Aviation safety investigations & reports

Engine flameouts on descent involving GIE Avions De Transport Regional ATR72-212A, VH-FVN, near Canberra Airport, Australian Capital Territory, on 13 December 2018

Investigation number:
AO-2018-081
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 530KB]
 

What happened

On 13 December 2018, a GIE Avions De Transport Regional ATR72-212A registered VH-FVN was operated by Virgin Australia Airlines on a scheduled passenger flight from Sydney to Canberra. The aircraft encountered icing, turbulence and rain associated with thunderstorm activity in the area, so the crew diverted and held as required in order to avoid the adverse weather. Shortly after commencing descent into Canberra, passing 11,000 ft, the No.2 engine flamed out. The engine’s automatic ignition system engaged and the engine recovered within five seconds without pilot input. Approximately one minute later, passing 10,000 ft, the No.1 engine flamed out and automatically recovered within five seconds, again without pilot input.

Because of the quick nature of the automatic recovery, the crew did not action any checklists. The crew selected manual ignition as a preventative measure and continued to Canberra without further incident.

What the ATSB found

The ATSB found no evidence to suggest a mechanical fault or failure caused the engines to flameout and that the flameouts were likely to have been caused by the environmental conditions during the flight, most likely either icing or moderate/heavy rain, or a combination of both.

Aircraft systems and procedures for protection and recovery from flameouts in these conditions were reliable and effective in relighting the engines. However, the decision to select manual ignition following the flameouts potentially reduced the recovery and protection of the engines in the event of any potential further flameout.

What's been done as a result

The operator has conducted an internal investigation, released internal communications for awareness of the occurrence and ensured its pilots are aware of the appropriate use of manual ignition.

The manufacturer is ensuring all operators of the ATR72-212A are aware of the appropriate use of manual ignition. They are also reviewing operational documentation as to whether this requirement could be explicitly included.

Safety message

An engine flameout event is not common in today’s modern turbo propeller engines, but it is still possible. Reliable and effective systems and procedures exist to protect and recover from such events and it is important that pilots follow manufacturer procedures for these systems. In the case of the ATR72-212A, the automatic ignition system worked as designed, correctly identifying the loss of engine power, initiating ignition and successfully relighting the engines without pilot input. The selection of manual ignition potentially reduces the recovery mechanism effectiveness against flameouts, and should only be used when directed by checklist or a minimum equipment list.

Download final report
[Download  PDF: 530KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety actions

Sources and submissions

General details
Date: 13 December 2018   Investigation status: Completed  
Time: 19:00 AEST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): near Canberra Airport   Investigation phase: Final report: Dissemination  
State: Australian Capital Territory   Occurrence type: Engine failure or malfunction  
Release date: 05 May 2020   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer ATR-GIE Avions de Transport Régional  
Aircraft model ATR72-212A  
Aircraft registration VH-FVN  
Serial number 1039  
Operator Virgin Australia  
Type of operation Air Transport High Capacity  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Sydney, New South Wales  
Destination Canberra, Australian Capital Territory  
Last update 05 May 2020