What happened
On September 5, 2002, at 18:14 local time, a TransAsia Airways flight, GE517, departed from Taipei Songshan Airport bound for Magong, Penghu. Shortly after takeoff, as the ATR72-212A climbed to 500 feet, air traffic control notified the crew of sparks and heavy smoke emanating from the tail section. Simultaneously, the number two engine fire warning was triggered.
As the aircraft continued its climb to approximately 800 feet, the non-handling pilot observed white smoke entering the cockpit. The crew immediately executed engine shutdown and fire suppression procedures and decided to return to the airport. The aircraft landed safely at Songshan Airport at 18:39. There were no fatalities or injuries among the 43 passengers and 4 crew members, though the number two engine sustained significant damage.
The investigation
The investigation conducted by the Taiwan Transportation Safety Board (TTSB) focused on the maintenance history of the engine and the installation of fuel components. Investigators examined the engine's disassembly report, which revealed extensive damage to the power turbine, including broken blades and evidence of severe overheating and oil fire.
Technical analysis of the fuel nozzles showed that the number 11 fuel nozzle had been installed incorrectly. Specifically, the nozzle's positioning pin was shorter than the standard specification, which caused it to be installed in reverse. The investigation also reviewed the airline's maintenance protocols, specifically the Required Inspection Items (RII) process, and the effectiveness of the airline's training regarding new service bulletins for fuel nozzle replacements.
Findings
- The primary cause of the engine fire was the incorrect installation of the number 11 fuel nozzle on the number two engine, which was installed in reverse.
- Maintenance personnel failed to maintain proper vigilance regarding the warnings for fuel nozzle installation steps.
- The maintenance technician did not follow the Required Inspection Items (RII) procedure, which would have required an inspector to be present to verify the work.
- The inspector failed to follow the RII standard operating procedure to perform the necessary verification.
- The airline's implementation of training and communication regarding service bulletins for new fuel nozzle replacements was insufficient, preventing maintenance staff from being fully aware of the risks of incorrect installation.
- The specific fuel nozzle involved lacked a "FWD" marking, which could have aided in correct orientation; the manufacturer has since updated the design to include this marking.