Serious incident Boeing 747-412 (BCF) VQ-BWT, Saturday 20 February 2021
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Date:Saturday 20 February 2021
Time:16:12 LT
Type:Silhouette image of generic B744 model; specific model in this crash may look slightly different    
Boeing 747-412 (BCF)
Owner/operator:Longtail Aviation
Registration: VQ-BWT
MSN: 24975/838
Year of manufacture:1991
Fatalities:Fatalities: 0 / Occupants: 3
Other fatalities:0
Aircraft damage: Minor
Category:Serious incident
Location:over Meerssen, Limburg -   Netherlands
Phase: Initial climb
Nature:Cargo
Departure airport:Maastricht/Aachen Airport (MST/EHBK)
Destination airport:New York-John F. Kennedy International Airport, NY (JFK/KJFK)
Investigating agency: Dutch Safety Board
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Longtail Aviation flight LGT5504, a Boeing 747-412 (BCF), suffered a contained engine failure of the no.1 PW4056 engine. Blade fragments were ejected from the engine, coming down in the village of Meerssen, 2 km past the end of the runway. The engine parts injured two people and damaged property such as houses and cars

The flight crew initially declared a Mayday and subsequently requested vectors for a holding pattern at FL100 to dump fuel.
The flight then diverted to Liège Airport, Belgium, as this airport had a longer runway. A safe landing was made at 17:10 local time, one hour after takeoff from Maastricht Airport.

Conclusions
The investigation into this contained engine failure with the departing engine debris, revealed that the turbine of the number one engine of the aeroplane had failed. This engine –turbine- failure was caused by elevated gas temperatures that existed for an extended period of time in the turbine of the engine causing wear and deformation of outer tranition duct panels. This resulted in one outer transition duct panel coming loose and one being fractured, which subsequently caused severe damage to the turbine. Consequently, engine debris -turbine parts- exited the tail pipe of the engine and came down in the village of Meerssen.
The manufacturer of the engine was aware of the problem with the outer transition ducts coming loose since the nineteen-eighties. To prevent the failure of the outer transition ducts and turbine section, several service bulletins were issued since 1993. Also airworthiness directives were issued to improve the reliability of the outer transition ducts and the safe working of the engine. These improvements concerned among others additional cooling features for the high pressure turbine and the installation of new outer transition duct panels. The investigation revealed that the engine was equipped with those new panels; however, the engine was not modified with the additional cooling features. The lacking additional cooling features were supposed to prevent a too high level of gas temperature. The installation of these cooling features, as adviced by a service bulletin, was not mandatory.
The operator, who had been using the aeroplane in its fleet for three months at the time of the incident, was not responsible for decisions not to embody Service Bulletin 72-462 at the shop visits in 1999 and 2009. Despite this, the operator was not able to present the documented reasoning regarding the non-incorporation of this service bulletin.
Having an adequate record keeping of maintenance documentation enables the operator and its maintenance organisation to make sound risk management decisions about the continuing airworthiness of their aeroplanes. This is crucial for the safe operation throughout the operating life of, in this case, the engine.

Accident investigation:
cover
  
Investigating agency: Dutch Safety Board
Report number: 
Status: Investigation completed
Duration: 2 years and 2 months
Download report: Final report

Sources:

https://www.flightradar24.com/data/flights/6t5504/#26debe99
https://flightaware.com/live/flight/LGT5504/history/20210220/1525Z/EHBK/EBLG/tracklog
https://www.telegraaf.nl/nieuws/1566523397/vliegtuig-verliest-motoronderdelen-bij-maastricht-aachen-airport
https://www.onderzoeksraad.nl/en/page/18344/engine-failure-boeing-747-412bcf-meerssen
https://youtu.be/ADQbwVW4Wuo

Images:



Photo: Onderzoeksraad voor Veiligheid

Media:

Revision history:

Date/timeContributorUpdates
20-Feb-2021 16:34 ron_wyler Added
20-Feb-2021 16:36 harro Updated [Time, Departure airport, Destination airport]
20-Feb-2021 18:10 gerard57 Updated [Narrative]
20-Feb-2021 18:23 Aerossurance Updated [Location, Embed code]
20-Feb-2021 18:36 harro Updated [Aircraft type, Embed code, Narrative]
20-Feb-2021 19:30 harro Updated [Source, Narrative, Category, Photo]
21-Feb-2021 10:12 Aerossurance Updated [Narrative]
21-Feb-2021 12:45 RobertMB Updated [Location, Narrative]
22-Feb-2021 18:36 Aerossurance Updated [Source]
22-Feb-2021 19:50 harro Updated [Photo]
09-Mar-2021 19:28 Anon. Updated [Source]
22-Jun-2022 01:35 Ron Averes Updated [Location]
29-Apr-2023 18:52 harro Updated

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