THEM TO VIEW THE #2 ENG TO VERIFY WE DID NOT HAVE ANY FIRE/SMOKE OR DAMAGE. THEN WE CONTINUED TO THE BLOCKS. WE REMAINED AT THE ACFT FOR THE NEXT 3 HRS. MAINT IN THESE HRS INSPECTED THE FAN BLADES AND TURBINE OF N1; REPLACED THE BOTTLE THAT WAS DISCHARGED AND STEPPED THROUGH A CHKLIST FOR THE EGT HI CAUTION THAT WAS DISPLAYED. A REQUEST TO TURN THE ENG WAS PRESENTED AND THE CAPT AND FO COMPLETED CHKLISTS; STARTED #2; AND SHUTDOWN THE ENG. THE ENG STARTED AND RAN WITH WHAT APPEARED NORMAL NUMBERS WITH EXCEPTION OF A FLUCTUATING EVM ON N1 VARIABLE BTWN 0.8 AND 1.4. NOW; THIS WAS AT IDLE THRUST. THEN MAINT SAID THAT THE ACFT IS SIGNED OFF AND A BORESCOPE WOULD BE DEFERRED. THE CREW WAS THEN TAKEN TO THE HOTEL FOR CREW REST. THE PLAN WAS TO FLY OUT THE FOLLOWING DAY. THE CAPT AND CREW DID NOT WANT TO TAKE THE ACFT WITHOUT A HIGH PWR ENG TURN AND A BORESCOPE WITH THE SEVERITY OF THE SHUTDOWN INFLT THAT EVENING. THE NEXT DAY MAINT DETERMINED THEY WOULD COMPLETE A BORESCOPE AND ENG TURN. THE STEPS WERE COMPLETED FOR THE BORESCOPE AND THE ENG HIGH PWR TURN. CREW ARRIVED AT THE ACFT 2 DAYS LATER AROUND XA00 LCL TIME. A MAINT MAN WAS THE FIRST PERSON I CAME ACROSS. I QUERIED TO HOW THE HIGHER PWR TURN WENT AND IF WE WERE GOOD TO FLY. HE STATED THAT THEY HAD DIFFICULTIES WITH THE APU AND SUBSEQUENTLY MEL'ED THE APU. WHEN ASKED WHY; HE STATED COMPRESSOR STALLS. HE ALSO STATED THAT AT THE CONCLUSION OF SECURING THE APU WHILE TURNING THE #2 ENG; THERE WERE NO FURTHER COMPRESSOR STALLS. AFTER REVIEWING THE LOGBOOK OF ALL SIGNOFFS; INCLUDING BORESCOPE; HIGH PWR ENG TURNS; AND INSPECTIONS; THE CREW READIED THE ACFT FOR FLT. NORMAL CHKLIST WERE COMPLETED FOR BEFORE START. WE STARTED THE #3 ENG IN THE BLOCKS DUE TO THE APU BEING MEL'ED AND THEN PUSHED BACK FOR OTHER STARTS AND TAXI. ALL ENGS STARTED NORMALLY. THE ACFT WAS TAXIED TO RWY XXL FOR DEP AND ALL INDICATIONS TO THIS POINT WERE NORMAL. WE WERE CLRED FOR TKOF; ROLLED INTO POS AND BEGAN THE TKOF ROLL. IMMEDIATELY AS PWR WAS PUSHED FORWARD; IRO NOTED #2 WAS NOT RESPONDING PROPERLY. WITH INCREASED THROTTLE POS; #1 AND #3 RESPONDED CORRECTLY AND #2 ENG N1 AND N2 ACTUALLY ROLLED BACKWARDS WITH AN INCREASE OF EGT. THE TKOF ROLL WAS ABORTED UNDER 30 KTS. WE TAXIED BACK TO THE BLOCKS AND TURNED THE ACFT OVER TO MAINT. AFTER SOME DISCUSSIONS WITH MAINT; THE MAINT CREW AT THE ACFT ASKED IF WE COULD TAXI THE ACFT TO THE RUN-UP AREA TO SHOW THEM WHAT HAD OCCURRED. WE AGREED AND AFTER DOWNLOADING ALL CARGO; MAINT CLRED THE MEL ON THE APU AND WE GOT THE ACFT READY FOR TAXI. WE STARTED THE ACFT ONCE PUSHED BACK AND ALL 3 ENGS STARTED NORMALLY. WITH BRAKES HELD; THE CAPT SHOWED THE MAINTAINER BY PUSHING THE #2 ENG THROTTLE UP; THE N1 AND N2 ROLLED BACKWARDS AND THE EGT BEGAN TO CLB. THROTTLE WAS RETURNED TO IDLE AND THE INDICATIONS SLOWLY ROLLED BACK TO AN IDLE THRUST SETTING. THE MAINTAINER; WHO HAD ANOTHER MAINT PERSON ON THE PHONE DURING THE TURN; SAID THEY ARE RIGHT; IT DOESN'T WORK. THE CAPT TAXIED THE ACFT BACK AND SHUTDOWN THE ACFT. IT IS OF MY OPINION THAT THE MAINT PERFORMED ON THIS ACFT WAS NOT THOROUGHLY EXECUTED AND IMPROPERLY DIAGNOSED. THE CREW DID THE BEST TO EXPLAIN THAT WE HAD A SEVERELY DAMAGED ENG; BUT THE MAINT PROCS PERFORMED DID NOT INITIALLY FIND ANY DAMAGE. IT WAS THE CAPT STANDING BY HIS INITIAL FEELINGS THAT THIS ACFT ENG HAD SIGNIFICANT PROBS THAT THE HIGH PWR AND BORESCOPE WERE EVEN ACCOMPLISHED. THE ACFT LOGBOOK SIGN-OFF THAT STATES A HIGH PWR TURN HAD BEEN ACCOMPLISHED IS VERY QUESTIONABLE.
Data retrieved from NASA's ASRS site as of May 2009 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.