ASN Wikibase Occurrence # 246791
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| Date: | Thursday 31 December 2020 |
| Time: | |
| Type: |  Airbus A330-203 |
| Owner/operator: | Air France |
| Registration: | F-GZCJ |
| MSN: | 503 |
| Year of manufacture: | 2002 |
| Engine model: | GE CF6-80E1A3 |
| Fatalities: | Fatalities: 0 / Occupants: 147 |
| Aircraft damage: | None |
| Category: | Incident |
| Location: | near N'Djamena -
 Chad
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | Brazzaville-Maya Maya Airport (BZV/FCBB) |
| Paris-Charles de Gaulle Airport (CDG/LFPG) | |
| Investigating agency: | BEA |
| Confidence Rating: |  Accident investigation report completed and information captured |
Air France flight AF736 was en route at FL380 from Brazzaville to Paris-Charles de Gaulle when the crew detected a fuel leak on engine 1. A Mayday call was made and the flight diverted to N'Djamena Airport in Chad.
The aircraft resumed regular service on 6 January 2021.
Contributing factors
Although the leak was identified and then located in the left engine, the crew decided to keep this engine operating contrary to the requirements of the FUEL LEAK procedure. It was shut down while taxiing after the landing, i.e. more than 1 h and 20 min later. The purpose of shutting down the engine is to both conserve the fuel in the associated fuel tank and prevent the fuel from being dispersed into potentially dangerous areas. The fire hazard was underestimated by the crew in part because it was not clearly indicated in the corresponding procedure or in the supplementary
manuals.
The crew’s partial application of the FUEL LEAK procedure contributed to degrading the decision-making process, in particular by excluding alternate options closer to the route, and resulted in the choice of a diversion to N'Djaména, where the infrastructure and the weather conditions were not optimal.
The following factors contributed to the occurrence of the fuel leak
- Design of the mounting flange.
- Intrinsic difficulties in assembling the mounting flange.
- Difficulties in checking that the mounting flange is correctly assembled.
- Use of a former mounting flange model, which made it possible to assemble the flange incorrectly and for a large leak to occur.
The following factors contributed to decreasing the flight’s safety margin, in particular with regard to the fire hazard
- Crew’s partial application of the FUEL LEAK procedure for the management of a fuel leak.
- Insufficient leadership and crew cooperation competency probably due to an excessive search for consensus and a possible group effect.
- No mention of the fire hazard in the manufacturer's documentation.
- Selection of N'Djamena airport for the diversion when other suitable airports were closer to the route.
The following factor contributed to limiting the fire hazard
- Intervention of the relief pilot who reminded the crew that, in accordance with the FUEL LEAK procedure, the thrust reversers should not be extended, even at idle speed.
The following factor contributed to the safety of the flight after the landing
- Chief purser preparing the cabin for a possible evacuation.
Accident investigation:
 |
|
Sources:
https://www.bea.aero/en/investigation-reports/notified-events/detail/incident-to-the-airbus-a330-registered-f-gzcj-operated-by-air-france-on-31-12-2020-en-route/
https://www.flightradar24.com/data/aircraft/f-gzcj#2674e402
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 16-Jan-2021 08:27 | harro | Added |
Corrections or additions? ... Edit this accident description
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