Accredited representative to the Japan Transport Safety Board’s investigation of abnormal engine behaviour during decent involving Boeing 787, VH-VKJ, on 29 March 2019

AE-2019-016

Summary

The occurrence

On 29 March 2019 at about 1857 JST (Japan Standard Time),[1] a Boeing 787-8 aircraft, registered VH‑VKJ, was operating by Jetstar as scheduled flight JQ15 from Cairns Airport, Queensland, to Kansai International Airport, Japan. During descent into Kansai, the aircraft experienced engine speed oscillations and temporary loss of thrust on the right and then the left engine. The aircraft landed safely at Kansai at 1919.

Investigation

The Japan Transport Safety Board (JTSB) was responsible for the investigation of this occurrence. As part of this investigation, the JTSB notified the ATSB as the State of the Operator of the aircraft. In accordance with clause 5.18 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to assist the JTSB with the investigation. In order to facilitate that assistance, an investigation under the Transport Safety Investigation Act 2003 was commenced.

Findings

The JTSB investigation is now complete and identified the probable cause of the engine oscillations and temporary loss of thrust as being residue from a previous biocide fuel system treatment interfering with the fuel metering of both engines. That biocide treatment, Kathon FP1.5, was loaded into the aircraft’s fuel system two days before the occurrence. The JTSB identified a number of safety actions regarding the use Kathon FP1.5 as a biocide treatment.

The JTSB have released the final report into this investigation, which is available at www.mlit.go.jp/jtsb/airrep.

Any enquires relating to the investigation should be directed to the JTSB: www.mlit.go.jp/jtsb.

With the completion of the JTSB investigation, the ATSB’s assistance activities are also complete and the investigation closed.

 

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The information contained in this update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the JTSB final investigation of the occurrence.

 

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  1. Japan Standard Time =UTC + 9 hours.

Occurrence summary

Investigation number AE-2019-016
Occurrence date 29/03/2019
Location near Osaka, Japan
State International
Report release date 23/07/2020
Report status Final
Investigation level Systemic
Investigation type External Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Engine failure or malfunction
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model B787
Registration VH-VKJ
Serial number 36236
Aircraft operator Jetstar Airways
Sector Jet
Operation type Air Transport High Capacity
Departure point Cairns, Queensland, Australia
Destination Osaka, Japan
Damage Nil