Aviation safety investigations & reports

Engine nacelle strike and continued operation involving Boeing 737-8FE, VH-YIW, Faleolo Airport, Apia, Samoa on 23 April 2016

Investigation number:
AO-2016-042
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 23 April 2016, a Virgin Australia Boeing 737-8FE aircraft, registered VH-YIW, operated as VA91 from Auckland, New Zealand to Faleolo Airport in Apia, Samoa, with the intent to conduct a return flight that day. The departure from Apia was planned to be completed before the arrival of an approaching tropical cyclone.

During the landing on runway 08, while correcting for a left drift from the runway centreline, the aircraft touched down in a nose-down, right wing-low attitude. This resulted in the right engine nacelle contacting the runway. The flight crew were not aware the nacelle strike had occurred, as the landing, while firm, was not assessed by the flight crew to be outside of normal landing parameters.

What the ATSB found

The ATSB identified that due to heavy rain, darkness and limited visual cues, the flight crew did not detect the aircraft's banked, nose-low attitude immediately prior to landing. Additionally, the subsequent routine flight crew and engineering inspections did not identify damage to the nacelle over the aircraft’s next four flights.

It was also found that the pilot flying was probably experiencing a level of fatigue that has been demonstrated to adversely influence performance.

What's been done as a result

Following this occurrence, the operator modified its aircraft external inspection procedures for flight crew and engineering staff. The flight crew training material was updated to reflect the inspection procedures in the flight crew operating manual, which stated that crew shall inspect the underside of engine nacelles. This action was supported by an internal flight operations update issued on 29 April 2016, re-emphasising that exterior inspections were to be conducted in accordance with the flight crew operating manual’s procedures.

The engineering daily inspection task card for pre‑flight inspections before extended operations was strengthened by issuing engineering technical advisories including the requirement to conduct checks of the underside surfaces of the engine nacelles during normal operation and also when there was indication of an increased likelihood of a nacelle strike on landing.

The operator also identified and implemented a number of improvements in the management of hazards associated with significant events, including cyclones.

Safety message

Detecting airframe damage, particularly to the underside of the engines, can be difficult due to the location not being within normal visual reference. Airframe damage in this location is more likely to be detected by thorough visual inspections of the lowest parts of the airframe before flight and during daily inspection.

While checking for damage in this inconspicuous location can be difficult, and influenced by an expectation that no damage is present, flight crew and engineers are reminded that damage can occur without flight crew awareness.

Download final report
[Download  PDF: 1.46MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

General details
Date: 23 April 2016   Investigation status: Completed  
Time: 0807 UTC   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Faleolo International Airport   Investigation phase: Final report: Dissemination  
State: International   Occurrence type: Ground strike  
Release date: 30 June 2020   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 737-8FE  
Aircraft registration VH-YIW  
Serial number 40700  
Operator Virgin Australia International Airlines  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Minor  
Departure point Auckland, New Zealand  
Destination Apia, Samoa  
Last update 30 June 2020