ASN Wikibase Occurrence # 234056
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| Date: | Monday 16 March 2020 |
| Time: | 11:29 LT |
| Type: |  Bombardier DHC-8-402Q Dash 8 |
| Owner/operator: | QantasLink, op by Sunstate Airlines |
| Registration: | VH-QOE |
| MSN: | 4125 |
| Fatalities: | Fatalities: 0 / Occupants: 12 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Jacksons Airport, Port Moresby -
 Papua New Guinea
|
| Phase: | Initial climb |
| Nature: | Passenger - Scheduled |
| Departure airport: | Port Moresby-Jacksons International Airport (POM/AYPY) |
| Cairns Airport, QLD (CNS/YBCS) | |
| Investigating agency: | AIC PNG |
| Confidence Rating: |  Accident investigation report completed and information captured |
On 16 March 2020, at about 01:30 UTC (11:30 local), shortly after departure from Port Moresby-Jackson’s International Airport, Papua New Guinea, on a scheduled international flight to Cairns, Queensland, Australia the flight crew of a Bombardier DHC-8-402 aircraft (flight QF192, registered VH-QOE) declared a PAN due to fumes in the cabin and subsequently returned and landed at Jackson’s International Airport. No injuries or damage were reported.
At about 01:22, during the climb and as soon as the normal After Takeoff procedures checklist was completed, the flight crew noticed the presence of a “strange smell” inside the cockpit.
The Pilot in command (PIC) indicated to the investigators that at the time the smell was detected by the flight crew it was not too strong and there was no alert or fault indication in the annunciator panel. For these reasons, they initially decided to continue climbing.
As the aircraft climbed through FL100, the flight crew noticed the smell appeared to increase and fumes were entering the flight deck. The examinations conducted at the initial stages of the investigation, revealed that the source of the fumes was located in the No. 2 engine compressor bleed air section.
The PIC called the cabin crew through the intercom and they confirmed the presence of a “strong weird smell” throughout the cabin. When the aircraft was approaching FL 150, the flight crew donned their oxygen masks and opted to return to Port Moresby and the PIC briefed the cabin crew accordingly.
At about 01:30, approximately 30 nm from Port Moresby the aircraft was levelled at FL 180. After broadcasting a PAN and obtaining the clearance from the Air Traffic Control (ATC), the flight crew commenced to return to Port Moresby, making a right turn and descending to FL 100.
During descent, the flight crew conducted the Smoke/Fumes Emergency procedure in accordance with the Quick Reference Handbook (QRH).
The flight crew levelled the aircraft off at FL 100 as it entered the Islok holding pattern. The cabin crew subsequently called the flight crew reporting smoke was entering the cabin.
As cleared by the ATC, the flight crew performed a ‘visual approach’ and landed on runway 32R. According to the PIC statement, the approach and landing were normal. The aircraft continued its landing roll to exit the runway via taxiway Foxtrot where it came to a complete stop. In that position, the passengers and the crew exited the aircraft through the main door.
Causes [Contributing factors]
The smoke/fumes that entered the cabin through the bleed air system was produced by the oil liberated at the No.3 bearing carbon seal coming in contact with hot surfaces inside the engine.
The wear-out and early fracture of the airside carbon element was believed to be caused by exudation of salt and oxidation of the air side carbon element, processes dependent of the high operating temperatures and humid environments.
The manufacturer of the engine had noted that No. 3 bearing carbon seal is likely to fracture earlier than its first overhaul shop visit as the earliest failure case reported was about 8,500 hours. At the time of the occurrence, the seal had 9,218.11 hours and had not reached the time for its first engine overhaul shop visit. The 718.11 hours more than the wear trend.
Service bulletin SB35341, issued by the manufacturer with regard to the conditions for replacement of No. 3 bearing carbon seal, did not include the wear trend of the component determined by the manufacturer as a condition or consideration for its replacement.
Accident investigation:
 |
|
Sources:
https://www.flightradar24.com/data/aircraft/vh-qoe#243295d5
Actual ATC transmission
Company dispatcher advice
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 16-Mar-2020 08:18 | Petropavlovsk | Added |
| 16-Mar-2020 08:19 | harro | Updated [Aircraft type, Total fatalities, Other fatalities, Departure airport, Destination airport, Source] |
| 16-Mar-2020 17:05 | RobertMB | Updated [Aircraft type] |
| 17-Mar-2020 06:54 | RobertMB | Updated [Total occupants, Location, Source, Narrative] |
| 20-Apr-2020 19:16 | harro | Updated [Time, Source, Narrative] |
| 19-Dec-2021 09:29 | harro | Updated [Time, Source, Narrative, Accident report] |
| 09-Jun-2022 00:00 | Ron Averes | Updated [Operator] |
| 27-Jun-2023 01:08 | Ron Averes | Updated [[Operator]] |
Corrections or additions? ... Edit this accident description
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