Pilot Debrief

ATR ATR72 near St. Croix — 2010-01-12

Final reportENG10IA010
Sign in to save
Date
2010-01-12
Location
St. Croix, USA
Airport
STX
Aircraft
ATR ATR72
Registration
N434AT
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Takeoff roll

Probable cause

The sealing failure between the fuel nozzle adapter assembly and fuel transfer tubes that allowed fuel to leak into the nacelle fire zone where it was subsequently ignited by the hot combustor case. Contributing to the failure was a combination of manufacturing defects of the fuel nozzle adapter assembly by the manufacturer and incorrectly overhauled fuel transfer tubes by the engine manufacturer. Contributing to the incident was a second defect of the fuel nozzle adapter assembly by the manufacturer which prevented maintenance personnel from detecting the internal fuel leak.

NTSB narrative

During takeoff the No. 1 (left) engine fire warning illuminated in the cockpit. The pilot declared an emergency, shut down the No. 1 engine and discharged one fire bottle. The fire warning continued and the pilot discharged the second bottle; but the fire warning did not extinguish. The pilot performed an air turnback and landed the airplane uneventfully approximately 11 minutes later. Engine testing at the manufacturer’s facility revealed a large fuel leak emanating from the No. 2 fuel nozzle manifold adapter-to-transfer tube O-ring connection. Examination revealed two manufacturing defects in the No. 2 fuel nozzle manifold adapter. The first defect, poor surface finish, caused damage to the transfer tube O-ring during the installation process, initiating an internal fuel leak. The second defect, blockage of the internal safety tell-tale drain due to an improper machining and subsequent cleaning procedure, prevented the leaking fuel from flowing into the tell-tale drain and being detected by maintenance personnel. Examination of the transfer tubes revealed an undersized O-ring retention zone, which allowed the O-ring to fit loosely such that it was not capable of withstanding continuous maximum fuel pressure load. Eventually the O-ring failed to seal properly, fuel leaked and was ignited by the hot combustor case. The undersized O-ring retention zone was created during the cleaning and overhaul process of the transfer tube.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Maintenance should have addressed the fuel manifold issues before the flight.

NTSB coding

  • Fire/smoke (non-impact) · Takeoff

Evidence available

  • CVR
  • FDR / data
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

Related mishaps