FINAL INVESTIGATION REPORT ON SERIOUS

INCIDENT TO M/S SPICEJET BOMBARDIER

DHC8-400 AIRCRAFT VT-SUM AT NAGPUR ON
24.11.2017

GOVERNMENT OF INDIA
MINISTRY OF CIVIL AVIATION
AIRCRAFT ACCIDENT INVESTIGATION BUREAU
 Foreword

In accordance with Annex 13 to the Convention on International Civil

Aviation Organization (ICAO) and Rule 3 of Aircraft (Investigation of
Accidents and Incidents), Rules 2017, the sole objective of this investigation
is prevention of accidents/ incidents and not to apportion blame or liability.

This report has been prepared based upon the evidences collected
during the investigation, opinion obtained from the experts and laboratory
examination of engine. Consequently, the use of this report for any purpose
other than for the prevention of such future incidents could lead to
erroneous interpretations.
 INDEX
CONTENTS PAGE No.
1 02
FACTUAL INFORMATION
1.1 HISTORY OF THE FLIGHT 02
1.2 INJURIES TO PERSONS 04
1.3 DAMAGE TO AIRCRAFT 04
1.4 OTHER DAMAGE 04
1.5 PERSONNEL INFORMATION 04
1.6 AIRCRAFT INFORMATION 07
1.7 METEOROLOGICAL INFORMATION 17
1.8 AIDS TO NAVIGATION 17
1.9 COMMUNICATIONS 17
1.10 AERODROME INFORMATION 18
1.11 FLIGHT RECORDERS 18
1.12 WRECKAGE AND IMPACT INFORMATION 19
1.13 MEDICAL AND PATHOLOGICAL INFORMATION 19
1.14 FIRE 19
1.15 SURVIVAL ASPECTS 19
1.16 TESTS AND RESEARCH 19
1.17 ORGANISATIONAL & MANAGEMENT INFORMATION 23
1.18 ADDITIONAL INFORMATION 23
1.19 USEFUL AND EFFECTIVE TECHNIQUES 27
2 ANALYSIS 27
2.1 GENERAL 27
2.2 SERVICE BULLETINS ON BEARING COMPARTMENTS 28
SEALS

2.3 SUBJECT INCIDENT 28

2.4 OTHER SIMILAR INCIDENTS 29
2.5 ACTIONS TAKEN BY OPERATOR TO AVOID RECURRENCE 29
3 CONCLUSIONS 30
3.1 FINDINGS 30
3.2 PROBABLE CAUSE OF THE INCIDENT 32
4 SAFETY RECOMMENDATIONS 32
 GLOSSARIES
APD Advanced Pneumatic Detector
ARP Aerodrome Reference Point
ARSR Air Route Surveillance Radar
ATPL Airline Transport Pilot Licence
CAR Civil Aviation Requirements
CFT Crash Fire Tender
CPL Commercial Pilot Licence
DGCA Directorate General of Civil Aviation
DME Distance Measuring Equipment.
DVOR Doppler VHF Omni Directional Range
FL Flight Level
ILS Instrument Landing System
MSN Manufacturer Serial Number
MSSR Mono-Pulse Secondary Surveillance Radar
NDB Non-Directional Beacon
OEM Original Equipment Manufacturer
PSIA Pounds per Square Inch Absolute
TOBI Tangential On Board Injector
UTC Co-ordinated Universal Time
 INVESTIGATION REPORT ON SERIOUS INCIDENT TO M/S SPICEJET

BOMBARDIER DHC8-400 AIRCRAFT VT-SUM AT NAGPUR ON 24.11.2017.

1. Aircraft Bombardier

Type DHC – 8 – 402 (Q-400)

Nationality Indian

Registration VT-SUM

2. Owner Maple Leaf Financing Limited

3. Operator Spice Jet Limited

4. Pilot – in –Command ATPL Holder

Extent of Injuries None

5. Co-pilot CPL Holder

Extent of Injuries None

6. No. of Passengers on board 59

Extent of Injuries None

7. Last point of Departure Hyderabad Airport

8. Intended landing place Jabalpur Airport

9. Place of incident En-route

10. Date & Time of incident 24.11.2017 & 0830 UTC

11. Phase of operation Cruise

12. Type of incident Smoke in Cockpit & Cabin.

(ALL TIMINGS IN THE REPORT ARE IN UTC)

1
1. FACTUAL INFORMATION.

1.1 History of the flight

On 24th November 2017, a DHC 8 - 402 aircraft was involved in a serious

incident of smoke in cabin & cockpit while operating scheduled flight

from Hyderabad to Jabalpur resulting in diversion to Nagpur. The flight

was under command of an ATPL holder on type as Pilot – In –Command

(Pilot Flying) with a CPL holder on type as Co-pilot (Pilot Monitoring).

There were a total of 59 passengers and 02 Cabin Crew members on

board the aircraft. On the day of incident prior to the incident flight,

the aircraft had operated 05 flights i.e. Hyderabad – Chennai –

Bengaluru – Hyderabad – Rajahmundry – Hyderabad. No snag was

reported by the crew and these flights were uneventful.

The aircraft was then scheduled to operate flight Hyderabad -

Jabalpur. The aircraft took-off from Hyderabad at 0753 UTC for

Jabalpur. At 0830 UTC, while cruising at FL 250 and about 140 Nm from

Hyderabad cabin crew reported to PIC that there is smoke in cabin. The

PIC asked co-pilot to verify the smoke and the same was later confirmed

by him. The PIC instructed the cabin crew to check the cabin for any

source of fire. The cabin crew checked the whole cabin but did not find

any source of fire. The cockpit crew then decided to divert to Nagpur

which was around 80 Nm from their position. At around 0833 UTC, the

cockpit crew contacted Nagpur ATC and informed that they are making

priority landing at Nagpur due to smoke in cockpit. Crew also asked for

emergency descent and safety services on arrival. Accordingly, at 0837

UTC full emergency was declared at Nagpur airport. The aircraft was

then cleared by ATC for landing at Nagpur with visibility 3200 meters

and winds calm. During descent, aft baggage cargo smoke warning along

2
with fire detected warning light came ON at master warning panel in

cockpit and the aft cargo fire extinguisher was operated from the

cockpit. Thereafter, the smoke was also felt in the cockpit and as per

the statement of PIC they have donned the oxygen mask. PIC then

asked co-pilot to carry out QRH (Quick Reference Handbook) actions

for fuselage fire, smoke or fumes. The crew heard the aural warning

(smoke detector) for lavatory and the forward cargo baggage

extinguisher was operated from the cockpit. Accordingly, PIC instructed

them to secure the cabin and informed that they are going to land at

Nagpur. During approach, low oil pressure warning for engine # 2 came

ON. At 0856 UTC, the aircraft landed safely on runway 32 and taxied

to the main isolation bay with follow me service and CFT’s. After

reaching bay, the PIC shut down the engine and instructed cabin crew to

evacuate passengers from the left side. All passengers were evacuated

from the left side. As per the statement of the cabin crew, post

evacuation while carrying out the cabin search they observed some

inflated life vests lying in the cabin. There was no injury to passengers

during evacuation. The crew also evacuated the aircraft from the left

side. At 0923 UTC, full emergency was withdrawn by ATC. There was no

injury to any occupant on board the aircraft.

On ground, engine oil level was checked, but nothing was visible in sight

glass. “Chip detector” message was found in “Eng health history”. Test

was carried out for chip detection wherein few metallic particles were

found which were out of limits. Engine was removed for further

investigation at OEM facilities.

3
1.2 Injuries to persons.

INJURIES CREW PASSENGERS OTHERS

FATAL Nil Nil Nil
SERIOUS Nil Nil Nil
MINOR/None 04 59

1.3 Damage to aircraft.

The aircraft sustained damages confined to engine No. 2. After removal

the engine was sent to OEM facility for investigation. The investigation

team participated in the strip examination and the details are covered in

Para 1.16.

1.4 Other damage

Nil

1.5 Personnel information:

1.5.1 Pilot- in- Command:

AGE 27 Years

License ATPL

Date of License Issue and Validity 04-08-2016 & Valid

Category Aeroplane

Class Multi Engine, Land

Endorsements as PIC PA-34, DHC-8 402

Date of Joining Company 23-Apr-12

Date of Endorsement as PIC on type 17-02-2017

Instrument Rating 23-Dec-2016 & Valid

Date of RTR Issue and Valid up to 17-Apr-17 valid upto 16-Apr-19

4
Date of FRTOL issue & validity 22-Mar-15 valid upto 21-Mar-20

Date of Med. Exam & validity 27-Jun-17 valid upto 05-Jul-18

Date of Route Check 18-Feb-17

Date of Last Proficiency Check 13-Jun-17

Date of English language Proficiency 05-Mar-16 & valid

Date of last CRM 06-Oct-17

Date of last Monsoon training 06-Oct-17

Date of Dangerous Goods Awareness 22-Apr-16

Training
Date of last Refresher/Simulator 06 – Oct 2017

Simulator Training for Critical 06 – Oct 2017

Emergencies
Familiarity with Route/ Airport 25-Jun-2017
flown for last 12 months and since
joining the company.
Total flying experience 4150

Total Experience on type 1550

Total Experience as PIC on type 1300

Last flown on type 23-Nov-2017 (DHC 8 Q400)

Total flying experience during last 918:56

01 Year
Total flying experience during last 520:46
180 days
Total flying experience during last 239:34
90 days
Total flying experience during last 72:45
30 days

5
1.5.2 Co- Pilot:

AGE 28 Years

License CPL-11254

Date of License Issue and Valid up to 13-Dec-11 valid upto 12-Dec-21

Category Aeroplane

Class Multi Engine, Land

Endorsements as PIC Cessna 152, Piper Seneca PA-34

Date of Joining Company 10thMarch 2016

Instrument Rating 28thApril 2017

Date of RTR Issue and Valid up to 27-Jun-11 valid upto 05-Jun-19

Date of FRTOL issue & validity 13-Dec-11 valid upto 12-Dec-21

Date of Med. Exam & validity 06-Mar-17 valid upto 16-Mar-18

Date of Route Check 24-Aug-17

Date of Last Proficiency Check 27-Oct-17

Date of English language Proficiency 08-May-13& valid upto 07-May-19

& Valid up to
Date of last CRM 06-Jul-17

Date of last Monsoon training 06-Jul-17

Date of Dangerous Goods Awareness 20-Jun-16

Training
Date of last Refresher/Simulator 06 – Oct 2017

Simulator Training for Critical 06 – Oct 2017

Emergencies
Familiarity with Route/ Airport 18-Nov-2017
flown for last 12 months and since
joining the company.
Total flying experience 1472 Hrs

Total Experience on type 1214:25 Hrs

Total Experience as PIC on type NIL

6
 Last flown on type 23-Nov-2017 (DHC 8 Q400)

Total flying experience during last 917:31 Hrs

01 Year
Total flying experience during last 455:31 Hrs
180 days
Total flying experience during last 188:54 Hrs
90 days
Total flying experience during last 85:23
30 days

1.6 Aircraft information:

1.6.1 General Information

The aircraft bearing MSN 4402 was manufactured in the year 2012 and

was registered under category ‘A’ with Certificate of Registration

Number 4336. The Certificate of Airworthiness Number 6445 under

“Normal category” subdivision Passenger / Mail / Goods was issued by

DGCA on 30.06.2012. The specified minimum operating crew is two and

the maximum all up weight is 29,257 Kgs. At the time of incident, the

Certificate of Airworthiness and Aero Mobile License No. A-

010/049/RLO was valid. As on 24.11.2017, the aircraft had logged

15888:53 Airframe hours and 15421 cycles.

The aircraft was fitted with two PW150A engines. As on 24.11.2017, the

left Engine (PCE-FA0890) had logged 13063:41 hrs and 12640 cycles and

the right Engine (PCE-FA0807) had logged 11328:53 hrs and 10871 cycles.

There was no snag pending rectification.

The aircraft and its engines are maintained as per the Maintenance

Programme consisting of calendar period / flying hours or Cycles based

maintenance as per maintenance programme approved by DGCA.

7
 The last major inspection was carried out at 11653:39 Airframe hours /

11196 cycles on 05.07.2016. Subsequently, all lower inspections were

carried out as and when due before the incident.

The aircraft was last weighed on 26.02.2017 and the weight schedule was

approved by DGCA. There was no major modification effecting weight &

balance since last weighing. Prior to the incident flight, the weight and

balance of the aircraft was well within the operating limits.

All concerned Airworthiness Directive, mandatory Service Bulletins,

DGCA Mandatory Modification on this aircraft and engines have been

complied with as on date of incident. The last fuel microbiological test

was done on 19.07.2017 and the microbiological growth was negligible.

1.6.2 PW150A Engine Description:

The engine has a low pressure (first stage) axial compressor and a high

pressure (second stage) centrifugal compressor, each attached to separate

single stage turbines. A two-stage power turbine drives a third shaft to

turn the propeller through a reduction gearbox. The high-pressure

compressor also drives the accessory gearbox.

8
1.6.3 Bearings

There are nine main bearing on the engine: six roller bearings and three

ball bearings. The ball bearings No. 1, 3 & 4 withstand the following

thrusts:

No.1 bearing: Power turbine shaft thrust (Rearward)

No.3 bearing: Low pressure spool thrust (Forward)

No.4 bearing: High pressure spool thrust (Forward)

Bearings number 2, 2.5, 5, 6, 6.5 and 7 are roller bearings. They support

radial loading and permit axial movement caused by thermal expansion. The

following table gives the direction of rotation of bearing along with the

shaft which these support.

Power Turbine Low Pressure Shaft High Pressure

Shaft Shaft

No. 1 Ball No. 2.5 Roller No. 4 Ball

No. 2 Roller No. 3 Ball No. 5 Roller

No. 6.5 Roller No. 6 Roller

No. 7 Roller

Clockwise Counter-Clockwise Clockwise

9
 The forward end of the HP (High Pressure) shaft is located longitudinally

and radially by a ball bearing at the No 4 position, in front of the impeller.

The aft end of the shaft is held radially by a roller bearing (No 5),

positioned forward of the HP turbine and enclosed by the reverse flow

combustor.

A number of parts of the HP spool rotate in close proximity to fixed parts

of the engine structure in the vicinity of the No 5 bearing. Their operating

clearance is assured by the No 4 bearing, preventing forward movement of

the HP spool.

1.6.4 Air/Gas Flow:

Air entering at the engine inlet is directed rearward and compressed. Two

compressors carry out compression for combustion and bleed extraction

purposes. Air is first ducted to the low-pressure axial compressor and then

to the high pressure centrifugal compressor where it undergoes a second

stage of compression. The compressed air then enters internal ducts, and

is discharged into the combustion chamber where fuel is added and ignited.

10
1.6.5 Bearing Compartments Sealing:

 The No. 2 and 2.5 bearing cavity is sealed using 2 different types of

seals. The front end is sealed by a face carbon seal, the rear end is

sealed by a double carbon seal ring and the clearance left between the

PT (Power Turbine) shaft and the LP (Low Pressure) shaft is sealed by

a single carbon seal ring mounted in the LPC rotor. The 2 carbon seal

rings are pressurized with P2.5 (LP compressor outlet) directed

through internal passages in the LP compressor section.

 The No. 3 and 4 bearing cavity is sealed on each end using a double

carbon seal ring and the clearance left between the LP and the HP

shafts is sealed by 2 single element carbon seal ring. All seals are

pressurized with P2.8 (HP compressor split vane impeller level)

directed through internal passages in the inter-compressor case.

 The No. 5 bearing cavity is sealed on each end using a single carbon seal

ring. These seals are pressurized with P3 (after HP impeller) directed

through internal passages in the gas generator case.

 The No. 6 and 6.5 bearing cavity is sealed on each end using a double

carbon seal ring and the clearance left between the LP shaft and the

PT shaft is sealed by 2 single carbon seal rings. All seals are

pressurized with P2.5 (LP compressor outlet) directed through internal

passages in the turbine support case.

 The No. 7 bearing cavity is sealed on the front end using a double

carbon seal ring. The seal is pressurized with P2.5 (LP compressor

outlet) directed through the PT shaft.

11
Brush Seals:

Wire type air restrictors, ensure proper air distribution between turbine

stages. Also ensure proper air distribution to cool HP turbine disk and

blades from the TOBI nozzle housing.

Bearing Area # 1, 2 & 2.5

Bearing Cavities # 3, 4 & 5

12
 Bearing Cavities # 6, 6.5 & 7
1.6.2.4 PW150A CABIN BLEED SYSTEM

The environmental control system (ECS) of PW150 engine provides

bleed air for the various aircraft systems including pneumatic system,

the air conditioning system, de-icing systems, etc.

 The engine provides air bleed extraction ports from both

compressors, the low pressure (LP/P2.7) and the high pressure

(HP/P3). As the two bleed ports are connected to the same duct, a

P2.7 check valve is installed in the low pressure port to prevent back

flow from the high pressure (P3) to the low pressure (P2.7)

 In general, the ECS is supplied with low pressure air (P2.7). At low

engine power, the LP or HP pressure switch (airframe supplied) opens

allowing P3 air to feed the airframe system. At a pre-determined

pressure (P3), the pressure switch (airframe device) closes the P3

13
 supply allowing the P2.7 check valve to open and feed the airframe

air system with P2.7 air pressure.

Cabin Bleed Piping

Operation:

During low power setting, the bleed air is extracted from the high pressure

port P3 and during high power setting the bleed air is extracted from low

pressure port P2.7. The P2.7 check valve is installed on the inter-

14
 compressor case in order to prevent back flow from high pressure bleed air

P3 to low pressure port P2.7.

When power is reduced i.e. when P3 pressure is less than 77 PSIA, the P3

Shut-Off Valve opens allowing P3 port to feed the bleed air to ECS. The P3

air also flows back to P2.7 check valve and since its pressure is higher than

that of the P2.7, the two flappers on the P2.7 check valve are moved down

causing the valve to close.

When power is increased i.e. P3 pressure is greater than 80 PSIA, the P3

Shut off valve closes making P3 to stop feeding the bleed air to ECS.

Hence, the bleed air from P2.7 is the only pressure force applied on the

flappers causing the valve to open. The bleed air from P2.7 now takes over

P3 and feeds to ECS.

1.6.3 ENGINE OIL SYSTEM

Green colour is oil system

15
1.6.4 CHECK FIRE DET warning light and Smoke Warning Light
CHECK FIRE DET warning light

When a fire overheat condition occurs, the alarm signals are processed by

the Control Amplifier then sent to the Fire Protection Panel in the flight

compartment.

If a fire or overheat condition occurs in either engine, this will cause the

gas within the APD to expand and turn ON the following lights in the

flight compartment:

• Applicable PULL FUEL / HYD OFF T-handle light (red) comes ON

• Both ENGINE FIRE warnings PRESS TO RESET lights (red) flash

• CHECK FIRE DET warning light (red) flashes.

As per the “Non Normal Procedures”, in the event of fire, smoke or

fumes, the flight crew is required to land the aircraft without, delay

16
 while completing fire suppression and / or smoke or fumes evacuation

procedures.

If it cannot be visually verified that the fire has been completely

extinguished, (whether the smoke or fumes have cleared or not), land

immediately at the nearest suitable airfield or landing site.

1.7 Meteorological information:

The following is the Met report of Nagpur Airport on the date of incident

between0800UTC to 0930 UTC.

Time Winds Visibility Weather Clouds QNH Temp Dew Trend

o
(UTC) ( /Knots) (Meters) (hPa) (oC) Point
(oC)
0800 10/03 3000 HZ No 1014 29 14 NOSIG =
Signific
ant
Cloud
(NSC)
0830 Calm 3000 HZ NSC 1014 30 15 NOSIG =

0900 Calm 3000 HZ NSC 1013 30 14 NOSIG =

0930 Calm 3000 HZ NSC 1013 29 14 NOSIG =

1.8 Aids to navigation:

The Dr. Babasaheb Ambedkar International Airport, Nagpur has 01 runway

and is equipped with NDB, DVOR/DME, ILS CAT-I, ARSR/MSSR.

1.9 Communication:

There was always two-way communication between the ATC and the aircraft.

At the time of incident, the aircraft was under the control of Nagpur ATC.

17
1.10 Aerodrome Information:

Dr. Babasaheb Ambedkar International Airport, Nagpur is owned and

operated by Mihan International. ARP co-ordinates are N 21° 05' 31"&E

079° 02' 54" with elevation of 1033 feet. Aerodrome Rescue & Fire

Fighting Category (ARFF) available is CAT-VII.

1.11 Flight recorders:

The Cockpit Voice Recorder (CVR) and the Digital Flight Data Recorder

(DFDR) were downloaded and the information has been used for

investigation purposes.

As per the DFDR data:

 At 083448 UTC while operating at 24152 feet (pressure altitude), the

aircraft started descent.

 At 083627 UTC while operating at 21164 feet, Smoke warning came ON

in Centralized Warning Panel (CWP) with master warning for 4 seconds.

The smoke warning remained till the engines were shut down after

landing.

 At 083645 UTC, while operating at 20474 feet Check Fire Detect

warning came ON with master warning for 3 seconds. The Check Fire

Detect warning remained till the engines were shut down after landing.

 Between 084724 and 085134, the master warning came ON

intermittently till the altitude of 2444 feet.

 At 084725 UTC at an altitude of 4616 feet, Right Engine Oil Pressure

warning came ON for 01 sec.

 At 084802 UTC at an altitude of 3664 feet, the right engine oil

pressure warning again came ON.

 At 084831 UTC, the aircraft leveled off at flight level 031.

18
  At 084856 UTC at an altitude of 3086 feet, the right engine oil

pressure warning again came ON and it came intermittently till the

altitude of 2570 feet.

 At 085012 UTC, the aircraft started descending again.

 At 085052 UTC, the right engine oil pressure warning came again and

remained till engine shut down after the aircraft was parked.

 At 085530 UTC, the aircraft landed with flap 15, power lever left at

32.6, power lever right at 27.2, torque left of 0.5% and torque right of

4.5 %.

 The master caution again came ON at 085729 UTC & 085810 UTC for

01 second & 04 seconds respectively.

1.12 Wreckage and impact information.

The aircraft sustained internal damages confined to engine # 2.

1.13 Medical and pathological Information:

Both pilots had undergone preflight medical check prior to the first flight.

The BA test for both of them was negative.

1.14 Fire:

There was no fire after the incident.

1.15 Survival aspects:

The incident was survivable.

1.16 Tests and research:

The involved engine was removed from the aircraft after the incident for

detailed examination. The tear down inspection was carried out at OEM

designated overhaul facility. The relevant extract and findings made at the

19
OEM designated overhaul facility during the teardown inspection are as

below.

Externally, there were no signs of oil leaking. The magnetic Chip Detectors

were found to have a little metal pickup. Some parts like the 2.2 and 2.7

Bleed off Valve (BOV) showed oil wetting on the internal passages. The 2.7

BOV (Blow–Off Valve) was wet on the external surface. Externally visible

oil lines were found to be satisfactory with no obvious leak areas. The Low

Pressure (LP) Compressor, High Pressure (HP) compressor and Power

Turbines assemblies were rotating freely.

20
 The o-rings of the RGB (Reduction

Gear Box) main oil filter housing

were found to be cut. The

magnetic Chip Detectors of the

TM Module, RGB Module and A/C

Generator were found with little

metal pick up.

The oil screen at the Inter Compressor Case was found to have carbon like

material, which became powder when handled.

After disassembly of the hot section, the area outside No. 7 bearing

compartment was found dry and the carbon seals were found in satisfactory

condition.

The oil staining was observed in the gas path indicating that the oil leak was

upstream. There was sooting or white discoloration throughout the gas path.

21
 No. 1 Brg. – Flaking at cage No.2.5 Brg. Dents on
Roller Elements

No.3 Brg.-Flaking of inner No.4 Brg: Corrosion on more

diameter of cage. than 30% of Area 1

No. DESCRIPTION REMARK

1. BEARING NO.1 FLAKING FOUND ON CAGE POCKET.
3. BEARING NO.2.5 DENT ON ROLLERS ELEMENT, CAN BE
FELT WITH DESIGNATED SCRIBER.
4. BEARING NO.3 FLAKING FOUND ON INNER
DIAMETER OF CAGE AND CAGE
POCKET.
5. BEARING NO.4 CORROSION FOUND ON 30 PERCENT
OF SURFACE AREA 1. FRETTING
CORROSTION FOUND ON INNER
RING

22
 Wave spring of No. 3 bearing carbon seal assembly had broken

1.17 Organizational and management information:

The airline is a scheduled airline and were having a fleet of 35 Boeing 737s

aircraft and 17 Bombardier Q-400 aircraft on the date of incident,

operating flights on domestic and international sectors. The Air operator

permit (S-16) of the Airlines was valid till 30/06/2018. The Company is

headed by Chief Executive Officer. The Flight Safety Department is

headed by Chief of Flight Safety approved by DGCA and reports directly

to the CEO.

The airline has in-house maintenance facility and maintenance activities are

carried out under CAR 145 issued by DGCA.

1.18 Additional Information:

There were two similar occurrences (though engines were removed as a

precaution) involving Dash 8, Q400 aircraft during the course of this

investigation. Details are as follows:

23
1.18.1 On 08.04.2018, during cruise, No. 2 engine of one of the other

Bombardier Dash-8 Q400 aircraft of the same operator made diversion

from its intended flight due to pungent oil smell and smoke in cabin with

an alarm from the lavatory smoke detector.

The smoke soon disappeared but the pungent smell continued without

any smoke. On ground during maintenance, waste leak was observed in

lavatory. There was no abnormality or warning as far as engine was

concerned. During maintenance on ground, engine inspection was carried

out as a preventive measure and a small amount of oil traces were

observed on No. 2 engine turbine blades. As a precautionary measure,

the engine was replaced and investigation was carried out at OEM

facility. Extract from the report covering failure of bearing seals is

given below.

The examination of the engine revealed oil wetness from P2.2, P2.7 and

P3 bleed ports. Internal inspection was carried out through P2.2 bleed

port after removal of the bleed valve. Presence of oil at the bottom of

the LPC case internal surface was observed. The high pressure turbine

(HPT), low pressure turbine (LPT) and power turbine (PT) could be

rotated freely. The main oil filter, the RGB scavenge filter were found

dirty/darkened and displayed some carbon debris. The main oil tank

strainer was found clean, but showed some carbon debris/fragments.

The turbo machinery (T/M) magnetic chip detector (MCD) showed some

debris. The reduction gearbox (RGB) scavenge MCD and the RGB Air

conditioner generator MCD were however clean. T/M & RGB Oil samples

showed some carbon fragments.

24
 As per the report of OEM, the reported smoke in the cabin was caused

by the distressed No. 2.5 and No. 3 bearing carbon seals that resulted

in internal oil leakage into the compressor secondary air systems and

engine bleed air system. The carbon 2.5 seal was axially reduced of its

original thickness because of rubbing / rotation of the carbon element.

The damages observed on the No. 3 bearing front carbon element

caused excessive seal clearance and a loss of air pressurized sealing.

The loss of sealing subsequently resulted in oil leakage which

contaminated the engine primary and secondary air systems.

1.18.2 On 11.04.2018, a Dash8 Q 400 aircraft of the same operator, while

operating flight from Coimbatore to Bangalore was involved in an

incident of smoke in the cabin and in the flight compartment. When the

flight was 20 nm away from Bangalore and at 10000 ft, a mild smoke

was observed along with smell in cabin. The non normal checklist actions

were carried out by the PIC. ATC was also informed.

When the aircraft was at about 6 nm from Bangalore, the Front

baggage Compartment smoke warning came ON. QRH actions were

carried out by the crew. Thereafter, there was no smoke in Cabin or

flight compartment, but the smell was still present. The Aircraft

landed safely at Bangalore. Rapid deplaning of passengers was carried

out and all passengers and crew deplaned safely. The passengers were

taken to the terminal building. Post flight, no fire was observed in the

baggage compartment, but mild smoke was observed in rear baggage

compartment.

The subject engine was removed and was stripped at OEM Centre.

Relevant extract from the report is reproduced below:

25
 External examination of the engine revealed oil wetness from the P2.2,

P2.7 and P3 bleed ports. Inspection through P2.2 bleed port after

removal of the bleed valve displayed presence of oil at the bottom of

the LPC case internal surface. The high pressure turbine (HPT), low

pressure turbine (LPT) and power turbine (PT) could be rotated freely.

The main oil filter and the RGB scavenge filter had carbon debris. T/M

and RGB Oil samples were dark, and the RGB samples also displayed

some debris.

As per the report of OEM, the presence of oil leakage at the P 2.2

valve in this case was confirmed. The reported smoke in the cabin was

caused by the distressed No. 2.5 and No. 3 bearing carbon seals that

resulted in internal oil leakage into the compressor secondary air

system and engine bleed air system.

The tension spring of no. 2.5 bearing carbon seal displayed fretting

wear and was axially reduced of its original thickness because of

rubbing / rotation of the carbon element.

The damages observed on the No. 3 bearing front carbon element

caused excessive seal clearance and a loss of air pressurized sealing.

The loss of sealing subsequently resulted in oil leakage which

contaminated the engine primary and secondary air systems.

1.18.3 Replacement of carbon seals:

1.18.3.1 Special Instructions

In Nov 2013, the manufacturer of the engine has given ‘Special

Instructions’ to remove carbon seals from service before reaching

10,000 hours. This was to be carried out whenever engine is sent in

shop for a Hot Section Inspection (HSI) or Hot Section Restoration

(HSR) work scope, irrespective of any work scope that may be planned

additional to the HSI.

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1.18.3.2 Service Bulletin (SB) 35341

The manufacturer observed that on PW150A engines exudation and

oxidation can occur on No. 3 bearing carbon seal while operating under

high temperatures and humid environments which can cause oil leakage

from No. 3 bearing carbon seal. To obviate the problem, SB No. 35341

was issued for all the PW150A engines on 6/10/2016 having S.No. PCE

– FA1238 or earlier.

As per this SB, the existing carbon seal was to be replaced with a new

one (as and when sub assembly is disassembled and access was

available to the necessary part).

1.18.3.3 Service Bulletin (SB) 35342R1

As the manufacturer has observed that the spring load range of no.

2.5 bearing seal is not optimal and can be improved, an SB No.

35342R1 was issued on 24/1/2018 which required that No. 2.5 bearing

seal be replaced with new one that has an increased minimum spring

load to prevent potential spinning of the air/oil bearing seal ring (as

and when sub assembly is disassembled and access was available to

the necessary part).

1.19 Useful or effective investigation techniques:

NIL

2. ANALYSIS

2.1 General:
The aircraft was having valid Certificate of Airworthiness and Certificate

of Registration. The certificate of flight release was valid on the day of

incident. All concerned Airworthiness Directive, Service Bulletins, DGCA

Mandatory Modifications of this aircraft and its engines were found

complied with. There was no snag reported prior to the incident flight.

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 Both pilots were appropriately qualified to operate the flight. The weather

was fine. The aircraft was always under positive control of ATC units.

2.2 Service Bulletins on Bearing Compartments Seals

The manufacturer had issued two service bulletins for PW150A engines for

No. 3 bearing carbon seal and No. 2.5 bearing seal. Both these SBs

required hardware replacement and was to be carried out as and when the

assembly was disassembled and access was available.

Service Bulletin 35341 replaces the #3 Brg. carbon seal with one made

from a carbon grade that is more resistant to high temperatures and

humid environments. Similarly, the SB No. 35342R1 requires that No. 2.5

bearing seal be replaced with new one that has an increased minimum

spring load to prevent potential spinning of the air/oil bearing seal ring.

2.3 Subject Incident

Scrutiny of the engine records revealed that though the engine had a shop

visit earlier, No. 3 bearing compartment Carbon Seal was of pre Service

Bulletin 35341 configuration. The reason for the non-replacement of seal

during that shop visit was that the area of the engine required for

replacement could not be accessed which is in line with the SB No. 35341

issued by manufacturer on the subject.

In the present case, the #1, #2.5, #3 and #4 bearings had all suffered

some form of damage resulting in generation of metal chips. The damage

could be attributed to a combination of lack of lubrication as well as

vibrations due to imbalance seen in the LPC.

To conclude, the aircraft incident is attributed to the #3 Bearing Carbon

Seal that had failed in service and caused oil to leak into the gas path. This

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 caused oil fumes to be released into the aircraft cabin through the Bleed

Off Valves. Eventually enough oil was lost to cause the engine to loose oil

pressure and trigger the Low Oil Pressure indication in the cockpit.

2.4 Other Similar Incidents

During the investigation, there were two engine removals as mentioned

above due to oil smell by flight crew/ maintenance crew. The reason in both

these cases was No. 2.5 & 3 Bearing Carbon seal distress for which the

manufacturer has already issued Service Bulletins. According to these SBs,

the existing carbon seals were to be replaced with new ones as and when

sub assembly is disassembled and access was available to the necessary

part.

2.5 Actions taken by operator to avoid recurrence.

The replacement was to be done during the shop visits subject to the

condition that access to the concerned area was available. As this could

have taken certain time, the operator has taken proactive measures in

coordination with Pratt and Whitney for early detection of degradation of

carbon seal in oil system installed on pre-modified engines such as

 Periodic Oil sampling and analysis for contamination on effected engines.

 Staggering of engines to avoid both engines to be pre-modified on same

aircraft.

 Reduction in water washes frequency to avoid water contamination to

carbon seal.

 Accelerated removal of pre-modified engines from fleet to get them

modified. The operator intends to remove and return all un-modified

rental engines from its fleet before December 2018. These engines (pre

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 SB) are being monitored at repeat weekly oil sampling program with

Pratt & Whitney OIL AT (Analysis Technology) program.

In the meantime, the operator advised its flight crew and engineers about

the cabin smoke issue due to internal oil leak on the engines where the

modified seals are not installed.

3. CONCLUSIONS:
3.1 Findings:
a) The Certificate of Airworthiness, Certificate of Registration and the

certificate of flight release of the aircraft was valid on the date of

incident.

b) Both Pilots were appropriately qualified to operate the flight.

c) All concerned Airworthiness Directive, Service Bulletins, DGCA

Mandatory Modifications on this aircraft and its engines were found

complied with.

d) On the day of incident prior to the incident flight, the aircraft had

operated 05 flights. No snag was reported by the crew and these

flights were uneventful.

e) During the incident flight, while cruising at FL 250 and about 140 Nm

from Hyderabad cabin crew reported to PIC that there is smoke in

cabin. The same was later confirmed by the co-pilot also.

f) Source of smoke/fire could not be established during flight.

g) The cockpit crew then decided to divert to Nagpur which was around 80

Nm from their position and asked for priority landing due smoke in

cockpit. Crew also asked for emergency descent and safety services on

arrival.

h) During descent, aft baggage cargo smoke warning along with fire

detected warning light came ON at master warning panel in cockpit and

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 the aft cargo fire extinguisher was operated from the cockpit.

Thereafter the smoke was also felt in the cockpit.

i) The crew heard the aural warning (smoke detector) for lavatory and the

forward cargo baggage extinguisher was operated from the cockpit.

j) During approach low oil pressure warning for engine # 2 came ON.

k) During the tear down inspection at OEM facility, it was observed that

the No.3 bearing carbon seal had failed in service.

l) Failure of No.3 bearing carbon seal in flight caused oil leakage into the

gas path and oil fumes released into the aircraft cabin through the

Bleed Valves.

m) As a precaution, the operator advised its flight crew and engineers

about the cabin smoke issue due to internal oil leak on the engines.

n) During the course of subject investigation, there were two more similar

occurrence reported. In both the cases the engine was removed due to

oil smell on ground by flight crew/ maintenance crew. The reason in both

these cases was No. 2.5 & 3 Bearing Carbon seal distress for which the

manufacturer has already issued Service Bulletin.

o) As per these SBs, the replacement was to be done during the shop visits

subject to the condition that access to the concerned area was

available. As this access to the area could have taken certain time, the

operator in the mean time took proactive measures in coordination with

the manufacturer for early detection of degradation of carbon seal in oil

system installed on pre-modified engines.

p) The operator intends to remove and return rental engines with un-

modified seals from its fleet before December 2018. Till that time, the

engines (pre SB) are being monitored at repeat weekly oil sampling

program with Pratt & Whitney OIL AT program.

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3.2 Probable cause of the incident

The incident occurred as No. 3 Bearing Carbon Seal failed in service

resulting in oil leak into the gas path causing oil fumes getting into the

aircraft cabin through the Bleed Off Valves.

4. SAFETY RECOMMENDATIONS

In view of the installation of new modified bearing seals introduced by the

manufacturer and preventive actions taken by the operator on the

recommendation of the manufacturer, no recommendations are being made.

Date: 29th March 2019

Place: New Delhi

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