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ikolkyo
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ANA 787 suffers double engine failure on rollout

Fri Jan 18, 2019 2:16 am

Quite an odd one here, bad computer glitch me thinks.

Engines are RR T1000s

An ANA All Nippon Airways Boeing 787-8, registration JA825A performing flight NH-985 from Tokyo Haneda to Osaka Itami (Japan) with 109 passengers and 9 crew, landed on Itami's runway 32L, touched down, the crew deployed the thrust reversers when both engines rolled back and shut down. The aircraft rolled out without further incident, came to a stop about 2450 meters/8030 feet down the runway and was disabled. The aircraft was towed off the runway about 40 minutes after landing.

The airline is investigating the cause of both engines shutting down unexpectedly. First examinations by maintenance dispatched from Tokyo do not suggest any anomalies with the engines.


http://avherald.com/h?article=4c2fe53a&opt=0
 
luv2cattlecall
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Re: ANA 787 suffers double engine failure on rollout

Fri Jan 18, 2019 5:20 am

Only 109 passengers??
 
cedarjet
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Re: ANA 787 suffers double engine failure on rollout

Fri Jan 18, 2019 5:25 am

luv2cattlecall wrote:
Only 109 passengers??

I don’t understand the economics but a lot of Japanese domestic flights seem to be half empty. I did a daytrip to Sapporo on Nippon 747Ds in 2013 and both sectors were ~150 pax, and apparently that’s not unusual.
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caliboy93
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Re: ANA 787 suffers double engine failure on rollout

Fri Jan 18, 2019 5:34 am

cedarjet wrote:
luv2cattlecall wrote:
Only 109 passengers??

I don’t understand the economics but a lot of Japanese domestic flights seem to be half empty. I did a daytrip to Sapporo on Nippon 747Ds in 2013 and both sectors were ~150 pax, and apparently that’s not unusual.


It's always high frequency, widebody aircraft on most major domestic routes within Japan.
 
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conaly
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Re: ANA 787 suffers double engine failure on rollout

Fri Jan 18, 2019 6:02 am

For a second I though "wasn't that the Dreamliner I was flying on a year ago?" but then I looked up and I flew on JA824A (ITM-HND).

Really weird incident though. Both engines failing simultaneously is extremely rare, even when you run out of fuel. If the engines are physically ok, I'd also suspect a software issue.
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Andrw
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Re: ANA 787 suffers double engine failure on rollout

Fri Jan 18, 2019 6:22 am

This reminds me of a BA flight (BA038) few years back that suffered bilateral engine failure of final approach to Heathrow. if I remember correctly there was a problem with fuel filter (bad design) and it was blocked by something that appears in fuel when temp falls below -35degC or something. Can't remember exactly. Same problem? That would not surprise me.
 
aviationaware
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Re: ANA 787 suffers double engine failure on rollout

Fri Jan 18, 2019 6:47 am

luv2cattlecall wrote:
Only 109 passengers??


The average load factor on domestic flights in Japan is around 65%, vs around 85% in the US.

Considering flights at certain times of the day are full to the brim, you need some flights around LF 33% like this flight to get to 65% on average. Nothing out of the ordinary. Japanese airlines need the widebodies for peak hours and can't just park them all other times of the day, so they just use them for off peak flying as well which then is more than half empty.
 
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Narfish641
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Re: ANA 787 suffers double engine failure on rollout

Fri Jan 18, 2019 7:11 am

That is extremely scary to have both engines fail like that even on landing. I'm glad everyone is ok and there was no further incident but it could been a lot worse depending on the time the incident took place. But I am gonna go along with ikolkyo and guess it was (or could of been) a software failure.
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EmoticonsAllDay
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Re: ANA 787 suffers double engine failure on rollout

Fri Jan 18, 2019 8:34 am

Andrw wrote:
This reminds me of a BA flight (BA038) few years back that suffered bilateral engine failure of final approach to Heathrow. if I remember correctly there was a problem with fuel filter (bad design) and it was blocked by something that appears in fuel when temp falls below -35degC or something. Can't remember exactly. Same problem? That would not surprise me.


That was a B777. The incident had caused due to ice in the fuel filters. A similar incident also took place in a DL B777 during cruise but the pilot was able to rectify the problem as he had enough time to troubleshoot. The problem was fixed by redesigning the filters.
 
StTim
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Re: ANA 787 suffers double engine failure on rollout

Fri Jan 18, 2019 8:44 am

EmoticonsAllDay wrote:
Andrw wrote:
This reminds me of a BA flight (BA038) few years back that suffered bilateral engine failure of final approach to Heathrow. if I remember correctly there was a problem with fuel filter (bad design) and it was blocked by something that appears in fuel when temp falls below -35degC or something. Can't remember exactly. Same problem? That would not surprise me.


That was a B777. The incident had caused due to ice in the fuel filters. A similar incident also took place in a DL B777 during cruise but the pilot was able to rectify the problem as he had enough time to troubleshoot. The problem was fixed by redesigning the filters.



If I remember correctly it was not the fuel filters but oil coolers where the cold fuel is used to cool the engine oil. It was proven by inference as obviously the ice had melted long before any investigation.
 
EmoticonsAllDay
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Re: ANA 787 suffers double engine failure on rollout

Fri Jan 18, 2019 9:01 am

StTim wrote:


If I remember correctly it was not the fuel filters but oil coolers where the cold fuel is used to cool the engine oil. It was proven by inference as obviously the ice had melted long before any investigation.


Yes, you are right. There was even a thread in a.net explaining its purpose at the time of the final report by AAIB regarding the BA 38 crash.

https://www.airliners.net/forum/viewtopic.php?t=760523
 
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AirlineCritic
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Re: ANA 787 suffers double engine failure on rollout

Sat Jan 19, 2019 7:48 am

aviationaware wrote:
Considering flights at certain times of the day are full to the brim, you need some flights around LF 33% like this flight to get to 65% on average. Nothing out of the ordinary. Japanese airlines need the widebodies for peak hours and can't just park them all other times of the day, so they just use them for off peak flying as well which then is more than half empty.


Thanks for the explanation. Makes sense, even if at first it feels weird.

But do think this is a scary event as well. Possibly related to some condition that only applies on landing (reversers etc), but what if this is a repeat of the BA38 icing incident in slightly different situation and equipment? It is winter, how cold was it?
 
nmcalba
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Re: ANA 787 suffers double engine failure on rollout

Sat Jan 19, 2019 8:12 am

Reading between the lines of a couple of posts elsewhere it seems that a possible cause of this roll back was a system called TCMA (Thrust Control Malfunction something-or-other). This is a function of the FADEC on many Boeing aircraft and is designed to shutdown one or both engines if it thinks that there is an uncommanded high thrust situation. A key thing is that this function only operates when the aircraft is in ground mode - if the aircraft is in the air then the FADEC keeps engines running almost regardless of circumstances.
It appears that there is a warning bulletin which alerts pilots that some handling errors during landing can cause this TCMA function to trigger - it seems to be a combination of selecting full reverse before the aircraft has properly transitioned to ground mode followed by a rapid deselection of reverse thrust. The bulletin cautions pilots not to select full reverse too quickly.
 
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LoganTheBogan
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Re: ANA 787 suffers double engine failure on rollout

Sat Jan 19, 2019 8:35 am

nmcalba wrote:
Reading between the lines of a couple of posts elsewhere it seems that a possible cause of this roll back was a system called TCMA (Thrust Control Malfunction something-or-other). This is a function of the FADEC on many Boeing aircraft and is designed to shutdown one or both engines if it thinks that there is an uncommanded high thrust situation. A key thing is that this function only operates when the aircraft is in ground mode - if the aircraft is in the air then the FADEC keeps engines running almost regardless of circumstances.
It appears that there is a warning bulletin which alerts pilots that some handling errors during landing can cause this TCMA function to trigger - it seems to be a combination of selecting full reverse before the aircraft has properly transitioned to ground mode followed by a rapid deselection of reverse thrust. The bulletin cautions pilots not to select full reverse too quickly.


Thrust Control Malfunction Accommodation. Do you have a link to the bulletin if its published online?
Anyone who has never made a mistake has never tried anything new.
 
nmcalba
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Re: ANA 787 suffers double engine failure on rollout

Sat Jan 19, 2019 9:18 am

LoganTheBogan wrote:
nmcalba wrote:
Reading between the lines of a couple of posts elsewhere it seems that a possible cause of this roll back was a system called TCMA (Thrust Control Malfunction something-or-other). This is a function of the FADEC on many Boeing aircraft and is designed to shutdown one or both engines if it thinks that there is an uncommanded high thrust situation. A key thing is that this function only operates when the aircraft is in ground mode - if the aircraft is in the air then the FADEC keeps engines running almost regardless of circumstances.
It appears that there is a warning bulletin which alerts pilots that some handling errors during landing can cause this TCMA function to trigger - it seems to be a combination of selecting full reverse before the aircraft has properly transitioned to ground mode followed by a rapid deselection of reverse thrust. The bulletin cautions pilots not to select full reverse too quickly.


Thrust Control Malfunction Accommodation. Do you have a link to the bulletin if its published online?


Sorry no - I did some googling but couldn't find anything - there was a reference to it deep inside an old pprune post, and it is also mentioned in one of the comments on avherald about the ANA incident, but no links.
 
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neutrino
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Re: ANA 787 suffers double engine failure on rollout

Sat Jan 19, 2019 11:26 am

Potestatem obscuri lateris nescitis
 
wjcandee
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Re: ANA 787 suffers double engine failure on rollout

Sat Jan 19, 2019 12:05 pm

If there is nothing wrong with the engines, then this is gonna be pilot error, which this airline is gonna fight tooth and nail, so B has to handle it verrrrrrrrrry delicately. Unlike how they dealt with Lion Air, I suspect that here they will create a good face-saving-for-the-airline way to explain it -- We may not have highlighted to the customer the full significance of the cautionary material on this safety system that we issued a year ago, or some such.

That this would have happened organically is beyond-unlikely, and they will have to find a way to say basically that the system did what it was supposed to do, that it works only in ground mode, and that the plane never endangered the passengers.
 
BlueberryWheats
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Re: ANA 787 suffers double engine failure on rollout

Sat Jan 19, 2019 12:17 pm

How easily do the fuel cut off switches move? I imagine there's some sort of safety on them, like having to lift them to move or something.

But they are just below the throttles, so I wondered if there was any chance that they could have been accidentally manipulated.

Surely it's not that easy, but I'm sure McDD thought that about the MD11 flap lever until they found out the hard way it could accidentally be nudged in flight with horrible consequences.
 
MalevTU134
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Re: ANA 787 suffers double engine failure on rollout

Sat Jan 19, 2019 12:22 pm

BlueberryWheats wrote:
How easily do the fuel cut off switches move? I imagine there's some sort of safety on them, like having to lift them to move or something.

But they are just below the throttles, so I wondered if there was any chance that they could have been accidentally manipulated.

Surely it's not that easy, but I'm sure McDD thought that about the MD11 flap lever until they found out the hard way it could accidentally be nudged in flight with horrible consequences.

That would be the slats, if you mean this incident:

https://aviation-safety.net/database/re ... 19930406-2
 
morrisond
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Re: ANA 787 suffers double engine failure on rollout

Sat Jan 19, 2019 12:29 pm

It was most likely exacerbated by the fact the plane was so light - 109 passengers and probably very little fuel and very low cargo means the aircraft would react very quickly to changes in thrust - possibly exceeding G parameters in the software.

I suspect selecting full reverse in a plane that light (I'm assuming) and then thrust deselected exceeded the parameters. It makes sense - but then again selecting full reverse thrust in a plane that light is probably just burning up the engines and not needed.
 
Antarius
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Re: ANA 787 suffers double engine failure on rollout

Sat Jan 19, 2019 1:33 pm

StTim wrote:
EmoticonsAllDay wrote:
Andrw wrote:
This reminds me of a BA flight (BA038) few years back that suffered bilateral engine failure of final approach to Heathrow. if I remember correctly there was a problem with fuel filter (bad design) and it was blocked by something that appears in fuel when temp falls below -35degC or something. Can't remember exactly. Same problem? That would not surprise me.


That was a B777. The incident had caused due to ice in the fuel filters. A similar incident also took place in a DL B777 during cruise but the pilot was able to rectify the problem as he had enough time to troubleshoot. The problem was fixed by redesigning the filters.



If I remember correctly it was not the fuel filters but oil coolers where the cold fuel is used to cool the engine oil. It was proven by inference as obviously the ice had melted long before any investigation.


Yes, it was the FOHE or Fuel Oil Heat Exchanger.

This definitely is a very different circumstance as variable engine thrust was working, up until the reverse thrust was applied.

Am very curious to learn what the investigation reveals.
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Re: ANA 787 suffers double engine failure on rollout

Sun Jan 20, 2019 6:31 pm

This function sounds sensible, but I am also scared of the different failure modes. Seems like this crew found potentially one failure mode... would be bad if this was triggered in the air. That being said, Boeing engineers certainly know that for something like this they need to run the full analysis of what could cause an inappropriate shutdown. As long as they are not relying on one AoA sensor as one of the inputs...
 
ikramerica
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Re: ANA 787 suffers double engine failure on rollout

Mon Jan 21, 2019 6:30 am

AirlineCritic wrote:
This function sounds sensible, but I am also scared of the different failure modes. Seems like this crew found potentially one failure mode... would be bad if this was triggered in the air. That being said, Boeing engineers certainly know that for something like this they need to run the full analysis of what could cause an inappropriate shutdown. As long as they are not relying on one AoA sensor as one of the inputs...

But it doesn’t happen in the air. Only happens in ground mode.
Of all the things to worry about... the Wookie has no pants.
 
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LoganTheBogan
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Re: ANA 787 suffers double engine failure on rollout

Mon Jan 21, 2019 7:10 am

ikramerica wrote:
AirlineCritic wrote:
This function sounds sensible, but I am also scared of the different failure modes. Seems like this crew found potentially one failure mode... would be bad if this was triggered in the air. That being said, Boeing engineers certainly know that for something like this they need to run the full analysis of what could cause an inappropriate shutdown. As long as they are not relying on one AoA sensor as one of the inputs...

But it doesn’t happen in the air. Only happens in ground mode.


Imagine the pilots suddenly needing to apply toga to go around. No engines, aircraft at the end of the runway...... Not good.
I'm not a pilot and I'm not aware of the procedures but I've experienced a touch and go after reverse deployment with Virgin Australia and Fiji Airways.
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mjoelnir
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Re: ANA 787 suffers double engine failure on rollout

Mon Jan 21, 2019 9:28 am

Airbus was attacked at the time for the A320 not allowing reverse thrust when having not enough weight on both MLG. That did lead to an overrun accident in one cross wind landing, with the delay of employing the thrust reverse. Airbus changed that feature.

Any so called safety feature, that cuts out the engines while landing, even if the frame is not any longer in the air, and so removing the possibility of TOGA or thrust reversers, should be carefully examined if that does not rather cut the safety.
IMO I would say the possibility, of damaging an engine should less of an consideration, than the availability of power until the frame has slowed down.
 
estorilm
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Re: ANA 787 suffers double engine failure on rollout

Mon Jan 21, 2019 7:42 pm

I'm really surprised this thread isn't blowing up. This is a HUGE issue. I don't care if it's a programming issue in the FADEC (unlikely) only related to ground ops, it's still going to have massive ramifications for the way software is coded, checked, certified, and employed.

Of course there is a possibility that some piece of hardware is faulty, but airliner redundancy dictates that be absolutely impossible as well.

Pilot error? Both at the same time? You can bump stuff - but not both.

I don't see any logical (or good/clean) explanation for this incident, but hope that it's going to be pursued INTENSIVELY by airframer, engine mfg, and certification bodies.
 
MeCe
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Re: ANA 787 suffers double engine failure on rollout

Mon Jan 21, 2019 8:28 pm

nmcalba wrote:
Reading between the lines of a couple of posts elsewhere it seems that a possible cause of this roll back was a system called TCMA (Thrust Control Malfunction something-or-other). This is a function of the FADEC on many Boeing aircraft and is designed to shutdown one or both engines if it thinks that there is an uncommanded high thrust situation. A key thing is that this function only operates when the aircraft is in ground mode - if the aircraft is in the air then the FADEC keeps engines running almost regardless of circumstances.
It appears that there is a warning bulletin which alerts pilots that some handling errors during landing can cause this TCMA function to trigger - it seems to be a combination of selecting full reverse before the aircraft has properly transitioned to ground mode followed by a rapid deselection of reverse thrust. The bulletin cautions pilots not to select full reverse too quickly.


What if ground mode fails ?

We had an oportinity ask a couple questions to a boeing engineer during an airshow. I was shocked there was a feature which allows remotely deactivate (pull) circuit breakers. Feature based on there is no thermal c/b on 787, so such an advanced design. When I bring about security issues, answer was there are multiple firewalls on system. Later this feature disabled fortunatelly. Sometimes automation scares me :D
 
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glideslope
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Re: ANA 787 suffers double engine failure on rollout

Mon Jan 21, 2019 8:34 pm

Ah, the good old days when we could pop the inboard reversers on the old DC-8 on final.
To know your Enemy, you must become your Enemy.” Sun Tzu
 
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JerseyFlyer
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Re: ANA 787 suffers double engine failure on rollout

Mon Jan 21, 2019 9:17 pm

Is the root cause of this as likely to apply to GE 787s as to those like ANA's with RR?
 
StTim
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Re: ANA 787 suffers double engine failure on rollout

Mon Jan 21, 2019 9:39 pm

JerseyFlyer wrote:
Is the root cause of this as likely to apply to GE 787s as to those like ANA's with RR?

Sounds like a 787 design feature rather than a particular engine implementation on the 787.
 
LDRA
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Re: ANA 787 suffers double engine failure on rollout

Mon Jan 21, 2019 10:10 pm

estorilm wrote:
I'm really surprised this thread isn't blowing up. This is a HUGE issue. I don't care if it's a programming issue in the FADEC (unlikely) only related to ground ops, it's still going to have massive ramifications for the way software is coded, checked, certified, and employed.

Of course there is a possibility that some piece of hardware is faulty, but airliner redundancy dictates that be absolutely impossible as well.

Pilot error? Both at the same time? You can bump stuff - but not both.

I don't see any logical (or good/clean) explanation for this incident, but hope that it's going to be pursued INTENSIVELY by airframer, engine mfg, and certification bodies.


It is false triggering of safety monitor on ground, worst case is losing power on ground. So not high severity hazard
 
2175301
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Re: ANA 787 suffers double engine failure on rollout

Mon Jan 21, 2019 11:28 pm

Folks: Why not wait until we find out what happened:

IF: it is the facts that the pilots made an error and triggered a "ground only" designed safety feature that shut down the engines; then their is no issue (other than potential embarrassment and improved training).

IF NOT: Then we will have to wait until the issue is investigated and formally diagnosed to be able to have any hints as to the potential significance.

I am quite sure that the ANA, Boeing, and likely the Japan Air Safety Board (by whatever name it is called) is looking at the situation; and will figure it out.

Have a great day,
 
Moostato
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Re: ANA 787 suffers double engine failure on rollout

Mon Jan 21, 2019 11:32 pm

What sort of operational configurations could cause such a failure?
 
skyharborshome
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Re: ANA 787 suffers double engine failure on rollout

Tue Jan 22, 2019 10:25 pm

2175301 wrote:
Folks: Why not wait until we find out what happened:

IF: it is the facts that the pilots made an error and triggered a "ground only" designed safety feature that shut down the engines; then their is no issue (other than potential embarrassment and improved training).

IF NOT: Then we will have to wait until the issue is investigated and formally diagnosed to be able to have any hints as to the potential significance.

I am quite sure that the ANA, Boeing, and likely the Japan Air Safety Board (by whatever name it is called) is looking at the situation; and will figure it out.

Have a great day,


Because this is a.net and speculation and theories are what keep the site alive (sometimes at a detriment). There is ALWAYS an issue when an airplane does something the pilot does not expect. Sometimes the issue is trivial such as this one may turn out to be or it could be the case where there is a flaw and luckily it was exposed at a time when using the engines was not critical. If one of the pilots made a mistake then we have the exact same logic applied as we are lucky it was a relative non-event.
Fly CHD!
 
skyharborshome
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Re: ANA 787 suffers double engine failure on rollout

Tue Jan 22, 2019 10:31 pm

estorilm wrote:
I'm really surprised this thread isn't blowing up. This is a HUGE issue. I don't care if it's a programming issue in the FADEC (unlikely) only related to ground ops, it's still going to have massive ramifications for the way software is coded, checked, certified, and employed.

Of course there is a possibility that some piece of hardware is faulty, but airliner redundancy dictates that be absolutely impossible as well.

Pilot error? Both at the same time? You can bump stuff - but not both.

I don't see any logical (or good/clean) explanation for this incident, but hope that it's going to be pursued INTENSIVELY by airframer, engine mfg, and certification bodies.


I am in total agreement with you. We were all shocked and mortified when the BA777 had its issue though a plane coming to a slow stop on a long runway is not the same as a plane landing short due to no thrust. Still, those of us who traverse the world want to know what could cause two engines to shut down because we have been told over and over that losing both engines on a plane is close to impossible. This is now the 3rd event I can recall without doing research (BA777, Hudson and now this) ignoring fuel starvation incidents. The two previous cases were fully investigated and now we know what happened and the same will happen here hopefully soon. Maybe one reason the thread is not getting the attention we expect is because everyone is really scratching their head on this one and there are not many ideas. So strange.
Fly CHD!
 
estorilm
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Re: ANA 787 suffers double engine failure on rollout

Wed Jan 23, 2019 2:44 pm

skyharborshome wrote:
estorilm wrote:
I'm really surprised this thread isn't blowing up. This is a HUGE issue. I don't care if it's a programming issue in the FADEC (unlikely) only related to ground ops, it's still going to have massive ramifications for the way software is coded, checked, certified, and employed.

Of course there is a possibility that some piece of hardware is faulty, but airliner redundancy dictates that be absolutely impossible as well.

Pilot error? Both at the same time? You can bump stuff - but not both.

I don't see any logical (or good/clean) explanation for this incident, but hope that it's going to be pursued INTENSIVELY by airframer, engine mfg, and certification bodies.


I am in total agreement with you. We were all shocked and mortified when the BA777 had its issue though a plane coming to a slow stop on a long runway is not the same as a plane landing short due to no thrust. Still, those of us who traverse the world want to know what could cause two engines to shut down because we have been told over and over that losing both engines on a plane is close to impossible. This is now the 3rd event I can recall without doing research (BA777, Hudson and now this) ignoring fuel starvation incidents. The two previous cases were fully investigated and now we know what happened and the same will happen here hopefully soon. Maybe one reason the thread is not getting the attention we expect is because everyone is really scratching their head on this one and there are not many ideas. So strange.

There are probably plenty of others - I'd put some of the weather incidents above the Hudson, just because those geese were massive and the engines weren't certified for it.
Southern Airways Flight 242 DC-9 comes to mind, Garuda 421, TACA 110, and Scandinavian 751 as well. All are ice/water ingestion related, although Scandinavian was due to wing ice impacting the fans on rotation. Pretty small list really, all things considered!

Also in response to the other reply - I realize it could be something totally stupid related to a ground mode (hopefully it is) but that's kinda why I'm confused about the ground crew being unable to restart either engine. THAT'S the part that doesn't make much sense.
 
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AirlineCritic
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Re: ANA 787 suffers double engine failure on rollout

Thu Jan 31, 2019 12:53 am

I am in agreement with others that this is an important topic and is getting less attention than it perhaps should. Is there any new information?

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