other potential sources of ignition were identified as being sufficient to have initiated the fire. The ATSB determined that the conditions within the tank were suitable for a short duration (flash) fire; however, they were not suitable to sustain the fire. A detailed report of the ATSB’s examination and analysis of the fire in the left inner fuel tank is at Appendix D. Observation: The ATSB determined that the passenger had a clear view of the No. 2 engine through the damaged section of the wing. The duration of the fire observed by the passenger probably indicated that they observed the No. 2 engine external fire (as discussed in section 1.11.1) through the holes in the left inner fuel tank, rather than the flash fire. Brake overheat The AES reported that after the aircraft came to rest, they observed smoke emitting from the left body gear wheels. The emergency responders described an ‘incipient fire’ developing in the landing gear, and that the tyres had deflated. As a precaution, they discharged dry powder fire retardant in that area. Even though was evidence that components of the left wing body gear wheels were affected by high temperatures, a post-flight inspection revealed no evidence of a fire, such as melting or charring, in any of the affected wheels. Survival aspects were no injuries as a direct result of the uncontained engine failure and the cabin environmental systems remained functional during the occurrence and return to Changi Airport. Portable electronic devices the passengers boarded, as part of the normal departure procedures, the cabin crew made a public address announcement requiring that all portable electronic devices (PEDs) were to be switched off and could not be turned on again until the aircraft had reached cruising altitude and the seat belt sign had been turned off. The engine failure occurred prior to the aircraft reaching cruise altitude and, after the failure, the seat belt sign remained on for the rest of the flight. Therefore, the conditions under which passengers could use PEDs were not met and permission to use them was not given. The cabin crew reported that additional PA announcements were made following the engine failure instructing passengers to remain seated with their seat belts fastened and to keep PEDs switched off. Video and still images showed that some of the passengers did not comply with the crew’s instructions, such as: moving about the cabin when they had been instructed to remain seated using PEDs during flight, and in particular during the approach, landing and post landing phases, when instructed to switch them off. Observation:
Engine No. 1 Bottle-2 Squib-1 Severed Did not discharge Severed Engine No. 2 Bottle-1 Severed Discharged Squib-2 Intact Engine No. 2 Bottle-2 Squib-1 Severed Did not discharge Squib-2 Severed
02:10:59 Hydraulic pressure green decreased. Loss of outboard aileron actuator function and spoilers 8 and 2 02:18:05 Aircraft commences left orbits over the ocean north of Bintan Island, Indonesia Altitude 7,400 ft 03:28:51 Aircraft completes ninth orbit and commences descent into Singapore 03:35:08 Flaps extended to Flap 3 Extension at 1/2 speed 03:36:39 CVR recording begins during descent 03:37:52 Landing gear down and locked FDR 03:38:38 PA announcement to secure cabin for landing CVR 03:39:58 confirmed secure CVR 03:40:58 Landing checks completed – flight crew brief carried out for ‘aircraft abnormal configuration’ CVR 03:41:58 Discussion of commit/goaround options CVR 03:45:36 Low energy audible warning (‘speed speed speed’) during final approach when passing 1,000 ft RA CVR and FDR 03:45:55 A/P off CVR and FDR 03:46:17 Low energy audible warning during final approach when passing 362 ft RA CVR and FDR 03:46:43 Stall warning at 3 ft RA CVR and FDR 03:46:47 Touchdown at Changi Airport on runway 20C CVR/ FDR 03:46:48 Max braking CVR 03:48:35 Feed Tank 2 fuel quantity 12,640 kg FDR 03:49:05 03:49:08 03:49:15 No. 3 engine shutdown No. 4 engine shutdown Attempted shutdown of No. 1 engine CVR/ FDR 03:51:01 radio contact between the flight crew and Singapore Rescue and Fire-fighting Service (AES) CVR