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Maint error on Airbus A321 and CFM engines.
2

Maint error on Airbus A321 and CFM engines.

Maint error on Airbus A321 and CFM engines.

(OP)
https://assets.publishing.service.gov.uk/media/5e9...

Thought some would find this interesting. Not least because it doesn't involve pilot error which is unusual for this level of incident. It was luck more than anything else that both engines didn't stop. Although the FADEC on the second engine will have been in emergency trash the engine mode.

Titan is what we call a white tail airline that only covers shortages in other airlines. They have a pretty good reputation amongst the pilot community, They get audited to hell by multiple organisations away from the official framework due to them being brought in as a wet lease. So all the big carriers audit them to be able to fly their routes at short notice.

Now Kathon is now banned it causes quiet a bit of issues with a lot of the European fleets grounded and parked up in hot places and no fuelling. Perfect breeding ground for the bio stuff in the tanks.

My knowledge on fuel tank quality and testing is limited to draining the tanks for water and signing a bit of paper after I have looked at the moisture test on the fuel bowser to say that its negative.

RE: Maint error on Airbus A321 and CFM engines.

Very interesting.

Reminds me of the great Formula Shell fuel additive fiasco of the 1980's when they traced the issue to some fuel terminals adding the additive for the Shell stations by a bucket poured into the top of the road tanker and relied on the general swish of fuel to mix it.

As with this they added too much and didn't mix it properly and then it started burning our inlet valves on certain high mileage vauxhall fleet cars.

I didn't expect they would still be doing the same thing with aircraft fuel though.

I didn't think they have banned the additive, just noted that it needs to be used in the right amounts and mixed properly with an injection pump into a moving stream of fuel.

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.

RE: Maint error on Airbus A321 and CFM engines.

The absence of an approved Biocide is a quite an operational issue even for parked airliners.

Had a Metro (SA227) with leaking fuel caps, when on preflight they found the "Oil contamination" as they called it, it was promptly biocided, the non drainage low spot in the wing tank still needed the pin hole corrosion cut out and repaired.

RE: Maint error on Airbus A321 and CFM engines.

(OP)
I would say its more of an issue in the current situation than it normally would be. Tanks are getting a flush through 2-6 times a day when its normal ops. And the bulk fuel temp never really gets above 10 degs for any length of time. Now they are sitting in the sun, no fuel through put.

In EASA ops they have withdrawn its approval which has left no alternative as a biocide.

I believe the FAA has also issued guidance on its usage but I suspect they have a few more options for use as a biocide in the FAA world.

This biocide treatment is something separate to the fuel additives that normally go into jet A when they deliver it. I have zero clue what those additives are. This is to kill the bio sludge growth in the aircraft tanks.

RE: Maint error on Airbus A321 and CFM engines.

The key additive is the anti icing or FSII (Fuel System Icing Inhibitor) as they seem to call it now.

Biocide is used on a batch basis and you can get smaller additives for corrosion prevention.

To be left with no biocide seems like a bad move. The tech simply put in far too much of it in a non approved manner ( dumping it in through the top of the tank).

Could easily get some interesting unintentional consequences of this imposed lay off.

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.

RE: Maint error on Airbus A321 and CFM engines.

(OP)
There was a chain of events as usual and plenty of places that it could of been caught.

The maint manual screw up in LGW could have prevented it as well. If the B1 had access to the proper maint manual system and been able to use the aircraft reg to pull the correct documents he would have run the procedure for the CFM engine instead of the LEAP and that would have made him do a borescope which would have shown the white stuff coating everything.

The calling B1 and B2's in the UK engineers is a national peculiarity. Most other places refer to them as technicians. That said some of them are qualified to BEng level but they tend to be the specialist trouble shooting types/managers.

Its a pretty daft way of expressing a mixture anyway in a manual in my view.

RE: Maint error on Airbus A321 and CFM engines.

Well at 100ppm it's not really a "mixture" it's a dosing rate and ppm is very common usage for such additives which are usually metered into a flowing line via a dosing pump. But yes an example of x,000 kg fuel = 0.x kg of addictive would have been useful.

The way they added it in one pour from the top of the tank was not allowed for either as you can't mix it properly and can end up with areas of much higher concentration.

Whilst ppm is commonly volume, I still can't work out how he got to be 37 times the volume. I would have thought it would have been closer to 10 or 100 or 1000. Maybe he inputted litres into a program using gallons or something. who knows?

You would though have thought someone would have checked what and how much he was pouring into an aircraft fuel tanks.

Problems with fuel = planes falling out of the sky so a fairly critical thing to check as far as I can see, even if it wasn't specifically in the manual to do that.

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.

RE: Maint error on Airbus A321 and CFM engines.

(OP)
While I agree with you that its normal in chemical plants its really not in aviation that I have seen.

I think the AMO was Cyprus based so it will be a none native English speaker. And apparently the airbus manuals are not the best having been written in French and then translated into English.

That's the sort of example I am meaning as a better way of presenting it.

I suspect you are correct a unit conversion got into the mix. The bowser will have been recording in litre's. But he could have also taken the tanks at full capacity.

There are multiple ways of this being caught from the stores saying "how much do you want?"

There are certain things that require a dupe signature for work done which means the work is checked twice by licensed technicians, this isn't one of those items. Although that may change.

Anyway in about a years time the full report will come out.

RE: Maint error on Airbus A321 and CFM engines.

Brings memories of the Gimli Glider.
Another units mixup. Actually more than one mixup.
There was a unit mixup when the tanks were loaded. The tanks were manually checked with a dip stick.
Another unit mixup.
There is an anecdote that a van carrying mechanics from the base in Winnipeg to Gimli to inspect the "Glider" ran out of fuel on the way.
And another memory:
During my time in the Moskito Coast, contaminated fuel was an ongoing problem.
I was often asked:
"Why do you think that this motor won't run?"
My stock answer:
"Probably not enough fuel in the water."
I was right much more often than I was wrong.
In this instance that would be;
"Not enough fuel in the Kathon."

Bill
--------------------
"Why not the best?"
Jimmy Carter

RE: Maint error on Airbus A321 and CFM engines.

(OP)
I think its more to do with it coating fairly critical profiles on the internals and also killing various sensors that the FADEC uses to manage the beast.

A similar effect is caused by volcanic ash.

RE: Maint error on Airbus A321 and CFM engines.

In aircraft fueling and storage / distribution systems additive injection is undertaken on regular basis and people know what ppm means and how to calibrate the injection equipment.

The issue here was trying to add it into fuel already in the tank and not adding it to the new fuel loaded into the tanks.

You get the same problem if a storage tank goes off spec. Trying then to re-circulate though something like a cyclone or a coalescer filter or add some magic chemical can take days and often involves some temporary connections and hoses.

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.

RE: Maint error on Airbus A321 and CFM engines.

(OP)
I used to drive a bowser in a smaller GA airport when I was an instructor, and we never added anything into the load. In fact we had to sign for the load and say nothing had been added while it was under our watch. You did a water check on it and then started pumping it into aircraft. Additional moisture checks were required for some owners of jet A. The biz jets sometimes used to spray something into the tanks while you were filling but you were sacked on the spot if you got involved with that. And the spray was extremely horrible stuff anyway so you kept well clear of it.

I can't remember if there is an injection point on the bowsers feed line. If there is on most of them its not something I was told about.

As a pilot I haven't flown anything that's required additions thankfully its just been x.y tons of jet A please.

What the fuel supplier does with the fuel before delivery I really have zero knowledge of, there is a certificate with fuel receipt that it is within spec outside Europe as well as normally some customs stuff to do with it immediately being exported so you don't have to pay tax on it. Inside EASA land you just get a quantity receipt I presume the QA system deals with the certification of fuel quality.


RE: Maint error on Airbus A321 and CFM engines.

For the non-aviation members: Fuel Bowser


Bill
--------------------
"Why not the best?"
Jimmy Carter

RE: Maint error on Airbus A321 and CFM engines.

(OP)
That's a special type of bowser that dispenses from a pipe system under the apron.

Certain places the fuel is piped in. Southern England has a pipeline setup to supply "product" directly from the supplier's production site. Other airports have off site bunkers of it and then piped in from there.

Other airports everything is tanker'd in. And the bowsers is a specialised lorry setup with pump and metering unit.

Apart from the bowser on the apron its as close as most get to fuel including technicians. When they pull from tanks it goes into cubes and is then considered dirty. The fuel farm where they fill the apron lorry's is off limits to pretty much everyone. Any fuel spillage and all hell lets loose. And there is a huge finger pointing exercise to avoid paying the fine.

Normally all a pilot will do with pressurised refuelling is set the fuel panel with the quantity that's required and the bowser plugs it and opens up the flow and the aircraft manages the fuelling and distribution from what you have set on the panel, then shuts the valves when its complete. We then take the declared S.G and the ltrs uplift and then do a cross check its sensible. The SG can vary between 0.78 and .82 depending on the fuel temp.

RE: Maint error on Airbus A321 and CFM engines.

I used to sit in the plane with the other passengers in Central America while the plane was being refueled.
The fuel truck had two ground cables. Both ground cables were supposed to be connected to the air-frame so that continuity with the air-frame could be proven. The two cables were almost always clipped together and lying on the ground near the air-craft.
Flying in the turd world was often an adventure.
Wrong in so many ways.

Bill
--------------------
"Why not the best?"
Jimmy Carter

RE: Maint error on Airbus A321 and CFM engines.

Most of the anti icing stuff is added as it comes into the airport fuel farm either by tanker or pipeline and then stored in the normally quite small airport tanks.

From there you then either have a hydrant system like the photo or a tanker / bowser which fills up and goes out to the planes.

Once a tank is filled, it is then sealed and tested to meet certain QA requirements. That tank QA note lasts until the tank is unsealed and filled again. You never draw in and out of an aviation tank at the same time. The major test on the fuel is taken at the larger storage tanks either at the refinery or the larger fuel farms befor ebeing shipped tot he airport tanks.

Gatwick (where the incipient took place) is predominantly a hydrant fed system fed by pipeline into storage tanks at the airport. Now whether the fuel transfer truck actually has an ability to inject other additives in ppm amounts such as biocide as required from time to time is not clear, but it should have and would have been a whole heap better than just dumping a load of biocide into the top of the tankand hoping that the normal fuel filling exercise swirled it around enough to properly mix it. Of course adding 37 times more than you're supposed to won't have helped....

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.

RE: Maint error on Airbus A321 and CFM engines.

(OP)
Gatwick wasn't where the biocide was added.

It was were the technician didn't get the right page in the manuals and follow the correct procedure after the engine difficulties were entered in the tech log.

The biocide part of the incident happened in another country to the UK. Cyprus is mentioned in the introduction which I can only presume either the technician was licensed through them or the maint was through a P145 maint organisation registered in Cyprus.

RE: Maint error on Airbus A321 and CFM engines.

aaah, now read it carefully. The unknown maintenance base is where it got added two days beforehand following some "major maintenance".

Pity they don't say where.

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.

RE: Maint error on Airbus A321 and CFM engines.

(OP)
these reports are not meant to point fingers of blame.

They are only to establish facts and guidance so it doesn't happen again.

Some countries shall we say stray away from this basic principle but the UK AIBB really doesn't. This does cause some legal issues with certain incidents which involve fatalities.

The Clutha pub in Glasgow helicopter crash and the Horsham display crash are prime examples of that.

Unfortunately the time scale of the process do cause a fair amount of distress to relatives. But in the long run it does promote safer air travel.

RE: Maint error on Airbus A321 and CFM engines.

For those wondering why fuel tank trailers are called "Bowsers" in the UK ... Bowswers is a UK manufacturer of tanks and tank trailers. They supplied most of the RAF bases in the 39 - 45 war etc and the name became ubiquitous

RE: Maint error on Airbus A321 and CFM engines.

(OP)
And the mobile toilet service system is called either the shite bowser or honey wagon in the UK/scotland... And the operator the honey monster.

RE: Maint error on Airbus A321 and CFM engines.

The original Honey wagons in North America were horse drawn wagons that emptied the buckets in the outhouses in small towns.
I don't know how old the name is, but old.

Bill
--------------------
"Why not the best?"
Jimmy Carter

RE: Maint error on Airbus A321 and CFM engines.

Quote (LittleInch)

Whilst ppm is commonly volume, I still can't work out how he got to be 37 times the volume. I would have thought it would have been closer to 10 or 100 or 1000. Maybe he inputted litres into a program using gallons or something. who knows?
We can take random guesses...

6,200 kg of fuel, divided by 100 (missing ppm), is 62 kg. If he tried to divide by the specific gravity of the Kathon, he'd get 59.6 kg (or he may have just rounded off... not much difference in 62kg vs 60kg at those quantities). He put in 30 (per wing), should have put in 0.8, that's ~37x.

Dan - Owner
http://www.Hi-TecDesigns.com

RE: Maint error on Airbus A321 and CFM engines.

It was 6,200 kg per each tank. But I think you're on the right path using mass.

I suspect though he put in 6200 lbs fuel into the convertor at 10,000 ppm (1%), got 62 lbs, then converted back to kg - 28.1 kg times density 1.04 = 29.3 kg

So yes either forgot it was 6,200kg per tank or input lbs somewhere thinking it was kg.

And got the ppm totally wrong using mass not volume never mind the order of magnitude error.

Well at least he made it back to Gatwick in one piece. I hesitate to think about where his flight path was if that had fallen out of the sky ( Over london somewhere I would have thought)

Remember - More details = better answers
Also: If you get a response it's polite to respond to it.

RE: Maint error on Airbus A321 and CFM engines.

"Lost in translation?"

Bill
--------------------
"Why not the best?"
Jimmy Carter

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