What happened
On June 24, 2013, an ATR-72-212A, registration EC-KKQ, operated by Swiftair, departed Madrid-Barajas (LEMD) for Vigo (LEVX) as an Air Europa flight. Shortly after takeoff, while performing a standard instrument departure, the crew received a cockpit warning indicating a fire in the number 1 engine.
Following the fire warning, the crew executed engine fire extinguishing procedures and notified Air Traffic Control (ATC) of the engine failure. While initially authorized to approach runway 32L, the crew subsequently declared an emergency (MAYDAY) and expressed their intention to land on runway 36L. At the time, runway 36L was configured for departures only. The aircraft landed safely at 16:22 UTC, and the 69 passengers and 5 crew members disembarked normally without an emergency evacuation.
The investigation
The CIAIAC investigation focused on the mechanical failure of the engine and the crew's management of the emergency. Investigators examined the engine components and found that the fire originated from the failure of the number 30 blade in the number 2 power turbine (PT2).
Technical analysis revealed that the blade failure was caused by fatigue, exacerbated by sulfur-rich corrosion deposits. The resulting mechanical vibrations likely caused the breakage of the oil ventilation pipe for bearings 6 and 7. When the escaping oil contacted hot engine components, it ignited. The investigation also scrutinized the crew's performance, noting that they failed to detect an abnormal interturbine temperature (ITT) during the initial climb and struggled with task prioritization during the emergency.
Findings
- The primary cause of the fire was the separation of a power turbine blade in the left engine.
- Mechanical vibrations from the blade failure led to the rupture of an oil line, which ignited upon contact with hot engine surfaces.
- The crew's management of resources (CRM) was inadequate; they prioritized non-essential communications over critical emergency tasks.
- Stress and a loss of situational awareness led the crew to perform an unintended approach to runway 36L, a runway not designed for arrivals.
- The crew did not execute a proper missed approach after realizing their positional error, resulting in a non-stabilized final approach.
Safety action
Following the investigation, the CIAIAC issued a safety recommendation (REC 45/15) to Swiftair, requesting the development of a specific instruction and supervision plan to ensure crews adhere strictly to emergency procedures.