AI2008-3 AIRCRAFT SERIOUS INCIDENT INVESTIGATION REPORT

AI2008-3 AIRCRAFT SERIOUS INCIDENT INVESTIGATION REPORT
AI2008-3
AIRCRAFT SERIOUS INCIDENT
INVESTIGATION REPORT
AIR NIPPON CO., LTD.
BOEING 737-500, JA8419
OVER THE SEA APPROXIMATELY 60 NM SOUTHEAST OF
KUSHIMOTO VORTAC
JULY 5, 2006
June 27, 2008
Aircraft and Railway Accidents Investigation Commission
Ministry of Land, Infrastructure, Transport and Tourism
The investigation for this report was conducted by Aircraft and Railway Accidents
Investigation Commission, ARAIC, about the aircraft serious incident of AIR NIPPON CO.,
LTD. BOEING 737-500, JA8419 in accordance with Aircraft and Railway Accidents
Investigation Commission Establishment Law and Annex 13 to the Convention of
International Civil Aviation for the purpose of determining cause of the aircraft accident
and contributing to the prevention of accidents and not for the purpose of blaming
responsibility of the accident.
This English version report has been published and translated by ARAIC to make its
reading easier for English speaking people those who are not familiar with Japanese.
Although efforts are made to translate as accurate as possible, only the Japanese version is
authentic. If there is difference in meaning of the texts between the Japanese version and
the English version, texts in the Japanese version are correct.
Norihiro Goto,
Chairman,
Aircraft and Railway Accidents Investigation Commission
AIRCRAFT SERIOUS INCIDENT INVESTIGATION REPORT
AIR NIPPON CO., LTD.
BOEING 737-500, REGISTRATION JA8419
OVER THE SEA APPROXIMATELY 60 NM SOUTHEAST OF
KUSHIMOTO VORTAC
AROUND 08:10 JST, JULY 5, 2006
June 20, 2008
Adopted by the Aircraft and Railway Accidents Investigation Commission
(Air Sub-committee)
Chairman
Member
Member
Member
Member
Member
1
Norihiro Goto
Yukio Kusuki
Shinsuke Endo
Noboru Toyooka
Yuki Shuto
Akiko Matsuo
1. PROCESS AND PROGRESS OF THE SERIOUS INCIDENT
INVESTIGATION
1.1 Summary of the Serious Incident
The event covered by this report is classified under the category of “Abnormal Cabin
Depressurization” as stipulated in Clause 10 (at the time of the occurrence; later amended to
Clause 11 effective as of October 1, 2006), Article 166-4 of the Civil Aeronautics Regulations of
Japan.
On July 5 (Wednesday), 2006 at 07:24 JST, a Boeing 737-500 airplane, JA8419, operated
by Air Nippon Co., Ltd. took off Fukuoka Airport as All Nippon Airways scheduled flight 2142.
At about 08:10, while flying at approximately 37,000 ft approximately 60 nm southeast
of Kushimoto VORTAC, a cabin depressurization warning was displayed and the oxygen masks
in the cabin were automatically deployed.
The aircraft made an emergency descent and, at
09:09, landed on Chubu International Airport.
Of the 46 persons on board the aircraft, including the Pilot in Command, 4 other
crewmembers and 41 passengers, no one was injured.
1.2 Outline of the Serious Incident Investigation
1.2.1
Investigation Organization
On July 5, 2006, the Aircraft and Railway Accidents Investigation Commission (ARAIC)
assigned an investigator-in-charge and another investigator for the investigation of this serious
incident.
1.2.2
Representatives from Foreign states
Accredited representative from the United States of America, the state of design and
manufacture of the aircraft, participated in the investigation of this serious incident.
1.2.3
Implementation of the Investigation
July 5 - 9, 2006
Interviews, investigation of the aircraft, and removal
of related equipment
July 12 - 14, 2006
Teardown examination of the removed equipment
July 21, 2006
Inspection of equipment functions and damage
conditions
July 28, 2006
Inspection of equipment damage conditions
October 5 - November 2, 2006
Analysis of deposits and detergent solution inside the
pneumatic system components
January 12, 2007
Investigation to check for water ingress into the bleed
air system components during engine washing
March 30 - April 5, 2007
Investigation to confirm equipment functions
2
1.2.4
Comments from the Parties Relevant to the Cause of the Serious Incident
Comments were collected from the parties relevant to the cause of the serious incident
through interviews.
1.2.5
Comments from the Participating State
Comments were invited from the participating state.
3
2. FACTUAL INFORMATION
2.1 History of the Flight
On July 5, 2006, a Boeing 737-500, registered JA8419 (hereinafter referred to as “the
aircraft”), operated by Air Nippon Co., Ltd. (hereinafter referred to as “the company”), was flying
as All Nippon Airways scheduled flight 2142 from Fukuoka Airport to Narita International
Airport.
The aircraft took off Fukuoka Airport at 7:24 with 46 people on board, including the
Pilot in Command (PIC), 4 other crewmembers and 41 passengers. In the cockpit, the PIC
occupied the left seat as pilot flying (primarily responsible for aircraft maneuvering tasks) and
the First Officer occupied the right seat as pilot not flying (primarily responsible for
non-maneuvering tasks).
The flight plan submitted to the Air Traffic Management Center, Fukuoka Area Control
Center of the Ministry of Land, Infrastructure, Transport and Tourism is as outlined below.
Flight rules:
Instrument flight rules (IFR)
Departure point:
Fukuoka Airport
Estimated off-block time:
07:10
Cruising speed:
439 kt
Cruising altitude:
FL370
Route:
TAE (Oita VOR) - V37 (Airway) - KEC (Kushimoto
VORTAC) - A1 (Airway) - ORGAN (Reporting point) Y231 (RNAV route) - MAMAS (Reporting point) ANGEL (Reporting point) - VENUS (Reporting point)
Destination:
Narita International Airport
Estimated flight time:
1 h and 26 min
Alternate aerodrome:
Tokyo International Airport
Quantity of loaded fuel as
expressed in endurance:
3 h and 37 min
2.1.1
History of the Flight based on Records of the Digital Flight Data Recorder, Cockpit
Voice Recorder and ATC Radio Communications
The history of the flight is summarized below, based on the records of the digital flight
data recorder (hereinafter referred to as “DFDR”), the cockpit voice recorder (hereinafter
referred to as “CVR”) and ATC radio communications.
07h42m17s The aircraft reached Flight Level*1 (hereinafter referred to as “FL”) 370
that had been approved by the Tokyo Area Control Center (hereinafter
referred to as “Tokyo Control”).
08h09m06s While flying at FL370, the throttle levers were retarded.
08h10m05s While flying at FL370, the master caution light and the system
annunciator’s AIR COND light came on.
*1:
Flight Level means a surface of constant atmospheric pressure, which is based on standard sea level
pressure of 29.92 in Hg. In Japan, altitudes at or above 14,000 ft are normally indicated by Flight Levels in
hundreds of feet.
4
08h10m21s
While flying at FL370, the crew requested clearance from Tokyo Control
to descend to FL290 due to a problem with the cabin pressurization
system.
08h10m31s
Tokyo Control cleared the descent to FL290.
08h10m40s
The aircraft began descending.
08h10m44s
The cabin altitude warning horn sounded.
08h10m50s
The crew requested clearance from Tokyo Control for an emergency
descent due to cabin depressurization.
08h10m56s
Tokyo Control cleared the emergency descent.
08h13m27s
The oxygen masks in the cabin were automatically deployed.
08h17m30s
The aircraft reached 10,000 ft.
(See Figure 1.)
2.1.2 Flight Crew Statements on History of the Flight
(1) PIC
After finishing the briefing in the dispatch room, I conducted an exterior check of
the aircraft and received a maintenance mechanic’s report stating that no abnormalities
were found with the aircraft. I determined that there was nothing that would pose any
problems and accepted the aircraft.
During the phase from engine start to takeoff, everything operated normally
including the air conditioning system.
After takeoff, during cruise at FL370, when we were about over Matsuyama, a
cabin attendant (hereinafter referred to as “CA”) told us that she felt the cabin air a bit
cold and requested raising the temperature.
The First Officer adjusted the
temperature control.
I then felt that the temperature rise was less quick than usual. Warm air usually
comes out as soon as the control knob (mix valve) is moved to a higher temperature, but
at that time I felt only a little difference of air temperature.
When we passed Shikoku region and were about to reach the Kii Peninsula,
considering on-board radar indication of developed cloud echo we requested change of
heading to Tokyo Control and flew around south of the echo region. I thought that we
would have no more echo region by the time we would reach abeam Kushimoto and that,
after passing that point, we would make a request for direct flight to the next point.
We then flew the direct course to SAKIT with clearance from Tokyo Control. During
that portion of the flight, the aircraft was shaken by turbulence and we immediately
decreased our airspeed using the speed selector on the MCP (Mode Control Panel).
At about 60 nm southeast of Kushimoto, the master caution light and the system
annunciator’s AIR COND light came on. I checked the overhead panel and found that
both of the two BLEED TRIP OFF lights illuminated. This indicated that the bleed air
systems from both engines had stopped supplying bleed air.
The duct pressure should normally be about 38 psi at FL370, but it was as low as
about 5 psi when the master caution light came on.
Concerns about the cabin altitude arose in my mind, so I checked and found that
the cabin altitude had risen to about 9,000 ft. It should be about 8,000 ft when flying
5
at about FL370.
I knew from a previous occurrence that using the wing anti-ice system when flying
at FL370 usually causes a substantial demand for bleed air, and this requires the use of
9th-stage bleed air, which may cause bleed air at too high a temperature to cool down
adequately to flow through the duct and may ultimately cause a “bleed trip” condition.
We were not using the wing anti-ice system at that time.
Expecting a shortage of oxygen inside the aircraft since the cabin altitude
continued rising, I ordered the First Officer to put on an oxygen mask.
It was at that time that I decided to make an emergency descent.
A short time after receiving ATC clearance and starting the emergency descent, the
horn for the “cabin altitude warning system” began sounding, which warns of cabin
altitude exceeding 10,000 ft, so we continued to descend to 10,000 ft.
Being in an
emergency, we also set the transponder to the emergency code.
Subsequently, because the cabin altitude should have exceeded 14,000 ft, the
passenger
address
system
automatically
started
broadcasting
a
pre-recorded
emergency-descent cabin announcement (hereinafter referred to as “pre-recorded
announcement”) and, at the same time, the oxygen masks were deployed automatically.
During the emergency descent to 10,000 ft, I checked the cabin altitude rate of climb
and found it considerably large.
While hearing the passenger address (hereinafter referred to as “PA”), I noticed the
CA saying, “Please put on your masks” between the pre-recorded announcement cycles.
We completed the checklist upon reaching 10,000 ft and, as the cabin altitude was
then also 10,000 ft, I instructed the First Officer to take off his oxygen mask and I took
mine off also, and I cancelled the emergency code setting.
permission to take off their oxygen masks.
I then gave the CAs
The CA’s answer to my question about the
situation in the cabin was that there were no problems to report with none of the
passengers suffering from hypoxia.
We requested to Tokyo Control a holding flight, before changing the destination,
which was cleared by Tokyo Control.
After completing the preparations for approach, I made an announcement over the
PA, saying “We have made an emergency descent to a safe altitude because of a problem
with the pressurization system that had developed while cruising at 37,000 ft.
We
have changed our destination to Chubu International Airport, the nearest airport, and
are heading there now.”
(2)
First Officer
After takeoff as I was going to turn off the seat belt sign, I told the CAs, “The seat
belt sign will be turned off, but shaking is always possible since we are flying in clouds.
So, you should be duly careful during passenger service.” After a while, a CA told us,
“Please raise the cabin temperature a bit as it is cold in the cabin.”
I then moved the
temperature control on the overhead panel by, I think, approximately one unit toward a
warmer temperature. The temperature did not rise quickly, but a while later it rose to
22 - 23°C, a temperature that made me feel a little warmer than before.
When the master caution light and the system annunciator's AIR COND light came
6
on during the flight, I looked at the overhead panel and found that both of the two
“BLEED TRIP OFF” lights illuminated.
I operated the pack switches on the overhead
panel, but this did not change the situation at all. I checked the cabin altitude and
found that it was rising gradually, reaching 9,400 - 9,500 ft in contrast with the normal
cabin altitude of about 8,000 ft at approximately FL370.
As I was told by the PIC, “Put on your oxygen mask.
We are going to make an
emergency descent,” I put it on, and then, as required by the procedure, turned on the
seat belt sign and set the engine start switch to the “continuous” position.
We declared
an emergency to Tokyo Control and started descending after receiving clearance.
Shortly after, while we were descending, I heard the pre-recorded announcements in
English, Chinese and Japanese, “Put on your oxygen masks,” and I also heard the CAs
loudly giving the same instructions to the passengers. The speed at that time was 310
kt.
Finding that the cabin altitude was equal to the actual altitude when we reached
10,000 ft, I told the CAs, “We are now at a safe altitude, so the masks may be taken off.
Please let me know about the conditions in the cabin.”
(3)
Nothing abnormal was found.
CAs (Mainly the purser’s statement supplemented by other CAs’ statements)
During the crew briefing held in the aircraft prior to departure, the PIC told us that
the aircraft would shake due to a seasonal rain front and this would necessitate keeping
the seat belt sign on for at least about 30 min.
We felt a little shaking during the climb but the seat belt sign went off in under 30
min.
Immediately before starting passenger service, it was cold in the cabin so that I
asked the flight crew to raise the cabin temperature. The First Officer responded,
“That’s what I expected.
I have been trying to bring up the temperature but it refuses
to rise.” All CAs felt cold.
After finishing the passenger service, we all sat in our seats when the seat belt sign
came on at about 08:13 - 08:14, although we were told that we would start descending
at 08:28.
A minute or two after we sat in our seats, the oxygen masks deployed with a thud
in the cabin, but there wasn’t any noticeable problem at that time.
experience ear popping or any further drop in cabin temperature.
We did not
A while later,
pre-recorded announcements started in Japanese, English and Chinese in sequence.
I
instructed the passengers, saying, “Please put on your oxygen masks immediately.”
However, since my voice was drowned out by the pre-recorded announcements, I also
gestured to the passengers to put on the masks.
The passengers were slow to respond
and they seemed to be only faintly aware of the emergency situation.
However, they
gradually started putting on their masks, probably because they realized that they
should when they saw the CAs wearing masks and heard the continuously repeated
pre-recorded announcements.
I then made announcements over the PA a couple of times in Japanese and English
with a mask on my face. At that time, I saw that all passengers were wearing masks.
A while later, I was told by the flight crew, “We are now at a safe altitude, so the
7
masks may be taken off.”
I was also asked about the situation in the cabin.
I
responded, “The cabin is perfectly calm.”
We started checking the passengers, and found that no one appeared upset and the
entire cabin was calm.
abnormal in the cabin.
No one complained of feeling sick and there was nothing
When I was told that we would be flying to Chubu
International Airport a while later, I made an announcement to that effect, which was
soon followed by an announcement by the PIC saying, “Because of a problem with the
cabin pressurization system, we are going to fly to Chubu International Airport.”
This serious incident occurred at about 08:10, over the sea (lat. 33º21'N, long. 136°42'E)
about 60 nm southeast of Kushimoto VORTAC.
(See Figures 1 and 4.)
2.2 Injuries to Persons
None
2.3 Damage to the Aircraft
There was no damage to the aircraft.
2.4 Crew Information
(1)
PIC
Male, aged 33
Airline transport pilot certificate (airplane)
Type rating for Boeing 737
October 6, 2005
July 21, 1998
1st class aviation medical certificate
Validity
Until September 11, 2006
Total flight time
5,300 h and 20 min
Flight time in the last 30 days
51 h and 53 min
Total flight time on the aircraft type
5,065 h and 20 min
Flight time in the last 30 days
(2)
First Officer
51 h and 53 min
Male, aged 59
Commercial pilot certificate (airplane)
Type rating for Boeing 737
October 9, 1973
December 27, 1994
1st class aviation medical certificate
Validity
Until December 7, 2006
Total flight time
14,266 h and 49 min
Flight time in the last 30 days
52 h and 33 min
Total flight time on the aircraft type
6,943 h and 44 min
Flight time in the last 30 days
52 h and 33 min
8
2.5 Aircraft Information
2.5.1
2.5.2
Aircraft
Type
Boeing 737-500
Aircraft serial number
27430
Date of manufacture
May 10, 1995
Certificate of airworthiness
No. To-10-588
Validity
The period through which the maintenance manual (Air
Nippon Co., Ltd) is applied, beginning on October 28, 1998
Airworthiness category
Airplane, Transport category
Total flight time
23,685 h and 58 min
Time in service since the last periodical check
(C07 check on June 30, 2006)
20 h and 57 min
(See Figure 3.)
Engines
Type
CFM International Model CFM56-3C1
Engine No.
No. 1
No. 2
858417
858198
Date of manufacture
June 28, 1996
March 27, 1995
Total time in service
21, 055 h and 49 min
Engine serial No.
Time in service since the last periodical check
19,279 h and 25 min
20 h and 57 min
(C07 check on June 30, 2006)
2.5.3
Weight and Balance
When the serious incident occurred, the aircraft’s weight and position of center of
gravity are estimated to have been 96,400 lb and 17.1% MAC, respectively, both of which are
estimated to be within the allowable ranges (maximum landing weight of 110,000 lb, and 5.029.5% MAC based on the estimated aircraft weight at the time of the serious incident).
2.5.4
Fuel and Lubricating Oil
The fuel was aviation fuel JET A-1 and the lubricating oil was BP Turbo Oil 2380.
2.5.5
Information on the Aircraft’s Cabin Altitude Warning System
The cockpit of the aircraft was equipped with a cabin altitude warning system. The
system provides an audible alarm when the cabin altitude exceeds approximately 10,000 ft, and
the alarm stops when the cabin altitude drops back below approximately 10,000 ft, or when the
cutout switch on the overhead panel is manually pushed.
2.5.6
Information on the Aircraft’s Cabin Oxygen System
The cabin of the aircraft was equipped with an oxygen supply system. When the cabin
altitude reaches approximately 14,000 ft, a pressure switch trips, and causes the oxygen masks
in the cabin to deploy automatically. When the system is activated, the following lights come
on in the cockpit: the “Pass Oxy ON” light on overhead panel, the system annunciator
“OVERHEAD” light and the master caution light on the glare shield.
9
2.6 Information on the DFDR and CVR
The aircraft was equipped with a DFDR (Part Number 980-4100-DXUS) of Sundstrand,
U.S.A., and a CVR (Part Number 2100-1020-00) of L-3 Communications, U.S.A.
The DFDR retained records of all data of the aircraft from the takeoff at Fukuoka Airport to its
landing at Chubu International Airport.
However, cabin altitude related data were not
included in the recorded items.
Capable of recording data for a period of up to 2 h, the aircraft’s CVR retained all voice
and other sound data related to this serious incident.
The DFDR data was time referenced by checking the VHF transmission keying data
against the time signals recorded together with the ATC communications records.
2.7 Tests and Research for Fact-Finding
Teardown and Functional Examination of Each Component Related to the Air
Conditioning System
Cockpit and cabin air temperature and pressure are controlled using the two air
conditioning packs on the aircraft.
The air conditioning system is supplied with part of the
high-temperature, high-pressure air created by the engine compressors and taken partway
through its flow (hereinafter referred to as “bleed air”).
In order to examine the functions of the equipment related to the air conditioning
system of the aircraft, the following components that had been installed on the aircraft at the
time of the occurrence of this serious incident, were removed from the aircraft and underwent
teardown and functional examination as per the company’s maintenance manual, the results of
which are presented below.
2.7.1 Pressure Regulator and Shutoff Valves (PRSOVs)
(1) The No. 1 valve had piston rings with the edges discolored to brown.
Shallow scores were found on the valve body and the lower section of the butterfly
plate. The damage was attributable to contamination that filled the groove in the
butterfly plate seal ring and prevented the seal ring from being compressed.
The inner surface of the actuator housing had scores that were caused by a piston
ring set stuck due to contamination.
(2) The No. 2 valve had traces of water ingress in its actuator cover.
The valve linkage hinge was corroded with granular contamination on it.
(See Figure 2 and Photographs 1 and 2.)
2.7.2 High-Stage Valves (HSVs)
(1) The No. 1 valve had slight traces of water ingress on the inside and outside surfaces of
the hollow piston actuator rod.
Traces of water ingress were found on the actuator cover.
(2) The No. 2 valve had traces of water pools on both faces of the piston actuator.
Traces of water ingress were found on the inside and outside surfaces of the hollow
piston actuator rod.
The valve linkage hinge was corroded.
10
The outer periphery of part of the spring was worn due to interference with other
parts.
(See Figure 2 and Photographs 3 and 4.)
2.7.3 High-Stage Regulators (HSRs)
(1) The No. 1 regulator had a small score on the diaphragm mounting area.
(2) The No. 2 regulator had deposits of contamination in the area around the reverse flow
check mechanism on the diaphragm end side, where traces of water ingress were also
found.
(See Photographs 5 and 6.)
2.7.4 Pre-coolers
(1) The No. 1 pre-cooler had been used for 7,556 h and 01 minute over 6,901 landings since
the last overhaul.
Air leakage was found from a welded corner.
(2) The No. 2 pre-cooler had been used for 10,271 h and 35 min over 9,729 landings since
the last overhaul.
There were openings both near the center of the ram air outlet core and in a
straight-line weld, from where heavy air leakage was detected.
(3) As a result of the functional tests conducted on the No. 1 and No. 2 pre-coolers at the
manufacturer, the pressure drop of the No. 1 unit (0 psi pressure drop within 10
seconds) and that of the No. 2 unit (27 psi pressure drop within 10 seconds) were both
found to conform to the design standard (33 psi or smaller pressure drop within 10
seconds after applying 50 psi initial pressure).
(See Figure 2 and Photographs 7 and 8.)
2.7.5 Pre-cooler Control Valves (PCVs)
(1) Functional examination of No. 1 PCV
① The results of the functional examination conducted on the servo reference pressure
regulator and actuator reference pressure regulator showed that both the servo
reference pressure and actuator reference pressure did not reach the permissible
range when the specified air pressure was applied.
② Examination of orifice feedback function
Servo reference pressure did not reach the permissible range when the specified
air pressure was applied.
③ Examination of overall functions
The remote temperature sensor port pressure as measured with the butterfly
plate moved to the “full open” position exceeded the permissible range.
In addition, the butterfly plate was found to have shifted toward the “open” side
from the normal position.
(2) Teardown examination of No. 1 PCV
① Traces of water ingress and contamination deposits were found inside the actuator
housing.
② The vent hole in the servo body assembly was found to be narrowed due to
contamination.
11
The retainer of the actuator reference pressure regulator diaphragm was found
③
broken into three pieces.
The servo reference pressure regulator had traces of water ingress on the guide set
④
side of the guide-set-to-poppet-valve connection.
The poppet valve was found to be partially darkened due to wear.
The actuator reference pressure regulator had traces of water ingress and deposits of
⑤
contamination on the guide set side of the guide-set to poppet-valve connection.
(3)
Functional examination of No. 2 PCV
The results of the functional examination conducted on the servo reference pressure
①
regulator and actuator reference pressure regulator showed that both the servo
reference pressure and actuator reference pressure exceeded the permissible range
when the specified air pressure was applied.
Examination of orifice feedback function
②
Servo reference pressure and remote temperature sensor port pressure exceeded
the permissible range when the specified air pressure was applied.
Examination of overall functions
③
The butterfly plate was found to have shifted toward the “closed” side from the
normal position.
(4)
Teardown examination of No. 2 PCV
Traces of water ingress and contamination deposits were found inside the actuator
housing.
(See Figure 2 and Photographs 9 and 10.)
2.7.6 Pre-cooler Sensors
(1) The results of the functional test on the No. 1 sensor showed that the signal pressure
level exceeded the limit when the bleed duct air temperature was lowered to 387°F.
Due to the insufficient drop in signal pressure level, the PCV was in a condition difficult
to close.
The ball in the valve assembly was not free to move. In addition, the sensor was
entirely fouled with contamination deposits.
(2) There were no abnormalities found with the No. 2 sensor.
(See Figure 2 and Photograph 13.)
2.7.7 Bleed Air Regulators (BARs)
(1) With the No. 1 BAR, the results of the functional examination of the reference pressure
regulator showed a control pressure exceeding the permissible range.
Contamination deposits on and around the reference pressure regulator valve were
wet with moisture, which impaired movement of the valve.
The relief valve poppet was worn.
(2) With the No. 2 BAR, the results of the functional examination of the reference pressure
regulator showed a control pressure exceeding the permissible range.
The results of the functional examination of the relief valve showed a control
pressure downstream did not reach the permissible range.
The valve, spring and retainer of the reference pressure regulator were rusted red
12
due to water ingress.
The relief valve poppet was worn.
(See Photographs 11 and 12.)
2.7.8
Analysis of Deposits on the Components
In order to identify the constituents forming the deposits on the PCV, PRSOV and other
components, qualitative analysis was conducted using an energy dispersive X-ray fluorescence
analyzer (EDX), in addition to a Fourier transform infrared spectroscope analyzer (FT-IR) and
an X-ray diffractometer. The analyses identified the deposits as detergent residues and their
constituents agreed with those of the solids formed through condensation of the alkali detergent
(meeting the “RMCG21” standard) that had been used at the company to water-wash the
engines.
2.7.9
(1)
(2)
(3)
(4)
Water Washing Test for Engine Gas Path Cleaning on a Same Type Engine as the
Aircraft’s Engines (CFM56-3)
With both the bleed air switch and anti-ice switch set to OFF, and in accordance with
the Aircraft Maintenance Manual (hereinafter referred to as the “AMM”), water was
sprayed onto the 12 o’clock position of the fan blade root. It was then found that 2 - 3
ml of water entered the PCV. Small amounts of water were also found on the supply
side of the HSR.
With both the bleed air switch and anti-ice switch set to OFF, water was sprayed onto
the fan blade root, starting from the 6 o’clock position and moving clockwise. It was
then found that approximately 12 ml of water entered the PCV.
With the bleed air switch set to ON and the anti-ice switch set to OFF, and in
accordance with the AMM, water was sprayed onto the 12 o’clock position of the fan
blade root. It was then found that approximately 14 ml of wash water entered the
PCV. Pools of wash water were also found on the supply and control sides of the HSR.
After conducting the tests described in (1) - (3) above on January 12, 2007, the test
engine was removed from the aircraft. On January 25, the related components were
removed from the engine and a teardown examination was conducted; the examination
results showed ingress of large amounts of water into these components. In addition,
the PCV, PRSOV and BAR developed red rust.
2.8 Other Relevant Information
2.8.1
Information on the Engine Bleed System
Bleed air is supplied from the 5th or 9th stage of the engine compressor.
As N1*2 drops and the 5th-stage pressure is no longer sufficient, bleed air is supplied
from the 9th stage where higher-pressure air is available. The 5th-stage pressure is at a
sufficient level during takeoff, climbing and cruising, so the 9th-stage valve is closed in these
phases.
With the engine bleed air switch set to ON, the PRSOV valve maintains the pressure of
*2: “N1” is the speed of the shaft that connects the low-pressure compressor to the low-pressure turbine of the
engine and is expressed in %, which represents the ratio of the actual shaft speed to a reference shaft speed.
13
bleed air from the 5th or 9th stage at levels appropriate for system operation.
Also, when the
temperature of bleed air becomes too high, the PRSOV reduces the bleed air output flow.
The pre-cooler is a heat exchanger that uses fan air to cool and maintain bleed air at a
temperature of approximately 390°F/199°C.
The PCV regulates the flow of fan air to the pre-cooler. The butterfly plate of the PCV
closes when the temperature of bleed air from the engine is low and opens when the temperature
becomes high, thus maintaining the temperature of duct air between 390°F/199°C and
440°F/227°C.
If the temperature or pressure of engine bleed air exceeds the preset limit, the
corresponding sensor causes the bleed trip off light (warning light) to illuminate.
(See Figure 2.)
2.8.2
Information on the Engine Bleed Air Control of the Aircraft
Under typical conditions while flying at FL370, if N1 is 37 – 53%, 9th-stage bleed air is
supplied to the duct without regulation by the high-stage regulator. If N1 is 53 - 84%, 9th-stage
bleed air is regulated at 32 ± 6 psi by the high-stage regulator before being supplied to the duct.
If N1 rises to approximately 84%, source of bleed air is changed to the 5th stage from the 9th
stage.
If N1 is 84 - 96%, 5th-stage bleed air is supplied to the duct. If N1 is 96 - 100%,
5th-stage bleed air is supplied to the duct after being regulated at 42 ± 8 psi by the pressure
regulator shutoff valve.
At about 08:08, the aircraft was flying at a cruising altitude of FL370 and N1 was then
85% for both the No. 1 and No. 2 engines.
Approximately 30 seconds after N1 dropped to 54%, the engine output was raised again
for both the No. 1 and No. 2 engines, and N1 was then stabilized at approximately 82%.
(See Figure 5.)
2.8.3
Illumination of the Bleed Trip Off Light
Illumination of the bleed trip off light indicates the closure of the engine bleed valve
(PRSOV) due to overheating (490°F/254°C) or overpressure (180 psi).
2.8.4
490°F Bleed Overheat Switches
The switch closes if the air temperature in the bleed duct exceeds 490 ± 10°F / 254 ± 3°C.
When the switch closes, the engine bleed air overheat relay inside the corresponding air
conditioning module is energized.
When the relay is energized, the PRSOV closes, causing the bleed trip off light on the
overhead panel to illuminate.
(See Figure 2.)
2.8.5
Water Washing of the Aircraft’s Engines for Engine Gas Path Cleaning at an
Overseas Maintenance Facility
On June 10, 2006, the aircraft was ferried to a maintenance facility in China for a
C-check. The aircraft received airframe maintenance and other servicing and then, on the
morning of June 26, the No. 1 and No. 2 engines underwent water washing.
Because the detergent was sprayed towards 6 o’clock position of the spinners, not in
14
compliance with the company’s procedures, by the instruction of the inspector, this time to fresh
water was sprayed towards the 12 o’clock position of each spinner.
After rinsing, the engines
were test-run in accordance with the AMM to completely remove any water that would have
entered the ducts and other components.
Subsequently, the aircraft underwent the remaining part of the airframe maintenance
service. After that, flight test was performed on June 29 and then it was ferried to Japan on the
afternoon of July 1.
It was the first time that the company performed engine water washing at an overseas
maintenance facility.
2.8.6 The company’s on site investigation for the Engine Washing
According to the company’s report, the engine washing was performed as follows;
When carrying out the water washing, I set the bleed air switches for both the No. 1 and No.
2 engines to OFF and the anti-ice switch to OFF, and then at the first time I sprayed the
detergent towards the 6 o’clock position of each spinner. Because the detergent failed to enter
the engine cores, at the second time I sprayed towards the 12 o’clock position of each spinner,
with good results.
Most of the detergent sprayed at the first time came out of the fan exits, but at the second
time it came out of the engine core exits.
I then rinsed the engines with water three times as specified in the AMM. The flow rate of
water during the rinsing was about 22 liters per minute. I then ran the engines free of load for
5 min as specified in the AMM, performed checks including the engine anti-ice, then ran the
engines at idle power with the air conditioning system set to ON.
2.8.7
Statements of Personnel in charge of teardown examination and functional
examination
I have done many teardown and functional examinations of valve related components thus
far, but this was the first time that I saw such traces of water ingress and contamination
deposits resulting from water ingress in valves and other components.
2.8.8
Engine Water Wash Information Issued by the Company
The TSI (Technical Service Information) and Aircraft Quality Information issued by the
company on October 1, 2005 for its Aircraft Maintenance Department include the following
descriptions.
(Excerpts)
We have experienced a problem with a Boeing 737-500 after engine water washing, the
cause of which was ingress of an unexpectedly large quantity of water into the engine core
section and by entry of water into the engine oil system. This TSI outlines the problem and
summarizes what must be especially noted during engine water washing.
Points that must be strictly observed during engine water washing are the following:
(1) During water washing, observe the recommended flow rate of water supply to the
engine. The recommended flow rate is 19 - 23 liters/minute.
* Spraying water at flow rates exceeding the above limit can cause water to enter the
engine oil system.
15
(2)
When spraying water for engine water washing, the spray must be directed at the area
around the flange bolts behind the cone aft of the spinner and centered upon the 12
o’clock position of the engine.
This is the most efficient way of letting water flow into the engine core.
2.8.9
Procedures of the Company related to Engine Water Washing
The AMM of the aircraft describes the steps to follow after engine water washing as
shown below.
(Excerpts)
Within 2 h after water washing, drain water in accordance with the procedure described
in this AMM.
(1) Operate the engine at low idle for 5 minutes.
(2) Make sure these switches are in the OFF position:
Engine 1 Bleed
Engine 2 Bleed
Put the applicable ENG-ICE switch in the ON position.
(3) Make sure there is an increase in the EGT of approximately 15°C.
(4) Put the ENG ANTI-ICE switch in the OFF position.
(5) Move the forward thrust lever until the engine speed is in high idle.
(6) Put the applicable ENG ANTI-ICE switch in the ON position.
(7) Make sure there is an increase in the EGT of approximately 15°C.
(8) Put the ENG ANTI-ICE switch in the OFF position.
(9) Make the engine idle stable at the low idle position and operate the engine for 5
minutes.
(10) Shut down the engine.
2.8.10 BLEED TRIP OFF Light Illumination Previously Experienced by the Aircraft
As a result of an investigation of problems experienced by the aircraft in flight, the
following case was identified as relevant.
Problem outline:
On April 23, 1999, the left BLEED TRIP OFF light illuminated when the aircraft
was about to begin a descent after flying at 33,000 - 37,000 ft.
Maintenance action taken:
Bleed air related components were replaced, but the problem persisted. Later, the
problem was resolved by replacing the pre-cooler with a replacement part.
2.8.11 Actions to Take When the Pressurization System Develops a Problem in the Air
In Subsection 10-4-7 Pressurization System Failure, Section 10-4 Actions to Take in
Different Emergency Cases in Chapter 10 Emergency Procedures, the company’s Operations
Manual (hereinafter referred to as “OM”) describes as follows the actions to take in the event of
rapid cabin depressurization during flight.
(Excerpts)
If the aircraft’s pressurization function is lost while flying, the flight crew shall
immediately take action following the relevant prescription in the Airplane Operations Manual.
16
If the aircraft must fly below the minimum safe altitude defined in Section 3-7-1
(Restrictions Related to Performance Limitations) of this manual, the Pilot in Command shall
pay utmost attention to avoid collision and shall notify ATC of the fact as soon as possible.
2.8.12 Procedure in case of Cabin Altitude Warning or Rapid Cabin Depressurization
The company’s Airplane Operations Manual (hereinafter referred to as “AOM”) provides
the following descriptions in the “CABIN ALTITUDE WARNING HORN / RAPID
DEPRESSURIZATION” section of Chapter 2 Procedures in Emergencies / System Failures
(Supplement).
(Excerpts)
(1)
CABIN ALTITUDE WARNING HORN / RAPID DEPRESSURIZATION
Condition: One or more of the following circumstances has arisen.
• Intermittent cabin altitude / configuration warning horn sounds.
• Cabin pressure is lost rapidly at an altitude above 10,000 ft.
Oxygen Masks ······················································· ON
PLT *3
Pack Switches ······················································· HIGH
PNF
Pressurization Mode Selector ·································· MAN
PNF
[If the cabin rate of climb drops after setting the pack switches to HIGH, select MAN
after the cabin rate of climb stabilizes.]
Outflow Valve Switch ············································· CLOSE
PNF
[It is not necessary to set to CLOSE if the cabin rate of climb has dropped.]
• After recovery of cabin pressure, continue manual operation.
If the cabin altitude cannot be controlled:
[Accomplish individual pilot’s checklists simultaneously under the control of the Pilot
in Command.]
Emergency Descent ··············································· INITIATE
PF
[Call out “Emergency Descent” over flight interphone.]
Altitude Selector ································· 10,000 FT OR LOWEST SAFE ALTITUDE,
WHICHEVER IS HIGHER
PF
[Set level-off altitude.]
[Lowest Safe Altitude is the lowest of the altitudes available from safe altitude
information sources (“MEA,”*4 “MOCA,”*5 “MORA”*6 and “Grid MORA”*7) and “an
altitude of 2,000 ft above the highest obstacle along the route.”]
LVL CHG Switch ··················································· PUSH PF
If there is no structural damage:
*3: In normal procedures, “PLT” means all flight crew members.
*4: “MEA” is the minimum en-route altitude in instrument flight rule operations.
*5: “MOCA” is the minimum obstacle clearance altitude, which is determined by adding a specific vertical
distance to the height of obstacles within a certain distance from the centerline of the airway or other type of
route.
*6: MORA is the minimum off-route altitude, which is determined by adding a certain clearance to obstacles
within 10 nm on either side of the centerline of the route.
*7: Grid MORA is determined by adding a certain clearance to obstacles within an area enclosed by latitude and
longitude lines.
17
Speed Selector ······················································· SET VMO/MMO*8
PF
• Accomplish high-speed descent.
Thrust Levers ······················································· CLOSE
PF
Speed Brake ························································· FLIGHT DETENT
PF
HDG Selector and
HDG SEL Switch (if desired) ······························· SET AND PUSH
PF
Cabin Signs ······················································ ON PNF
Passenger Oxygen Switch (if required) ·················· ON PNF
[Set switch to ON if passenger oxygen system fails to operate at a cabin altitude
higher than 13,000 ft.]
Engine Start Switches ········································ CONT PNF
Transponder ····················································· 7700
Speed Brake ····················································· DOWN DETENT PF
[Level off by smoothly moving the speed brake lever to the down position. Stabilize
at the desired air speed.]
Altimeters ························································ SET&X-CHECK PLT
Crew Oxygen Regulators ···································· NORMAL PLT
[Flight crew must use oxygen masks if the cabin altitude exceeds 10,000 ft. To save
oxygen, set the NORMAL/100% selector to NORMAL.]
Engine Start Switches ········································ CONT/OFF PNF
• After the cabin altitude drops to 13,000 ft or below, tell the cabin crew that they
may take off their oxygen masks.
[After the cabin altitude drops to 10,000 ft or below, the flight crew may take off
their oxygen masks.]
(2) BLEED TRIP OFF
Condition: Illumination of BLEED TRIP OFF light indicates that the temperature or
pressure of engine bleed air is excessively high.
Wing Anti-Ice Switch ········································· OFF PNF
Trip Reset Switch················································ PUSH PNF
[BLEED TRIP OFF light goes out when bleed air temperature drops below the limit.]
If BLEED TRIP OFF Light stays ON:
Pack Switch (Affected Side) ································· OFF PNF
[If the flaps are up, operative pack is regulated for high flow mode operation.]
• Avoid icing conditions.
*8: VMO/MMO is the maximum operating limit speed, which must not be deliberately exceeded in any phase of
flight, i.e. climb, cruise or descent.
18
3. ANALYSIS
3.1 The PIC and First Officer possessed adequate airman certificates and valid airman
medical certificates.
3.2 The aircraft had a valid certificate of airworthiness and was properly maintained and
inspected.
3.3 As to the history of events resulting in the abnormal drop in cabin pressure during
cruising,
(1)
The DFDR records described in 2.1.1 indicate that, while the aircraft was cruising at
FL370, the master caution light and the system annunciator’s “AIR COND” light
illuminated in the cockpit at 08h10m05s,
(2)
According to the DFDR records described in 2.1.1 and the statements of the PIC, the
cabin altitude warning activated at 08h10m44s after the aircraft began its descent,
(3)
According to the DFDR records and the statements of the PIC, after the cabin altitude
warning activated, the oxygen masks in the cabin automatically deployed at
08h13m27s,
Based on the above and the descriptions in 2.5.5 and 2.5.6, it is estimated that the cabin
altitude reached about 10,000 ft immediately after the aircraft began descent from FL370, which
triggered the cabin altitude warning system, and within 3 min after that, the cabin altitude
reached about 14,000 ft, causing the oxygen masks to automatically deploy in the cabin.
It is
also estimated based on the DFDR records that, at that time, the aircraft was descending
towards 10,000 ft at a rate of 4,000 fpm.
3.4 Based on the descriptions in 2.1.2 (1) and 2.1.2 (2), it is estimated that, because of
abnormal cabin depressurization that occurred while the aircraft was cruising, the PIC
and First Officer put on their oxygen masks, set the pressurization mode selector to
“MANUAL” and made a descent to 10,000 ft in accordance with the OM procedure
mentioned in 2.8.11 and the AOM procedure mentioned in 2.8.12.
3.5 Bleed Air Sources of the Aircraft
As described in 2.8.2, N1 was 85% for both the No. 1 and No. 2 engines while the aircraft
was flying at FL370, from which it is estimated that bleed air at that time was being supplied
from the 5th stage of each engine’s high-pressure compressor.
When the aircraft encountered turbulence while cruising at FL370 and the engine power
was quickly reduced to prevent the increase in airspeed, N1 for both engines dropped from 85%
to about 54%. It is estimated, as described in 2.8.2, that the bleed air source at that time
changed from the 5th stage to the 9th stage of each engine’s high-pressure compressor, which
has higher temperature.
Then, approximately 30 seconds after N1 dropped to 54%, the engine power was
increased again and N1 for both the No. 1 and No. 2 engines stabilized at about 82%.
19
3.6 Activation of No. 1 and No. 2 Overheat Switches
It is estimated that, when higher-temperature 9th-stage bleed air flowed into the
pre-coolers, both the No. 1 and No. 2 PCVs, the role of which is to control the fan air, operated
sluggishly due to contamination deposits and thus failed to allow sufficient fan air to flow to the
pre-coolers, causing insufficient cooling and the No. 1 and No. 2 overheat switches to trip, which
then caused both bleed valves to close (as indicated by illumination of both BLEED TRIP OFF
lights), resulting in an abnormal drop in cabin pressure.
3.7 Causes of Contamination Deposits in Pre-cooler Control Valves (PCVs)
As to contamination deposits inside the PCVs, it is estimated that the cause was a
significant amount of detergent having entered the bleed related valves and other components
during water washing of the engines for gas path cleaning, which was conducted at the time of
C-check of the aircraft as described in 2.8.5.
It is estimated that, even after the engine test run carried out to remove water in
accordance with the AMM, water still remained in the bleed related valves and other
components.
In addition, since the aircraft was parked for about three days after the engine test run,
it is estimated that detergent in the remaining water dried out to form a solid residue, which
subsequently constituted contamination that would have caused sluggish movement of the
PCVs.
3.8 Actions Taken after Engine Water Washing
The results of the test conducted on an engine of the same type as that of the engines on
the aircraft as described in 2.7.9 showed that water entered the valves and other components
after water washing and also that leaving the engine untouched for several days caused the
PCVs, PRSOVs and BARs to develop red rust.
Based on the test results, it is estimated that, in the case of this serious incident, the
contamination deposits were formed because the engines had been left unused for three days
after engine water washing.
When performing water washing, it is essential that the bleed air switch is set to OFF,
the anti-ice switch is set to OFF, and then water is sprayed towards the 12 o’clock position of
each spinner in accordance with the AMM.
It is estimated that the serious incident could have
been avoided if the aircraft had been put into service the day after the water was removed from
the bleed related valves and other components as per the AMM or if water washing had been
accomplished between flights.
3.9 Factors Contributing to Water Ingress into Valves and Other Bleed Related
Components
It is considered that water and detergent that had remained in the bleed air manifolds
of the 5th- and 9th-stage high-pressure compressors during the water washing for gas path
cleaning, then entered the bleed-air related valves and other components via the supply lines
(bleed ducts, etc.) and control lines when the engines were subsequently run at idle with the
bleed switch set to ON as part of the post-water-washing procedure specified in the AMM.
20
4. PROBABLE CAUSE
It is estimated that this serious incident would have occurred through the following
process:
the aircraft encountered turbulence when flying at FL370, quickly reduced the engine
power in order to avoid excessive airspeed, and this in turn caused a change of the source of
bleed air, which resulted in bleed air with higher temperature flowing into the pre-coolers, but
the bleed air was not cooled sufficiently, and the overheat switches activated, closing the bleed
valves for both systems and thus preventing the air supply necessary for pressurization of
aircraft, ultimately resulting in an abnormal cabin depressurization.
It is estimated that the overheat switches activated because the operation of the control
valves (PCVs) was sluggish due to contamination.
It is estimated that contamination deposits on the bleed related valves and other
components resulted from incomplete draining of water and detergent which entered these
components in large quantities during water washing conducted for engine gas path cleaning.
21
5. REFERENTIAL MATTERS
5.1 Actions Taken by the Company to Prevent the Recurrence
After this serious incident, the company issued an AMM Bulletin, which has higher
priority than the TSI, to implement improvements including those enumerated below as
measures to ensure complete removal of water after water washing of the engines on aircraft of
the same type as the aircraft involved in this serious incident. In addition, the company decided
to carry out engine water washing at its own facilities.
(1)
A reminder to all personnel concerned that the bleed switch must be set to OFF when
performing water washing.
(2)
The aircraft must be put in service for one or more flights within 48 hours after water
washing of its engines. If it is not possible to fulfill this requirement, the engines must
be run at 80% N1 or higher for five min.
(3)
The pressure sensing lines for the 5th- and 9th-stage high-pressure compressors must
be disconnected before water washing using detergent.
5.2 Actions Taken by the Aircraft Manufacturing Company to Prevent the
Recurrence
The aircraft manufacturing company’s AMM issued before this serious incident had
stipulated in one item of the procedure that the anti-ice switches and bleed switches should be in
the OFF position as a preparation work performed prior to the water spraying of the water
washing. However, after this serious incident, taking into account the importance of this work,
the aircraft manufacturing company amended the AMM as of July 12, 2007 and stipulated each
switch operation as two independent items.
22
付図1 1 推定飛行経路図
Figure
Estimated Flight Route
N
Chubu International Airport
Fukuoka Airport
Kushimoto VORTAC
SAKIT
Aircraft Reached FL370
Master caution light
came on
0
100Km
Aircraft began
descending
Aircraft reached
10,000ft
Figure 2 Schematic diagram for bleeding-air related components
450°F Thermostat
PCV Sensor
490°F Overtemp
Switch
Fan Air
To Left
Pack
System
Precooler
PRSOV
5th Stage
HSV
9th Stage
PCV
To
Right
Pack
System
Figure 3
Three views of Boeing 737-500
Unit: m
11.13
28.88
31.01
Figure 4 Records of DFDR
Pressure Altitude (ft)
気圧高度 (単位:ft)
40000
35000
30000
25000
20000
15000
Thrust lever retarded
10000
CAS (単位:kt)
CAS (kt)
Master Caution
340
320
300
280
260
240
220
200
Left (%)
N1N1
左 (単位:%)
Oxygen masks deployed
90
80
70
60
50
40
30
N1
Right (%)
N1
右 (単位:%)
90
80
70
60
50
40
30
Left Thrust Lever Angle (%)
スラストレバーアングル 左 (単位:Deg)
35
30
25
20
15
10
5
0
Right
Thrust Lever Angle (%)
スラストレバーアングル 右 (単位:Deg)
35
30
25
20
15
10
5
0
客室気圧高度警報
Cabin Altitude
Warning
Time (JST)
8:18:00
8:17:30
8:17:00
8:16:30
8:16:00
8:15:30
8:15:00
8:14:30
8:14:00
8:13:30
8:13:00
8:12:30
8:12:00
8:11:30
8:11:00
8:10:30
8:10:00
8:09:30
8:09:00
8:08:30
8:08:00
マスターコーション
Master Caution
Figure 5 Bleed Air Control Table
9th
Sea Level: 37,000FT
5th stage is
being used
stage is being used
45
40
Duct Pressure (psi)
ダクトプレッシャー(
psi)
35
During
cruise
30
After retarding
thrust lever
25
20
15
10
30
40
50
60
N1(%)
70
80
90
100
Photo 1
Dismantled No.1 PRSOV
Actuator Housing Assembly
Piston Ring
Scores
Scores and attached contamination
Contamination caused by
water and attached volcanic
ash
Actuator Cover
Photo 2
Butterfly plate
Dismantled No.2 PRSOV
Traces of water ingress
Actuator Cover
Corrosion
Valve Linkage Hinge
Granular Contamination
Photo 3
Dismantled No.1 HSV
Traces of water flow
Actuator Cover
Actuator Piston Rod
Traces of water ingress
Traces of water ingress
Actuator Housing
Photo 4
Dismantled No.2 HSV
Corrosion
Valve Linkage Hinge
Actuator Cover
Traces of water ingress
Ring Set
Volcanic Ash
Wear
Spring
Piston Actuator
Traces of water ingress
Butterfly Plate
Photo 5
Score
Dismantled No.1 HSR
Diaphragm
Photo 6
Dismantled No.2 HSR
Deposits of contamination
caused by water ingress
Reverse Flow Check Mechanism
Photo 7
Test of No.1 Pre-cooler
air leakage point
detected air leakage
Photo 8
Test of No.2 Pre-cooler
big openings of leakage
detected air leakage
Photo 9
Dismantled No.1 PCV
Actuator Cover
Guide Set
Poppet
Traces of water ingress
Contamination caused
by water ingress
Diaphragm
Photo 10
Dismantled No.2 PCV
Actuator Cover
Traces of water ingress and
contamination
Photo 11
Dismantled No.1 BAR
Contamination
Wear
Reference Pressure Regulator
Relief Valve Poppet
Photo 12
Dismantled No.2 BAR
Traces of water
ingress and rust
Reference Pressure Regulator
Photo 13
Dismantled No.1 Pre-cooler Sensor
The ball was not free to move
and the sensor was fouled
with contamination deposits.
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