FINAL INVESTIGATION REPORT ON SERIOUS INCIDENT

TO M/s CATHAY PACIFIC LTD. BOEING B747-400

AIRCRAFT REGISTRATION B-HUL AT IGI AIRPORT
DELHI ON 27.07.2015

COMMITTEE OF INQUIRY B-HUL

(K Ramachandran) (Raje Bhatnagar)

AAIB AAIB
Member Chairman
 Foreword

In accordance with Annex 13 to the Convention on International Civil

Aviation Organization (ICAO) and Rule 03 of Aircraft (Investigation of
Accidents and Incidents), Rules 2012, the sole objective of the investigation
of an accident/incident shall be the prevention of accidents/incidents and not
apportion blame or liability.

This document has been prepared based upon the evidences collected during
the investigation, opinion obtained from the experts and laboratory
examination of various components. Consequently, the use of this report for
any purpose other than for the prevention of future accidents/incidents could
lead to erroneous interpretations.
 INDEX
CONTENTS PAGE No.
SYNOPSIS 02
1 FACTUAL INFORMATION 03
1.1 HISTORY OF THE FLIGHT 03
1.2 INJURIES TO PERSONS 04
1.3 DAMAGE TO AIRCRAFT 04
1.4 OTHER DAMAGE 12
1.5 PERSONNEL INFORMATION 12
1.6 AIRCRAFT INFORMATION 14
1.7 METEOROLOGICAL INFORMATION 25
1.8 AIDS TO NAVIGATION 26
1.9 COMMUNICATIONS 26
1.10 AERODROME INFORMATION 26
1.11 FLIGHT RECORDERS 27
1.12 WRECKAGE AND IMPACT INFORMATION 28
1.13 MEDICAL AND PATHOLOGICAL INFORMATION 33
1.14 FIRE 33
1.15 SURVIVAL ASPECTS 33
1.16 TESTS AND RESEARCH 33
1.17 ORGANISATIONAL & MANAGEMENT INFORMATION 35
1.18 ADDITIONAL INFORMATION 35
1.19 USEFUL AND EFFECTIVE TECHNIQUES 37
2 ANALYSIS 37
2.1 SERVICEABILITY OF AIRCRAFT 37
2.2 WEATHER 38
2.3 PILOT FACTOR 38
2.4 CIRCUMSTANCES LEADING TO INCIDENT 39
3 CONCLUSIONS 43
3.1 FINDINGS 43
3.2 PROBABLE CAUSE OF THE INCIDENT 46
4 SAFETY RECOMMENDATIONS 47
 FINAL INVESTIGATION REPORT ON SERIOUS INCIDENT TO M/s CATHAY
PACIFIC AIRWAYS LTD. BOEING B747-400 AIRCRAFT REGISTRATION B-HUL
AT IGI AIRPORT DELHI ON 27.07.2015

1. Aircraft Type Boeing B 747-400

2. Nationality Hong Kong

3. Registration B-HUL

4. Owner Cathay Pacific Airways Ltd., Hong Kong

5. Operator Cathay Pacific Airways Ltd., Hong Kong.

6. Pilot – in –Command ATPL holder (Hong Kong)

Extent of Injuries Nil

7. Co-Pilot ATPL Holder (Hong Kong)

Extent of Injuries Nil

8. Place of Incident Delhi

9. Co-ordinates of incident Site 28o 34’ 01” N, 77o 05’ 14” E

10. Last point of Departure Hong Kong

11. Intended place of Landing Delhi

12. Date & Time of Incident 27th July 2015, 1240 UTC

13. Passengers on Board Nil

15. Crew on Board 02

16. Extent of Injuries Nil

17. Phase of Operation Landing Roll

Aircraft part (Flap) disintegration during

18. Type of incident: landing.

(ALL TIMINGS IN THE REPORT ARE IN UTC)

1
Synopsis

On 27th July 2015, M/s Cathay Pacific Airways Ltd. Boeing B747-400F aircraft
with registration B-HUL was involved in a serious incident while operating cargo
flight CX3217 (Hong Kong – New Delhi). The aircraft was under the command of
a pilot ATPL Holder (Hong Kong) on type with a co-pilot also an ATPL holder
(Hong Kong) on type. There was no injury to any person on board the aircraft.

The aircraft landed in Delhi on runway 10 at 1240 UTC and during the taxi-in, the
Ground controller contacted the flight crew and informed them that a part had
separated from the aircraft during the landing. The flight crew after reaching the
bay, instructed the ground engineer to perform a walk around inspection (WAI)
which initially did not reveal any missing parts. The flight crew then fully extended
the wing flaps and the engineer reported that the left wing inboard trailing edge
fore-flap was missing. The damage was limited to the failed aircraft parts and
their associated system. There was no injury to any occupant on board the
aircraft. There was no fire.

Ministry of Civil Aviation constituted a Committee of Inquiry to investigate into the

causes of the serious incident under Rule 11 of Aircraft (Investigation of
Accidents and Incidents) Rules 2012 vide MoCA order no. AV.15018/209/2015 -
DG.

2
1.0 FACTUAL INFORMATION

1.1 History of Flight

On 27th July 2015 M/s Cathay Pacific Airways Ltd. Boeing B747-400F aircraft
was scheduled to operate cargo flight CX3217 from Hong Kong to Delhi under
the command of pilot and Co-pilot both ATPL holder (Hong Kong) and qualified
on type.

The aircraft which was a cargo flight departed from Hong Kong at 0645 UTC for
Delhi. The enroute flight was uneventful. The approach and descent to Delhi was
also uneventful and there was no signal in the cockpit for any abnormality. The
Delhi ATC cleared the aircraft for landing on runway 10. The aircraft landed in
Delhi on runway 10 at 1240 UTC. After landing, while the aircraft was taxiing in,
the ground controller contacted the flight crew and informed them that a part of
the aircraft had separated from the aircraft during landing. The flight crew after
parking the aircraft at the designated bay instructed the ground
personnel/engineers to perform a walk around inspection (WAI) to verify any part
of the aircraft missing. During the initial walk around inspection the ground
personnel/engineers did not find any part missing. The flight crew then fully
extended the wing flaps and again instructed the engineers to perform the WAI.
During the WAI the ground engineer reported that the left wing inboard trailing
edge fore-flap was missing. The ATC was then informed about the same. The
ATC then instructed M/s Delhi International Airport Limited (DIAL) to carry out
runway inspection for the missing part. The same was carried out and the
separated inboard trailing edge fore flap was recovered. The fore flap was
broken into three pieces after impacting with ground. Further a sweep of runway
& taxiways were performed by DIAL personnel to confirm there were no further
parts separated from the aircraft. The flight crew stated that they did not realise
that the fore flap had separated during landing as they did not observe any
abnormalities during the flight. The damage was confined to the separated fore
flap and its associated components. There was no injury to any of the occupant
on board the aircraft. There was no fire.

3
1.2 Injuries to Persons

INJURIES CREW PASSENGERS OTHERS

FATAL Nil Nil Nil

SERIOUS Nil Nil Nil

MINOR/NONE 02 Nil

1.3 Damage to the aircraft

The left wing inboard trailing edge fore-flap detached from its mounting. The fore
flap fell on the runway and was broken into three pieces.

4
Following main damages were observed on the aircraft structure.

5
Damage 1 Damage 1A Bull Nose of about 24 Inches from inboard edge was
found missing.

Damage Inboard Mid Flap to foreflap Cut out was found Ripped
1B Off.

6
Damage 2 Dents Measuring 4” X 1.5”X 3/32” and 18” X 1” X 3/64”
1C were found on the upper surface of the mid flap.

Damage Crease along the AL Skin 9” X 0.5” X 3/32” with skin

1D puncture at outboard side and Honeycomb Visible.

7
Damage 2 Damage Puncture to Bull Nose Upper Surface with Area 20” and
2A depth 1” Honeycomb Visible.

Damage Puncture to skin to Honeycomb L X B = 4”X 3”

2B

8
 Damage Linkage Cut out Bottom Angle Bracket deformed and
2C detached.

Damage 3 Linkage (Mid Flap Track) sheared off (Missing) with Damage to
attachment Point. Also skin missing (L X B =19”X5”).

9
Damage 4 No. 4 Flap Track Inboard Fore Flap Carriage Assembly Broken.

Damage 5 No. 3 Flap Track Inboard Fore Flap Carriage Assembly Intact With
Broken Linkage Eye End Attached.

10
Damage 6 LH Inboard Aileron Inboard Attachment Frame rubber seal partially
missing with few scratches on Flap Stowage Bracket Track.

Damage 7 Detent roller of #4 sequence carriage was found broken and detached
from the carriage.

11
1.4 Other Damage

Nil

1.5 Personnel Information

1.5.1 Pilot-in-Command (Pilot Flying)

AGE 43 Years
License ATPL (Hong Kong – CAD)
Date of License Issue 12/11/2005
Category Aeroplane
Class Multi Engine, Land
Endorsements as PIC B747-400
Date of Joining Company 12/09/2005
Instrument Rating 04/01/2015
Date of Med. Exam 23/09/2014
Date of Route Check 16/05/2015
Date of Last Proficiency Check 04/01/2015
Total flying experience 9772:24 hours
Total Experience on type 4635:30 hours
Total Experience as PIC on type 2212:12 hours
Last flown on type 23/07/2015
Total flying experience during last 01 Year 491:27 hours
Total flying experience during last 180 days 223:53 hours
Total flying experience during last 90 days 137:48 hours
Total flying experience during last 30 days 25:30 hours
Total flying experience during last 07 Days 15:44 hours
Total flying experience during last 24 Hours Nil

12
1.5.2 Co-Pilot (Pilot Monitoring)
AGE 45 Years
License ATPL (Hong Kong - CAD)
Date of License Issue 28/10/2004
Category Aeroplane
Class Multi Engine, Land
Endorsements as PIC B747-400
Date of Joining Company 23/08/2004
Date of Endorsement as PIC on type 10/09/2009
Instrument Rating 23/05/2015
Date of last Medical Exam 11/05/2015
Date of Route Check 11/12/2014
Date of Last Proficiency Check 23/05/2015
Total flying experience 9216:25 hours
Total Experience on type 2990:00 hours
Total Experience as PIC 2980:00 hours
Last flown on type 26/07/2015
Total flying experience during last 01 Year 594:59 hours
Total flying experience during last 180 days 281:17 hours
Total flying experience during last 90 days 143.44 hours
Total flying experience during last 30 days 46.59 hours
Total flying experience during last 07 Days 17: 40 hours
Total flying experience during last 24 Hours Nil

13
1.6 Aircraft Information
1.6.1 Aircraft Description
Boeing B747-400 is a subsonic, medium-range, civil transport aircraft. The aircraft
is designed for operation with two pilots. The aircraft is certified in Transport
(Cargo) category, for day and night operation under VFR & IFR. The maximum
take-off weight is 394625 Kgs. The Maximum Landing weight is 302092 Kgs.

Three View Diagram of Boeing B747-400

14
1.6.2 Trailing Edge Flap System - Description and Operation
Two triple-slotted trailing edge (TE) flaps on each wing provide additional lift during
take-off, approach & landing and a decreased stalling speed for take-off & landing.
As the trailing edge flaps are progressively extended, wing geometry is changed
by first extending the chord and then increasing camber. Wing area and camber
are further increased by a total number of 28 leading edge (LE) flaps, which
operate in conjunction with the trailing edge flaps.

 The inboard and outboard trailing edge (TE) flaps are positioned by
independent drive systems. In normal operation, the TE flaps are hydraulically
powered. As a backup to hydraulically powered operation, the flaps may be
positioned by electric motors.
 The flaps are normally controlled from a flap control lever on the pilots' control
stand. The lever is linked to a triple Rotary Variable Differential Transformer
(RVDT) assembly. Each RVDT converts flap lever position to an electrical
signal which is sent to the flap control units in the main electrical equipment
centre. The flap control units monitor flap lever position and other airplane
systems to command the flap actuator to change flap position.
 The flap actuator in the left body gear wheel well moves the input cranks to the
inboard and outboard flap power packages when commanded by the flap
control units. The input cranks position a control valve in each power package
to port hydraulic fluid to the hydraulic motors. Each hydraulic motor is joined to
a reduction gearbox which drives a torque tube extending into each wing. Angle
gearboxes are installed along the torque tubes to permit change of direction.
The torque tubes connect to two transmissions at each flap. The transmissions
position the mid flap of each three-part TE flap set through ball screw drives.
Fore flaps and aft flaps are positioned as the mid flap is moved.
 An electric motor in each power package drives the TE flaps as an alternate to
hydraulically powered operation. If flaps fail to move under hydraulic power, the
flap control units automatically activate the alternate electric motors to position

15
 the flaps. The motors can also be controlled independently of the flap control
units with switches on the pilots centre instrument panel.
 RVDT flap position transmitters are installed in 7 places throughout the TE flap
drive mechanisms. An RVDT transmitter is installed in each power package and
in the outboard transmission of each flap. The flap actuator has an integral
RVDT transmitter. Each RVDT transmitter is wired to all 3 flap control units,
which process the position signal for use in flap control, position indication, and
asymmetry and failure detection.
Each flap assembly is a triple-slotted flap which consists of a fore flap, mid flap,
and aft flap. The three flap segments are mechanically separated to form three
slots as the flaps are extended. Each mid flap is attached to and is supported by
two flap carriages which travel on the flap tracks. The mid flap is attached to two
ball screw and ball nut assemblies which are each driven by a transmission to
extend or retract the flap.

Fore flaps
The fore flaps consist of front and rear spars connected by skin panels, a curved
nose skin section, and a trailing edge. The fore flaps are supported by a track
which extends into the mid flap where it contacts rollers. The position of the fore
flap is established by sequencing carriages attached to this surface. The fore flap

16
extends with the mid flap until the sequencing carriages contact detents in the flap
tracks. At this point, the fore flaps and mid flaps separate and the fore flaps do not
extend further aft but are rotated relative to the mid flap by cam action of the
sequence carriages against the flap carriages.

Mid flaps
The mid flaps consist of three spars and honeycomb skin panels. The mid flaps
are connected directly to flap carriages which ride on the flap tracks. The mid flaps
are also connected to the flap transmission ball screw. Additional rollers on the
ends of the mid flap contact tracks on wing structure to provide deflection control.

Aft flaps
The aft flaps are constructed in the same manner as the fore flaps. The aft flaps
are supported by trunnion-mounted tubes which are connected through fittings to
the mid flap rear spar.

Flap Carriage
Two flap carriages support each trailing edge flap. The aft end of the flap carriages
extends into the nose of the mid flap. The flap carriage is positioned in the mid flap
17
by two steel bearings. The aft bearing is adjustable to control the flap trailing edge
vertical position and is not rigid, which allows the carriage to move relative to the
mid flap during flap operation. The carriage is retained by thrust collars, washers,
and nuts. As the flaps are driven by the transmissions, the flap carriages travel
along the flap tracks on roller bearings holding the flaps in the desired position.

Flap Sequence Carriage

Two sequence carriages are attached to each fore flap. The sequence carriages
are constructed of aluminium and steel forgings. The sequence carriages travel on
roller bearings on the upper flange of the flap tracks. As the flaps extend, the
sequence carriages are held in position by detent in the flap carriages and travel
with them. At approximately 5 degrees of flap extension, the sequence carriages
contact stops on the flap tracks. The stops prevent further aft travel of the fore flap
causing the fore flap and mid flap to separate. The angle of the fore flap is
controlled by the fore flap tracks as they extend into and retract out of the mid flap
assembly.

Flap Tracks and Fairings

 Each flap is mounted to two flap tracks. The flap tracks are curved, forged steel
beams which attach to the lower surface of the wing. A flap transmission is
18
 mounted on each flap track. The flap tracks and transmissions are housed in
aerodynamic fairings.
 Each fairing consists of two parts. The forward section is rigidly attached to the
wing. The aft section rotates about a hinge support on the flap track. The
fairings are constructed of aluminium frames covered with epoxy reinforced
fiberglass honeycomb. The fairings are actuated by a fairing drive mechanism
linkage and control rod. As the flaps move, the drive mechanism pivots about
the end of the flap track and positions the fairing in the proper relationship with
the flap. Access panels are provided on the fairing to facilitate system
adjustment.

Operation
Functional Description - High Lift System
 The high lift system is normally driven by hydraulic power for the TE flaps and
pneumatic power for the LE flaps. Hydraulic system 1 provides power for the
inboard TE flaps, and hydraulic system 4 provides power for the outboard TE
flaps.
 The flaps are controlled in 4 groups: TE inboard, TE outboard, LE group A (the 8
inboard LE flaps on each wing), and LE group B (the 6 outboard LE flaps on
each wing). Each group can be independently driven by electric motors if the
group fails to move under hydraulic or pneumatic power.
 Each flap group can operate independently in the primary hydraulic/pneumatic
mode, or the primary electric mode, or together in the alternate electric mode. In
either of the primary operating modes, flap movement is controlled by the Flap
Control Unit (FCU) based on the position of the flap control lever. In alternate
electric mode, flap movement is controlled from the alternate flaps control
switches.

19
 Trailing Edge Flap System

When the flaps are extended, they moves aft away from the wing and then down.
The flap segments remains together until about 5° of extension (Flap 5), when the
fore flap segment stops moving aft but rotates, and the main flap (mid flap) begins
to separate from the fore flap. The fore flap rotation is controlled from Flap 5 to
Flap 30 by the fore flap (mid flap) tracks. Just past Flap 20, as the main flap
continues to extend, the aft flap began to separate from the mid flap until Flap 30
20
 when the flaps are fully extended. The reverse occurs during retraction, where the
mid flap picks up the fore flap and pushes it to its retracted position tucked
beneath the aft section of the wing. In its retracted position the fore flap is
sheltered from the normal airflow by the wing. The aircraft manufacturer only
classified the mid flap as the primary structure.

1.6.3 General information

a) Aircraft Model : B747-467F
b) Aircraft SL. No. : 30804
c) Year of Manufacturer : 2000
d) Owner & operator : Cathay Pacific Airways Limited
e) C of R : 486, Hong Kong CAD
f) C of A : 343-14, Hong Kong CAD
g) C of A Validity : 01st Sep 2014 to 11 Sep 2015
h) ARC issued on : 22nd Aug 2014 (Certificate of Maintenance Review)
i) ARC valid up to : 11th Sep 2015
j) Aeromobile License No & Validity: 30804 (Approval of Aircraft Radio Installation)
k) Engine Type : RB211-524GT
l) Aircraft Empty Weight : 160206 Kgs / 353194 lbs
m) Maximum Take-off weight : 394625 Kgs / 870000 lbs
n) Date of Aircraft weighment : 22 Aug 2014
o) Total aircraft (Airframe) Hours : 66584:26
p) Last Major Inspection C/o on aircraft : C check in XMN (Xiamen Gaoqi
International Airport), China on 26 Aug 2014 at 63974:17 FH
q) Last Inspection carried out on aircraft with Date, engine & airframe hours: Daily
Check in HKG (Hong Kong) on 27 Jul 2015 at 66578:56 FH

The subject Boeing 747-400 aircraft (MSN 30804) was manufactured in year 2000.
The aircraft was registered with Hong Kong Civil Aviation Department (HK CAD)
under the ownership of M/s Cathay Pacific Airways Limited. The aircraft is
registered under the Certificate of registration No. 486.

21
The Certificate of Airworthiness Number 343-14, under "Transport category
(Cargo)" subdivision Passenger / Mail / Goods was issued by HK - CAD (Hong
Kong Civil Aviation Department) on 01st September 2014. At the time of incident
the Certificate of Airworthiness was current and was valid up to 11th September
2015. After C of A, the aircraft flew 2565:38 hrs before the incident flight. The
Certificate of Maintenance Review was issued on 22nd August 2014 and was valid
upto 11th September 2015.
The aircraft and its Engines are being maintained as per the maintenance program
consisting of calendar period/ flying Hours or Cycles based maintenance as per
maintenance program approved by HK CAD. The scrutiny of the Airframe Log
book revealed that as on date of incident i.e. 27.07.2015, the aircraft had
completed 66584:26 Hrs and 11942 landings since new.
The aircraft was having Aeromobile License No. 30804 and was valid at the time
of incident.
Last major inspection ‘C’ check Inspection schedule was carried out at 63974:17
Hrs on 26th August 2014 at XMN. During the ‘C’ check, it is required to carry out
the inspection of the aircraft structural components including the condition of the
trailing edge flap assembly. The same was carried out and no discrepancy was
reported on the trailing edge flap assembly.
As per store records, last component replaced on the aircraft was No. 8 Main
wheel assembly which was replaced on 26th July 2015.
The aircraft is powered by four RB211-524GT high bypass turbofan engines
manufactured by Rolls - Royce. The details of the Engines are given below:
Engine # 1 Engine # 2 Engine # 3 Engine # 4
Engine Model RB211-524GT RB211-524GT RB211-524GT RB211-524GT
Serial Number 13201 13085 13358 13303

TSN 99411:07 99606:41 75601:11 71260:21

(Hrs)
CSN 16310 16598 11740 10473

22
 The aircraft was last weighed on 22nd August 2014 at XMN and the weight
schedule was prepared and duly approved in accordance with M/s Cathay Pacific
Airways (CPA) procedures approved by the HK CAD. As per the approved
weight schedule the empty weight of the aircraft is 160206 Kgs. Maximum
Usable fuel Quantity is 174093 Kgs. Maximum payload with full fuel tanks is
67456 Kgs. Empty weight CG is 1359.593 inches aft of datum. The next weighing
was due on 21st August 2019.

1.6.4 Airworthiness Directive, Service Bulletins & Its Compliance

An Airworthiness Directive (AD) is a directive issued when the Airworthiness

Authority relevant to the State of the Type Certificate (TC) Holder {in the present
case it is Federal Aviation Administration (FAA)} or State of Aircraft Registration
realizes that an unsafe condition exists in a product (aircraft engine, airframe,
appliance or propeller). They notify aircraft operators and owners of potentially
unsafe conditions that need special inspections, alterations, or repairs.

A Service Bulletin (SB) is a notice to aircraft operators from a manufacturer

informing them of a product improvement. An alert service bulletin is issued when
an unsafe condition shows up that the manufacturer believes to be a safety
related as opposed to a mere improvement of a product. Service bulletins often
result to issuance of Airworthiness Directives by the FAA. An Airworthiness
Directive references the alert service bulletin as a way of complying with the AD.

There are distinct levels of seriousness to a service bulletin, and accordingly

manufacturers have started to categorize them as optional, recommended, alert,
mandatory, informational, etc. It was left to the manufacturers to classify a
service bulletin as they considered best for there was no standard for the
terminology. Differentiation between non-mandatory service bulletins is done
and decided only by the FAA.

Although a service bulletin may be categorized as mandatory by the

manufacturer, however its compliance is not necessarily required to be so as per

23
 the FAR’s (Federal Aviation Regulations) or by regulations of concerned state
authorities unless the service bulletin includes or is accompanied by an
airworthiness directive. As opposed to service bulletins, airworthiness directives
affect the safety conditions of a flight. It’s for this reason its compliance becomes
mandatory.

So, just because the FAA doesn’t necessarily mandate the compliance of Service
Bulletins, doesn’t imply that an aircraft owner/operator can overlook service
bulletins. The inaction/non-compliance may lead to serious safety issue which
consequently may result in any occurrence of serious nature at some time in the
future. Therefore, it is always safe to comply with the service bulletin specially
those which require only performing more detailed inspection and does not
require replacement of any component which may translate into higher cost to
the aircraft owner/operator. It is therefore very important to realise that
manufacturers issue service bulletins because they believe that its compliance
will make their products safer.

1.6.5 Service Bulletin 747-27-2366

In order to ensure continued reliable operation of the inboard and outboard
trailing edge fore flap system, the aircraft manufacturer had issued Service
Bulletin (SB) 747-27-2366 which was initially issued on 22nd December 1998 and
was later revised as revision 1 on 13th December 2001. As there was numerous
reports of damage to the fore flap and associated components due to skewed
operation of the fore flap assembly in flight which in most of the cases, has
resulted in fore flap separation it was considered as the ‘known mode of failure’.
Based on this, the manufacturer had further revised the SB 747-27-2366 as
revision 2 which was issued on 3rd August 2011.

The service bulletin presents a compilation of the recommended service bulletins

and routine system maintenance tasks that when accomplished, will allow
maximum inboard and outboard trailing edge fore flap system reliability. The
inspection will prevent fore flap malfunction and abnormal loading that can
24
 develop from wear and the accumulation of debris resulting in seized and broken
rollers. If this service bulletin is not performed, debris from seized or broken fore
flap rollers could result in the fracture of the fore flap attachment fittings and
subsequent loss of the fore flap.
As per the SB the manufacturer has recommended inspection intervals as below:

Work Package # Interval Time

1 06 Months
2 18 months
3 08 years

The operator did not comply with the service bulletin as it was not mandated by
FAA and nor by HK-CAD. However, after the incident, as per aircraft
manufacturer’s advice, CPA Engineering had taken steps to incorporate
repetitive inspection and lubrication to trailing edge flap system in accordance
with Boeing SB 747-27-2366 Revision 2 work packages.

To enhance the maintenance of TE fore flap system so that to increase its

durability, the manufacturer has issued Revision 3 to SB 747-27-2366 on 22nd
March 2016. This Revision 3 of SB requires detailed inspections and lubrication
of TE flap system and its associated components as per the intervals mentioned
above.

1.7 Meteorological Information

At the time of incident at IGI Airport, Delhi, following meteorological conditions

existed.
Time Winds Visibility Clouds Temp Dew Point QNH
(UTC) (o/Kts) (meters) (°C) (oC) (hPa)
1200 120/10 4000 SCT 350 m 33 24 1000
1300 110/07 3500 SCT 350 m 30 26 1000
1330 130/05 3500 SCT 350 m 30 26 1000

25
1.8 Aids to Navigation

The IGI Airport, New Delhi has 03 runways and are equipped with NDB, DVOR,
ILS CAT-I, CAT-II, CAT-IIIA, CAT-IIIB, ASMGCS, SMR.

1.9 Communications

There was always two ways communication between the ATC and the aircraft. At
the time of incident, the aircraft was under control of Delhi ATC.

1.10 Aerodrome Information

The aircraft landed on runway 10 of IGI Airport, New Delhi. The details of the IGI
airport New Delhi are as follows:

Co-ordinates

ARP : N 28° 34' 07"

E 077° 06' 44"
Elevation : 778 Feet.
Runway Orientation and Dimension

Orientation - 10/28 Dimension 3810 x 45 Meters

11/29 Dimension 4430 x 60 Meters
09/27 Dimension 2813 x 45 Meters
Approach and Runway Lighting

RWY. APCH LGT THR LGT PAPI Rwy Centre RWY edge
Line LGT LGT

09 SALS Yes Yes Yes Yes

27 CAT-I Yes Yes Yes Yes

10 CAT-I Yes Yes Yes Yes

28 CAT IIIB Yes Yes Yes Yes

11 CAT IIIB Yes Yes Yes Yes

29 CAT IIIB Yes Yes Yes Yes

26
 ATS Airspace:

a. Designation Delhi CTR. 30 NM centred at DPN VOR

b. Vertical Limits SFC to FL50
c. Airspace Classification D
d. Transition Altitude 4000 FT MSL
Fire Fighting Services: CAT – 10

Met Services

Met Office Hour of service is 24 Hrs. TAF, Trend Forecast and Briefing is
available.

Navigation and Landing Aids

NDB, DVOR, ILS CAT-I, CAT-II, CAT-IIIA, CAT-IIIB, ASMGCS, SMR

ATS Communication Facilities

Delhi Radar 119.3/127.9 MHZ

Delhi Flow Control 119.5 MHZ
Delhi Approach 119.3/127.9 MHZ
Delhi Approach/Radar 124.2/124.25/124.6/125.675/125.85 MHZ
Delhi Tower 118.1/118.25/118.75/118.825 MHZ
DATIS 126.4 MHZ
Delhi Ground 121.625/121.75/121.9 MHZ

1.11 Flight Recorders

Both Solid State Cockpit Voice Recorder (SSCVR) and Solid State Flight Data
Recorder (SSFDR) were downloaded and readout carried out.

The CVR circuit breaker was not pulled immediately after the incident as the CPA
Engineering Organisation Maintenance Practices (EOMP) does not require the
CVR circuit breaker to be pulled unless an accident is declared. The CVR
records, whenever it is powered from the electrical essential bus. The CVR

27
 playback revealed that it had only captured the Delhi Ground controller’s
communications while some maintenance work was carried out in the aircraft
post incident.

The DFDR was removed from the aircraft and the data was retrieved. Relevant
data was analysed and there were no abnormalities observed. There was no
warning in the cockpit and the landing was normal. The slats and flaps extended
and retracted normally.

1.12 Wreckage and Impact Information

During landing at Delhi the left inboard trailing edge fore flap separated from the
aircraft. The separated fore flap was later recovered from the runway by DIAL
personnel after getting information from ATC about the same. In addition
sweeping of runway and taxiway was carried out in order to confirm no other
parts were separated from the aircraft. On visual examination of the separated
fore flap and the aircraft following observations were made:

 The fore flap was broken into three span wise pieces after impacting with the
runway.
 Mid flap track & fore flap track (Mid flap track linkage with fore flap)
 The outboard mid flap track (which supports the fore flap and extends into the
mid flap) was found attached to the fore flap track (which is attached to lower
surface of fore flap). The outboard mid flap track was found broken at the aft
end (point of attachment with mid flap) which resulted into its separation from
the mid flap. Only a piece of fractured end segment of the mid flap track was
recovered from inside mid flap. The mid flap cut out (outboard) at leading edge
for mid flap – fore flap track was found ruptured and part of upper skin missing.

28
 The centre mid flap track was found attached with the mid flap, however was
found slightly bent due to overload. The fore flap track was broken from its aft
end (point of attachment with mid flap track). The broken end segment of fore
flap track was found attached to the mid flap track along with bolt and nut. The
mid flap cut out lower skin was found ruptured.

29
 The inboard mid flap track was also found attached with the mid flap and like
centre fore flap track, the inboard fore flap track was found broken from aft end.
The broken end segment of fore flap track was found attached to the mid flap
track along with bolt and nut. Bull Nose of about 24 Inches from inboard edge
was found missing and Inboard Mid Flap Cut out skin was partially ripped off.

30
 Fore flap sequence carriage and fore flap inner attachment link
 The # 3 (outboard) sequence carriage assembly was found intact on flap track.
The fore flap attachment link (with carriage) was found broken from attachment
eye end. The broken end segment of fore flap attachment link was missing.
However the self-aligning mono-ball bearing of link was found attached to the
sequence carriage.

 The # 4 (inboard) sequence carriage was found intact on flap track. However the
carriage linkage (with fore flap attachment link) was found broken and separated
from the carriage. The broken segment was found attached with fore flap link
along with attachment bolt & mono ball bearing. The detent roller was found
broken and separated from carriage. The carriage slide on the flap track without
roller as evident from the friction marks observed on the upper flange of flap
track. The detent roller was recovered from the inner flap track fairing.

31
 Scratches were observed on the Flap Stowage Bracket Track probably due to
separation of outboard mid flap track from mid flap causing the fore flap to come
in contact with adjacent surface.

 The fore flap separation caused damage to mid flap skin and honeycomb.

32
  There was no damage observed on the other parts of aircraft structure due to
separation of fore flap.

1.13 Medical and Pathological Information

Crew had undergone Pre-flight Medical i.e. Breath Analyser Test on the day
before the first flight of the day at Hong Kong and were found not under the
influence of alcohol.

1.14 Fire

There was no fire.

1.15 Survival Aspects

The incident was survivable.

1.16 Tests and Research:

After the incident some of the damaged aircraft parts were recovered from the
aircraft and out of these, some items were later released to Cathay Pacific
Airways (CPA), Hong Kong for further transportation to NTSB, USA for detailed
examination in order to find out the cause of the failure. During transit of the
shipment in Hong Kong, three of the four items that were to be sent onward for
examination by the NTSB, USA were lost.

CPA Engineering and HAECO (CPA’s MRO in Hong Kong) investigated the
circumstances that lead to the loss of the items. It was found that during handling
of the shipment in HAECO, three of the four items were mistakenly identified as
‘scrap’ and disposed of. The missing items were considered lost after all
reasonable efforts to recover them were exhausted. The remaining 01 item i.e.
the LH wing mid flap track (outboard position) was further sent to NTSB, USA for
detailed examination.

Observations made during the examination of LH wing mid flap track are as
follows:

33
The lower flange at the aft end of the track was fractured, optical examination of
the fracture faces found markings and adjacent deformation patterns indicating a
bending overstress separation. The bending direction was as if the aft end of the
track bent upward. No Indications of pre-existing cracking or corrosion were
noted on the fracture or other locations on the track. The lower running surface of
the track near the fracture had a local deformation on the outboard side. The
overall track also had a slight longitudinal twist and a slight sideways bend.

The lower flange at the aft end of the track was fractured

Close view of the fractured end

34
1.17 Organizational and Management Information

The operator has been issued with an Air Operator’s Certificate by Hong Kong –
Civil Aviation Department and was valid on the date of incident. The aircraft
maintenance is carried out by HAECO (Hong Kong Aircraft Engineering Co. Ltd.)
which is the operator’s MRO situated in Hong Kong.

Cathay Pacific Airways is a scheduled operator which has its main base at Hong
Kong, China. The Cathay Pacific Group operates more than 150 aircraft to some
130 destinations across the globe. The Cathay Pacific has fleet of approximately
146 wide-body aircraft. The fleet combines of 777-300ER, Airbus 350 – 900 with
Boeing 747-400 "Extended Range Freighters" and New-Generation Boeing 747-
8F.

1.18 Additional information:

1.18.1 Occurrences of trailing edge fore flap failure worldwide

As this was not the first instance of trailing edge fore flap failure during flight, the
committee decided to study and analyse similar events of fore flap separation
during flight that occurred worldwide on Boeing 747-400 aircraft of different
operators. The purpose of the study was to observe the mode of failures of these
events and to analyse the same with the subject event so that some possible
scenarios can be derived in the absence of conclusive evidences.

Some of the occurrences referred are as follows:

 On 7th June 1997 a Boeing 747-400 aircraft was on approach to land, when a
portion of inboard trailing edge fore flap separated from the aircraft. As in the
present case the aircraft landed without getting any warning/signal in the
cockpit. But during the post landing inspection it was observed that 60% of the
fore flap was missing.
During the investigation it was found that the incident occurred due to failure of
inboard fore flap link (attachment with sequence carriage).

35
 On 30th August 2002 a Boeing 747-400 aircraft took-off from runway and
during a left turn shortly after departure, with the flaps still extended to the
take-off setting, about 70% of the right inboard trailing edge fore flap separated
from the aircraft. The pilots did not receive any cockpit indications and only felt
some slight bumps, which they thought to be some turbulence. The flight crew
were unaware of the separation until the landing approach after about 12
hours of flight. The crew took appropriate actions and the aircraft landed
safely.

During the investigation it was found that the flap separated due to failure of
inboard fore flap inner attachment link. The link failed due to a pre-existing
stress corrosion crack that had grown to a critical size. Post this incident and in
view of the similar incidents in near past the aircraft manufacturer made a
design change to overcome the limitations of the fore flap attachment links.

 On 19th May 2013 a Boeing 747-400 aircraft a cargo flight during approach to
runway just after pilot selected flaps 30, experienced a partial separation of
the right inboard fore flap. The flight crew performed a go around and landed
safely. The pieces of the fore flap were later recovered from buildings and the
ground in the area below the approach path.

During the investigation it was found that the fore flap separated due to fatigue
and bearing anomalies on the sequence carriages.

Apart from the above events few other instances of fore flap separation were also
considered. In all the above events the fore flap was separated from the aircraft
during flight (landing or take-off) when the flaps were extended to its optimum.
The primary cause of separation of fore flap for most of the cases was observed
to be the failure of one of the fore flap inner attachment link (with sequence
carriage) or anomalies in the sequence carriage(s) and its associated
components. On observing the repetitive nature of fore flap inner attachment link
failure, the manufacturer in 2003, altered the design of the fore flap attachment

36
 fittings to prevent such failures. Also, in all the above cases including the present
case the separation of fore flap did not compromise with the safety of the aircraft.

1.19 Useful or Effective Investigation Techniques: Nil

2. ANALYSIS:

2.1 Serviceability of the aircraft

2.1.1 The aircraft was manufactured in the year 2000. The certificate of registry and
certificate of airworthiness were valid on the day of incident. The Certificate of
maintenance review was valid upto 11th September 2015. The aircraft had flown
66584:26 Hrs/ 11942 landings since new and 2565:38 hrs after issue of last C of
A, before the incident flight.

The aircraft and its Engines were maintained as per the maintenance program
consisting of calendar period/ flying Hours or Cycles based maintenance as per
maintenance program approved by HK CAD. The scrutiny of the Airframe Log
book revealed that as on date of incident i.e. 27.07.2015, the aircraft had
completed 66584:26 Hrs and 11942 landings since new.

Last major inspection ‘C’ check Inspection schedule was carried out at 63974:17
Hrs on 26th August 2014 at XMN (Xiamen Gaoqi International Airport), China.
During the ‘C’ check, inspection of the condition of the trailing edge flap assembly
was carried out and no discrepancy was reported on the same.

The scrutiny of the records revealed that there was no defect reported on the
flaps/flap mechanisms and its associated components before the incident.

2.1.2 In order to ensure continued reliable operation of the inboard and outboard
trailing edge fore flap system of B747 aircraft, the manufacturer had issued
Service Bulletin (SB) 747-27-2366 Revision 2 considering the ‘known mode of
failure’ which was based on the numerous reports of failure of fore flap and its

37
 associated components. The service bulletin calls for detailed inspections &
lubrication of inboard & outboard TE fore flap system for atleast every 06 months.
The incorporation of SB, which is a good maintenance practice, will allow
maximum reliability & safety which subsequently could have prevented fore flap
malfunction. The operator did not comply with the service bulletin as it was not
mandated by FAA and nor by HK-CAD. The Non-compliance of this SB may
have resulted in malfunction of trailing edge fore flap system which subsequently
led to the incident.

2.2 Weather

At the time of incident, the visibility was 3500 meters with winds 110o/07 Kts,
temperature 30o C, Dew point 26o, QNH 1000 and clouds SCT 350 m.

In view of the above the weather at the time of incident was fine and is not a
contributory factor to the incident.

2.3 Pilot Factor

Both the cockpit crew were qualified to operate the subject flight. The PIC and
the co-pilot both were holding a valid ATPL license and were qualified on type.
Both the crew were current in all the trainings and ratings as per the
requirements. The PIC had total flying experience of more than 9,500 hours with
approximately 4600 hours on type and about 2200 hours as PIC on type. The co-
pilot had total flying experience of about 9216 hours and approximately 3000
hours on type.

The aircraft was cleared for landing at Delhi. The crew then correctly configured
the aircraft for landing and the flaps were selected to Flaps 30 (fully extended).
There was no signal/indication in the cockpit and the crew did not experience any
control abnormalities, during landing. Hence, the flight crew were not aware that
the fore flap had separated from the aircraft during landing and carried out taxi &
subsequent operations normally. When the aircraft was taxing in, the ground

38
 controller contacted them and informed that a part had separated from the
aircraft during the landing. After parking the aircraft on bay, the flight crew
instructed the Delhi ground engineer to perform a walk around inspection but this
initially revealed no missing parts. The flight crew then fully extended the wing
flaps, after which the engineer reported that the left wing inboard trailing edge
fore-flap was missing. They then informed the ATC about the same.

2.4 Circumstances leading to the incident:

The aircraft took off from Hong Kong at 1240 UTC and during take-off there was
no abnormality observed by the pilot. After about 06 hours of uneventful flight,
the aircraft approached Delhi. The aircraft was cleared for landing and
accordingly it was configured for landing with flaps fully extended i.e. flaps 30.
During landing the left inboard trailing edge fore flap separated from the aircraft
and fell on runway.

After the incident some of the damaged aircraft parts were recovered from the
aircraft for detailed examination in order to find out the cause of the failure.
During transit of the shipment in Hong Kong, three of the four items that were to
be sent onward for examination by the NTSB, USA were lost. Only the outboard
mid-flap track was available for examination by the NTSB, USA. Hence the exact
cause of the failure could not be determined.
In view of the above the committee analysed the available evidences, the
damage pattern and also studied & analysed the similar events of fore flap
separation during flight that occurred on Boeing B747 aircraft (different
operators) worldwide. Based on the same the committee deliberated on the
possible circumstances which could have led to the failure of the fore flap and the
incident.

As discussed earlier the trailing edge fore flap is mainly supported by three mid
flap tracks which extends into the mid flap. One end of the mid flap track is
attached to a linkage whose one end is attached to lower surface of fore flap.
The fore flap is also attached to two sequence carriages with the help of an inner

39
link. Therefore, the fore flap has total of five attachment links with the airframe
and as the entire fore flap had separated from the aircraft, depicts that all the five
attachment links failed during the flight, though primarily one (or two) of them
would have failed causing others to fail consequently. Hence possibility of failure
of each link and its associated parts was considered and is discussed below:

Mid flap Track & Fore flap links

There are three mid flap tracks that supports the fore flap through a link which is
attached to lower surface of fore flap. Two of the three mid flap tracks (inboard
and centre) were found attached to the mid flap. However, their respective
attachment fore flap links were found fractured from the aft end i.e. near the
attachment end with mid flap track and were separated along with the fore flap.
On analysing (visually) the aft damaged segment of these links which was found
attached with mid flap track along with bolt & nut, the damages were observed to
be fresh in nature, depicting that the damages may have been consequential.
Also being designed strong to withstand air loads, the probability of these links to
fail primarily is improbable.
The third mid flap track i.e. the outboard one was fractured from the aft end and
was separated from the mid flap along with the fore flap. The track was found
attached with the fore flap. The track was examined in detail by NTSB, USA and
optical examination of the fractured faces was carried out. The markings and
adjacent deformation patterns on the fractured faces indicated that it separated
due to bending overstress. The bending direction was as if the aft end of the
track bent upward. There was no indication of pre-existing cracking or corrosion
on the fractured face or other locations on the track. The track also had a slight
longitudinal twist and a slight sideways bent. This depicts that after the flaps were
extended fully during landing, all the other adjacent fore flap support link(s) may
have failed before the outboard mid flap track. Hence, all the air loads on the fore
flap was mainly supported by the outboard mid flap track which eventually got
fractured due to bending overstress. In addition to the above, the damages to the
cut out (outboard) at leading edge of mid flap (for mid flap track) which was found
ruptured along with part of upper skin missing and the scratch marks observed
40
on the flap stowage bracket track & its adjacent surface also indicates that the
fore flap was floating in the air mainly with the support of outboard mid flap track
after the other attachment link(s) failed. In view of the above it may be concluded
that fracture of outboard mid flap track was not the primary failure for the fore flap
separation.

Fore flap inner link

As discussed earlier the fore flap is attached to sequence carriage with the help
of fore flap inner link. This inner link is considered as the weakest link and has
the highest probability of failure among all the fore flap links. The same was also
observed during the study of similar events of fore flap separation which occurred
on B747 aircraft worldwide. In most of the events the primary cause of the event
was the failure of one of the fore flap inner link which resulted in separation of the
fore flap from the aircraft during flight (landing & take-off). In the present case
also the outboard fore flap inner link (attached to outboard sequence carriage)
was found fractured and got separated from the carriage attachment. This
fractured inner link may have led to failure of other links one after another under
severe air loads when the flaps were extended fully for landing, thereby causing
the fore flap to separate from the aircraft. Hence it is highly probable that the
failure of outboard fore flap inner link may be the primary failure.

Fracture of a fore flap attachment link would not necessarily result in immediate
partial or complete loss of the fore flap. Because of the design, it is possible for
the fore flap to remain functional for an indeterminate period with a fractured link.

The other fore flap inner link i.e. the inboard one was found intact and attached
with the fore flap along with the bolt & nuts.

The Inboard Sequence Carriage & Detent roller

The inboard sequence carriage was found intact with the flap track. However
while inspecting the carriage it was found that the attachment lug (attachment
with fore flap inner link) was fractured and the fractured segment of the lug was
41
found attached with the fore flap inner link along with bolt, nut, washers and
bushings. The detent roller of the carriage was also found sheared and
separated from the carriage assembly. Friction marks were observed on the flap
track which indicates that when the flaps were extended the sequence carriage
moved on the flap track for some distance after the detent roller was separated.
This reveals that there may be some anomalies in the inboard sequence carriage
assembly thereby resulting in inboard sequence carriage getting out of phase
with the other sequence carriage. This may have led to fracture of carriage
attachment lug (attachment with fore flap inner link) or the outboard fore flap
inner link and subsequently led to failure of other links one after another under
severe air loads when the flaps were extended fully for landing. Hence anomalies
in sequence carriages may be the primary reason for failure/fracture of carriage
attachment lug and fore flap inner attachment link.

SB 747-272366
The above failures discussed may be consequential as Boeing SB 747-272366
Revision 2 calls for detailed inspection and lubrication of fore flap and associated
components. The SB was not complied by the operator as it was not mandated
by FAA and nor by the HK-CAD which may have led to skewed operation of fore
flap assembly. The skewed operation of the fore flap assembly in flight can be
caused by worn or broken centre toggle rollers or by binding of the fore flap track
rollers in the mid flap. This lead to accumulation of debris from seized or broken
fore flap rollers. This debris could result in the fracture of the fore flap attachment
fittings (as discussed above) and subsequent separation of the fore flap.

In view of the above the committee has concluded that if the SB had been
complied, the failure of any of the trailing edge fore flap components could have
been timely traced and the occurrence could have been avoided.

42
3. CONCLUSIONS:

3.1 Findings:

1) The certificate of Airworthiness, Certificate of Registration, and CRS of the

aircraft was valid on the date of incident.
2) The aircraft was certified and maintained in accordance with prescribed
procedures.
3) The CG of the aircraft was within the prescribed limits. There was no snag
reported on the aircraft prior to the incident flight.
4) Last major inspection ‘C’ check Inspection schedule on the aircraft was carried
out at 63974:17 Hrs on 26th August 2014 at XMN. During the ‘C’ check no
discrepancy was reported on the trailing edge flap assembly.
5) All navigational and approach aids were functional and were operating
normally at the time of incident.
6) The PIC & Co-pilot had undergone the requisite pre-flight medical examination
and were certified as not being under the influence of alcohol.
7) The PIC had a total flying hours of about 9,500 Hrs of which 4600 hrs were on
type and 2212 Hrs as PIC on type. Co-Pilot had a total flying experience of
9216 hrs and approximately 3000 hrs as PIC on type. Both the cockpit crew
were qualified to operate the subject flight.
8) The aircraft took off from Hong Kong at 1240 UTC and during take-off there
was no abnormality observed by the pilot. After about 06 hours of uneventful
flight, the aircraft approached Delhi.
9) The aircraft was cleared for landing and accordingly the crew correctly
configured the aircraft for landing with flaps fully extended i.e. flaps 30.
10) During landing the left inboard trailing edge fore flap separated from the
aircraft and fell on runway.
11) There was no signal/indication in the cockpit and the crew did not experience
any control abnormalities, during landing. Hence, the flight crew were not
aware that the fore flap had separated from the aircraft during landing.
12) The crew carried out taxi & subsequent operations normally.

43
13) When the aircraft was taxing in, the ground ATC contacted them and
informed that a part had departed the aircraft during the landing.
14) After parking the aircraft on bay, the flight crew instructed the ground
engineer to perform a walk around inspection and after fully extending the
flaps the engineer reported that the left wing inboard trailing edge fore-flap
was missing.
15) The flight crew then informed the ATC about the same.
16) The fore flap was recovered from the runway and was found broken into
three pieces.
17) There was no injury and there was no fire during the incident.
18) Some of the damaged parts were recovered after the incident for further
detailed examination. During transit of the shipment of damaged parts in
Hong Kong, three of the four items that were to be sent onward for
examination by the NTSB, USA were lost.
19) During handling of the shipment in HAECO, three of the four items were
mistakenly identified as ‘scrap’ and disposed of. The missing B-HUL items
were considered lost after all reasonable efforts to recover them were
exhausted. Only the LH wing mid flap track (outboard position) was further
shipped to NTSB, USA for detailed examination.
20) The fore flap has total of five attachment links with the airframe and as the
entire fore flap had separated from the aircraft, depicts that all the five
attachment links failed during the flight, though primarily one (or two) of them
would have failed causing others to fail consequently.
21) Examination of the LH wing mid flap track revealed that it sustained bending
overstress separation. The bending direction was as if the aft end of the track
bent upward. There were no Indications of pre-existing cracking or corrosion
was noted on the fracture or other locations on the track.
22) It indicated that the fore flap was floating in the air mainly with the support of
outboard mid flap track after the other attachment link(s) failed and may be
concluded that fracture of outboard mid flap track was not the primary failure
for the fore flap separation. Hence it is not the primary failure for the fore flap
separation.
44
23) Other mid flap tracks (inboard and centre) was found attached to the mid
flap. However, their respective attachment fore flap links were fractured,
though the damages were observed to be fresh in nature, which indicates
that it may have been consequential. The probability of these links to fail
primarily is slightly improbable.
24) The study of similar events of fore flap separation which occurred on Boeing
747 aircraft worldwide of different operators revealed that the primary cause
of separation of fore flap for most of the cases was observed to be the failure
of one of the fore flap inner attachment link (with sequence carriage) or
anomalies in the sequence carriage(s) and its associated components.
25) On observing the repetitive nature of fore flap inner attachment link failure,
the manufacturer in 2003, altered the design of the fore flap attachment
fittings to prevent such failures.
26) The outboard fore flap inner link (attached to outboard sequence carriage)
was found fractured and got separated from the carriage attachment. Hence
it is highly probable that the failure of outboard fore flap inner link may be the
primary failure which caused the other attachment links to fail one after
another under severe air loads during landing.
27) Fracture of a fore flap attachment link would not necessarily result in
immediate partial or complete loss of the fore flap. Because of the design, it
is possible for the fore flap to remain functional for an indeterminate period
with a fractured link.
28) The detent roller of the inboard sequence carriage was also found sheared
and separated from the carriage assembly.
29) When the flaps were extended the sequence carriage moved on the flap
track for some distance after the detent roller was separated. This reveals
that there may be some anomalies in the inboard sequence carriage
assembly thereby resulting in inboard sequence carriage getting out of phase
with the other sequence carriage. This may have led to fracture of carriage
attachment lug (attachment with fore flap inner link) or the outboard fore flap
inner link.

45
 30) Based on numerous reports of damage to the fore flap and associated
components the manufacturer considered the failure as the ‘known mode of
failure’. Based on this the manufacturer had revised the SB 747-27-2366 as
revision 2 issued on 3rd August 2011.
31) The SB was not complied by the operator as it was not mandated by FAA
and nor by the HK-CAD which may have led to skewed operation of fore flap
assembly.
32) The skewed operation of the fore flap assembly in flight can be caused by
worn or broken centre toggle rollers or by binding of the fore flap track rollers
in the mid flap. This will lead to accumulation of debris from seized or broken
fore flap rollers. This debris could result in the fracture of the fore flap
attachment fittings and subsequent separation of the fore flap
33) The accumulation of debris from seized or broken fore flap rollers could result
in the fracture of the fore flap attachment fittings and subsequent loss of the
fore flap.
34) At the time of incident the weather was fine and did not contributed to the
incident.

3.2 Probable cause of the incident:

The incident may have occurred due to non-compliance of SB 747-27-2366 by

the operator which resulted in fracture of fore flap inner attachment link
(outboard) or the carriage attachment lug (inboard) leading to subsequent
separation of the fore flap.

The SB 747-27-2366 was not mandated by FAA & accordingly neither by HK-
CAD which may have prompted the operator to not incorporate it in their
maintenance programme.

46
4. SAFETY RECOMMENDATIONS:

SB 747-27-2366 Revision 3 issued by aircraft manufacturer covers the

maintenance of Trailing edge fore flap system & increase its durability providing a
long term solution necessary to prevent similar failures. Hence no safety
recommendations were considered necessary.

Place : New Delhi

Date : 27.07.2018

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