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2017

7/17

Releases Final Report of TransAsia Airways Flight GE367 Occurrence Investigation

The Aviation Safety Council (ASC) releases final report on investigation of a TransAsia Airways flight GE367, during climbing, a water heater in the rear galley emanated smoke.

On July 24, 2016, TransAsia Airways (TNA) scheduled passenger flight GE367, an Airbus A320-200 aircraft, registered B-22317, around 1452 Taipei local time departed from Taichung/ Ching-Chuan-Kang Airport (RMQ) to Macau International Airport (MFM), with two flight crew, six cabin crew and 99 passengers, totally 107 persons on board. After takeoff when the aircraft was climbing over Magong, a water heater in the rear galley (G5) emanated smoke with burnt odor. The cabin crew immediately turned off the related galley power, disposed the suspected area with a fire extinguisher, and then pulled all the relevant galley equipment circuit breakers. After the flight crew confirmed that there were no more safety concerns, they decided to continue flying to the destination. Flight GE367 landed safely without further incident at 1604 in Macau International Airport.

According to the Aviation Occurrence Investigation Act of Republic of China (ROC) and the content of Annex 13 to the Convention on International Civil Aviation, the Aviation Safety Council (ASC) an independent aviation occurrence investigation agency, was responsible for conducting the investigation. The investigation team also included members from CAA (Civil Aeronautics Administration, Taiwan), BEA (Bureau d'Enquêtes et d'Analyses, France), Airbus company, DSB (Dutch Safety Board), B/E Aerospace (The Netherlands), and TransAsia Airways.

There are six findings from the Final Report, and one Safety Action taken from a related organization. The Findings related to probable causes and Safety Action accomplished as follows,

Findings related to probable causes:

The water heater emanating smoke was primarily caused by the thin external conductors of the water heater printed circuit board (PCB) resulting in a higher resistance and heat generation, and manually correction of the misaligned Faston connectors after wave soldering process may make flawed connection. The combination of higher resistance and flawed connection could have made the PCB accumulating high temperature then resulting in heat damage and smoke under normal operation.

Safety Action Accomplished:

B/E Aerospace inc. the Netherlands

The water heater manufacturer, B/E Aerospace Inc., released a service information letter, No. H0212-25-0245, on February 28, 2017, with title of "ADDITIONAL INSPECTION INSTRUCTION FOR POWER MODULE ASSEMBLY". The letter indicated if the bad contact occurred at some specific connectors on power module assembly, this could cause arcing and possible overheating. All applicable units including the occurrence water heater type DR4101, the power module assembly must be examined at the next available shop visit. If the discolored marks are found, the power module must be replaced according to component maintenance manual.

Full Final Report is in Chinese only and available for download at http://www.asc.gov.tw

 

Sherry Liu, Engineer
Tel: 89127388-330
Email:sherry@asc.gov.tw

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