Section/division Accident and Incident Investigations Division Form Number: CA 12-14b

PRELIMINARY INCIDENT REPORT

Accident and Incident Investigations Division

Incident - Preliminary Report - AIID Ref No: CA18/3/2/1273

Aircraft Type

ZS-ZWE Boeing B737-800

Description:

Comair aircraft operated by Kulula, flight CWE494 was bound to FALA from FACT diverted to FAOR following an inflight engine shutdown due to a possible oil leak on the left hand side engine number 1.

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DESCRIPTION OF INCIDENT

Reference Number : CA18/3/2/1273 Name of Owner/Operator : Limited Pty Manufacturer : Boeing Aircraft Company Model : B737-800 Nationality : South African Registration Marks : ZS-ZWE Place : South of Potchefstroom Aerodrome (FAPS) at 30Nm from FALA Date : 08 July 2019 Time : 1112Z

All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z). South African Standard Time is UTC plus 2 hours.

Purpose of the Investigation:

In terms of Regulation 12.03.1 of the Civil Aviation Regulations (CAR) 2011 this report was compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to apportion blame or liability.

Any person who has information concerning this incident should contact the AIID on [email protected]

Investigations process:

The Accident and Incident Investigations Division (AIID) of the SACAA was informed about an Aircraft incident, involving a B737-800 which occurred in flight on 08 July 2019. The incident was notified to the AIID Investigator on call at 0810Z on 09 July 2019.

The AIID appointed an Investigator-in-charge with an Investigation Team. Notifications were sent to the Sate of Registry, State of Operator, State of Manufacture and Design (United State of America through NTSB), the State has not yet assign an Accredited Representative to the Investigation. The AIID will lead the investigation and issue the Final Report.

The information contained in this Preliminary Report is derived from the factual information gathered during the ongoing investigation into the Occurrence. Later Interim reports or the Final Report may contain altered information in case new evidence appears during the ongoing investigation that requires changes to the information depicted in this Report.

The AIID Reports are made publicly available at: http://www.caa.co.za/Pages/Accidents%20and%20Incidents/Aircraft-accident-reports.aspx

Notes: 1. Whenever the following words are mentioned in this Report, they shall mean the following:

• (Incident)- this investigated incident; • (Aircraft)- the B737-800 involved in this incident; • (Investigation)- the investigation into the circumstances of this incident; • (Pilot) – the pilot involved in this incident; • (Report)- this incident Report.

2. Photos and figures used in this Report were obtained from different sources and may be adjusted from the original for the sole purpose of improving the clarity of the Report. Modifications to images used in this Report are limited to cropping, magnification, file compression, or enhancement of colour, brightness, contrast, or the addition of text boxes, arrows or lines.

Disclaimer:

This report is produced without prejudice to the rights of the CAA, which are reserved.

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TABLE OF CONTENTS PAGE NO

List of abbreviations 4 1. Factual Information 5 1.1. History of flight 5 1.2. Injuries to personnel 5 1.3. Damage to aircraft 5 1.4. Other Damages 5 1.5. Personnel Information 6 • Pilot In Command 6 • Flying Experience 6 • 1st Officer 6 • Flying Experience 6 • Aircraft Maintenance Engineer 6 1.6. Aircraft Information 7 • Airframe 7 • Engine 1 7 • Engine 2 8 8 1.7. Meteorological Information 8 1.8. Aid to Navigation 8 1.9. Communication 8 1.10. Aerodrome Information 8 1.11. Flight Recorders 8 1.12. Wreckage and Impact Information 9 1.13. Medical and Pathological Information 9 1.14. Fire 9 1.15.Survival Aspects 9 1.16.Tests and Research 9 1.17.Organization and Management Information 10 1.18.Additional Information 11 1.19. Useful Effective Investigative Techniques 11 2. Findings 11 2.1. General 11 • Findings 11 3.On-going Investigation 12

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ABBREVIATION DEFINITION

° Degrees °C Degrees Celsius AIID Incident and Incident Investigations Division AMO Aircraft Maintenance Organisation ASL Air Service License CAR Civil Aviation Regulations CAVOK Ceiling And Visibility OK C of A Certificate of Airworthiness C of R Certificate of Registration E East ft. Feet FAR75 Restricted Area 75 near Potchefstroom FALA Lanseria International Airport FACT Cape Town International Airport FAOR O. R Tambo International Airport GPS Global Positioning System Coordinates hPa Hectopascal (1 hPa = 100 Pa) km Kilometres kt Knots L Litres m Metres MPI Mandatory Periodic Inspection MSG Meteos at Second Generation image MCC Maintenance Control Centre S South SACAA South African Civil Aviation Authority QNH Q code indicating the atmospheric pressure adjusted to mean sea level UTC Co-ordinated Universal Time

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1. FACTUAL INFORMATION

1.1. History of Flight

1.1.1 A Comair Limited aircraft operated by Kulula with flight number CAW494 was in a flight to Lanseria Aerodrome (FALA) from Cape Town international Aerodrome (FACT) on 8 July 2019. On board the aircraft was a crew of 6 and 194 passengers (188 souls) on board. According to the PIC reporting, 10 nautical miles (Nm) prior to initiating a descend, the crew noticed a number 1 engine low oil quantity indication warning caption reading 17%. Following the warning, the crew followed requirements of the emergency check list and contact FALA air traffic control (ATC) requested an early descend from 33000 feet (ft) or flight level (FL) 330 to FL210, and they stated the emergency situation. He further stated that, they contacted the maintenance control centre (MCC) to request further technical assistance. The MCC advised the crew to continue with route to FALA and monitor the aircraft engine oil quantity until it run to 0% on which they can commence with an engine shutdown.

1.1.2 The MCC also requested that the crew divert to OR Tambo International Aerodrome (FAOR) in case the number 1 engine oil quantity run to 0% prior to reaching FALA and if it was permissible for the flight. The crew proceeded to FALA and kept consistent monitoring of the aircraft engine oil quantity indication that did not stop reducing. Upon reaching FALA when the aircraft was overhead the engine low oil quantity indication reached 0% and the crew requested a go around and diverted to FAOR and permission was granted. An inflight engine shutdown procedure was carried out by the crew and the number 1 engine was shutdown. The aircraft proceeded to FAOR and requested a further descend to FL110 and was handed to RADAR monitoring procedure. On approach for FAOR emergency landing procedure were carried out by the crew and the airport emergency fire and rescue (AEFRS) were put on standby. The aircraft landed safe on Runway 21L and was escorted to the apron by the AEFRS.

1.1.3 No injuries were sustained by any of the aircraft occupants and the aircraft had no damages. The aircraft damages were limited to the starter.

1.1.4 The aircraft incident occurred in flight during day light meteorological condition at position south of FAPS FAR75 at a distance 30Nm from FALA.

1.2. Injuries to Persons

1.2.1 There were no injuries sustained by any of the occupants during this incident phase.

Injuries Pilot Crew Pass. Other Fatal - - - - Serious - - - - Minor - - - - None 2 4 194 -

1.3. Damage to Aircraft

1.3.1 Damages were limited to the starter that was removed following the incident.

1.4. Other Damage

1.4.1 None

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1.5. Personnel Information

Pilot In Command (PIC) Nationality South African Gender Male Age 41 Licence Number ************* Licence Type Airline Transport Pilot Aeroplane Licence valid Yes Type Endorsed Yes Ratings Instrument, Night Medical Expiry Date 31 March 2020 Restrictions Corrective lenses Previous Accidents None

Flying Experience: Total Hours 10569 Total Past 90 Days 157 Total on Type Past 90 Days 157 Total on Type 6879

First Officer (FO) Nationality South African Gender Male Age 30 Licence Number ************** Licence Type Airline Transport Pilot Aeroplane Licence valid Yes Type Endorsed Yes Ratings Instrument, Night & Instructor Grade II Medical Expiry Date 31 August 2019 Restrictions None Previous Accidents None

Flying Experience: Total Hours 3459.2 Total Past 90 Days 194 Total on Type Past 90 Days 194 Total on Type 1012.5

1.5.1

Technician Experience: Nationality South African Gender Male Age 55 Licence Number *************** Licence Type Aircraft Maintenance Engineer Licence valid Yes Type Endorsed Yes A340-212/313/642, B737-200/300/400, CFM56-3/5 series, P&W Ratings JTBD series and R R RB211-524, B737-800 (CFM56-7BE) License Expiry Date 02 October 2020 Restrictions None Previous Accidents None

1.5.2 The aircraft maintenance engineer (AME) who conducted maintenance on the aircraft is qualified, rated and licensed on the aircraft maintenance in accordance with approved regulatory procedures and the Technical (SAAT) procedures.

An interview with the AME and evidence provided by the air traffic controller (ATC) revealed the following

On the date of the maintenance 07 July 2019, the AME who is permanently based in Cape Town was the only person on duty standing in on a relief duty for the local AME at George Aerodrome (FAGG) line station.

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(i) ZS-ZWE landed at FAGG on Sunday 7 July 2019 at 0646Z. It was pushed back from the bay at 0720Z and Engine #1 starter experienced dificulty during start up, and the aircraft returned to the bay. (ii) The AME phoned the MCC in Johannesburg and advise them about the starter failure on ZS- ZWE. The MCC advised the AME that there was no spare starter available however there was one available on a serviceable engine which was in the engine shop. He was then advised that the starter is available and it will be shipped on site for installation on the same day. The starter arrived from Johannesburg on ZS-ZWB at 1125Z. (iii) The next Kulula aircraft, ZS-ZWJ, arrived at 1149Z. (iv) The AME had to first accomplish the “Through Check” (line transit check) on ZS-ZWB upon arrival in preparation for departed at 1155Z. (v) The AME accomplished the “Through Check” on ZS-ZWJ and the aircraft departed at 1223Z. (vi) The AME then began removal of the defect starter and noticed the starter had a different part number from the one supplied, on which he communicated with MCC to confirm interchangeability. The interchangeability of the part number 3505945-9 with part number 3505945-10 is permitted by the illustrated parts catalogue (IPC). (vii) The next aircraft, ZS-SJB, arrived at 1225Z. The AME had to attend the aircraft as he was responsible for the Headset and Chocks on this aircraft as the pilots were responsible for the line transit checks. The aircraft departed at 1300Z and the AME continued with starter change on ZS-ZWE aircraft. (viii) During the starter change a SAFAIR aircraft landed. SAAT provide only standby assistance for SAFAIR aircraft. This aircraft requested assistance with an oxygen bottle, but the AME informed them that he was not rated to carry out that kind of maintenance. (ix) The aircraft with the starter change, ZS-ZWE, departed at 1329Z with the supplied starter installed. (x) The AME reported that he completed the paperwork on the label and briefed SAAT MCC after ZS-ZWE departed. He scanned a copy of the TL/36 (Defect report) and mailed it to SAAT MCC. He also completed a GT/79 (Delay Report) and submitted it.

1.6 Aircraft Information

1.6.1 The Boeing 737-800NG aircraft was first produced in 1996 by Boeing Commercial Airplanes known as the next generation (NG) type of aircraft. They are short to medium range, narrow-body jet airliners powered by two engines. The production series includes four variants and can seat between 110 and 210 passengers.

Airframe: Type Boeing B737-800 LD Serial Number 40854 Manufacturer Boeing Aircraft Company Date of Manufacture 2015 Total Airframe Hours (At time of Accident) 11460 Last MPI (Date & Hours) (A-Check) 22 June 2019 11325 Hours since Last MPI 135 C of A (Expiry Date) 17 August 2019 C of R (Issue Date) (Present owner) 19 August 2015 Comair Limited Operating Categories Standard Part 121

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Engine 1: Type CFM56-7BE Serial Number 863206 Hours since New 11460 Hours since Overhaul Modular type

Engine 2: Type CFM56-&BE Serial Number 863212 Hours since New 11460 Hours since Overhaul Modular type

Engine number 1

A preliminary review of maintenance records was conducted in relation to the reported incident, a review of specific engine maintenance record revealed the following: According to the available maintenance records, on the 07 July 2019, a starter change was conducted at George airport following an aircraft starter failure for number 1 engine during departure preparation following a push back. The aircraft proceeded with flight to FACT following a sign off by a qualified technician on site on the same day of installation on 07 July 2019. On 8 July 2019 the engine experienced oil loss during flight which led to an inflight engine shutdown followed by the aircraft diverting to FAOR were it landed safe.

The aircraft starter

Figure 2: Aircraft engine starter attachement

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Figure 3: Starter installation diagram

1.7 Meteorological Information

1.7.1 Meteorological conditions as per the mandatory occurrence reporting.

Wind direction 220 Wind speed 09kt Visibility 9999 Temperature 17 Cloud cover None Cloud base None Dew point 00 QNH 1027

1.8 Aids to Navigation

1.181.1 The aircraft was equipped with the standard communication equipment approved by the manufacturer. None were reported unserviceable prior to or during the flight.

1.9 Communications.

1.19.1 The aircraft was equipped with a high frequency radio communication approved by the regulator. No defects were recorded or experienced with communication system during flight. All communication conducted during with relevant parties were conducted through radio communication.

1.10 Aerodrome Information

1.10.1 The aircraft landed uneventfully at FAOR runway 21L following a flight divert due to an inflight shutdown. FAOR is situated at approximately 21Nm South East of FALA at GPS coordinates (S 26° 8'25.93",E 028°14'34.07")

1.11 Flight Recorders

1.11.1 The aircraft is equipped with quick access recorder (QAR), flight data recorder (DFDR) and a voice data recorder (CVR). Both solid state type recorders D-FDR and the CVR data was downloaded by the investigation team with the assistance of the SAAT data downloading facility for data analysis.

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1.11.2 FDR and CVR information

Equipment D-FDR CVR Part Number 980-4750-003 980-6022-001 Serial Number FDR-06156 CVR120-07-492

1.11.3 D-FDR Recordings

According to the D-FDR downloaded information analysis the following was revealed

• The first indication of a reduced in number 1 engine oil quantity was at 11:11:25, with 12.8 units recording. The previous recording was at 11:07:53 which indicated 06min 24seconds earlier with 13.3 units of oil quantity recorded. • The N1 engine oil quantity continued to drop at a constant rate during the cruise up to 3 units remaining at 11:54:01. Then the N1 engine oil quantity began to drop slower rate of 1 unit during a descent approximately 12:10:29. • The oil quantity dropped to 0 during a go around at approximately 12:14:37 over FALA. Following this the N1 engine fuel flow was reduced to 0 at approximately 12:17:32 which was 02minutes and 55seconds after the oil quantity was reached 0 units indication in the cockpit display. • The N1 oil pressure dropped to 0 at approximately 12:18:12 which was 40seconds following fuel flow shutdown. • The N1 engine oil drained from 13.3 units to 0units in a period of approximately 1hr 6min and 44sec (From 11:07:53to 12:14:37).

1.12 Wreckage and Impact Information

The aircraft incident occurred in flight and an inflight engine shutdown was conducted by the crew before diverting from FALA to FAOR.

1.13 Medical and Pathological Information

1.13.1 None

1.14 Fire

1.1.41 There was no evidence of pre or post incident fire during this incident.

1.15 Survival Aspects

1.15.1 The aircraft landed safely at FAOR,

1.16 Tests and Research

1.16.1 According to the SAAT during the post incident inspection oil was found on the inside of the engine cowlings. Also the starter drain/fill magnetic plug housing was found loos inside the cowlings.

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Figure 3: The drain/fill magnetic plug and the starter without locking wires

1.16.2 During the installation of the starter, the AME did not follow the requirements of the 737- 600/700/800/900 AMM CML D633A101-CML Rev69-15 June 2019 which required the use of an adopter or alternatively to use gravity feed for oil servicing. See attachment ???

1.16.3 Also the AME did not fallow the 737-600/700/800/900 AMM CML D633A101-CML Rev69-15 June 2019 which requires that the starter drain/fill plug to be torqued to 7.3-4.52Nm or 65.0-40.0 in-lb and be safety wired. See attachment ???

1.17 Organizational and Management Information

1.17.1 The aircraft is operated by Comair Limited’s Kulula as a scheduled commercial transportation flight operating between George, Cape Town, Lanseria and O.R Tambo international airport. The operator holds a valid air service license issued in accordance with applicable procedures by the Department of Transport.

1.17.2 The aircraft maintenance service is conducted by SAAT as per the available contractual agreement between the operator and the SAAT. The maintenance service extends to the line services within South African border for the operator’s contracted routes and for several other operators. SAAT hold a valid approved certificate of maintenance (#: 001) issued by the regulator on 19 October 2018 with an expiery date of 30 October 2019.

1.18 Additional Information

1.18.1 To be discussed in the final report.

1.19 Useful or Effective Investigation Techniques

1.19.1 To be discussed in the final report.

2. Findings

2.1. General

From the evidence available, the following preliminary findings were made with respect to this Incident. These shall not be read as apportioning blame or liability to any particular organisation or individual.

To serve the objective of this Investigation, the following sections are included in the conclusions heading:

2.2 Findings- are statements of all significant conditions, events or circumstances in this Incident. The findings are significant steps in this Incident sequence but they are not always causal or indicate deficiencies. CA 12-14b 10 October 2018 Page 11 of 19

2.2.1 The PIC was issued with an air transport pilot licence (ATPL) on 12 December 2018 with an expiry date of 31 December 2019. His last skills test was carried out on 23 March 2019.

2.2.2 The PIC was issued with a medical certificate on 26 March 2019 with an expiry date of 31 March 2020.

2.2.3 The FO was issued with an air transport pilot licence (ATPL) on 23 January 2019 with an expiry date of 3 April 2020. His last skills test was carried out on 23 January 2019.

2.2.4 The FO was issued with a medical certificate on 22 August 2018 with an expiry date of 31 August 2019.

2.2.4 The AME was issued with a AME licence on 26 July 2018 with an expiry date of 02 October 2020. 2.2.5 The interview with the AME revealed that he did not use the applicable AMM due to unavailability on the used available computer software system. Also on completion of the starter installation, the AME did not torque and secure the magnetic plug with a safe locking wire.

2.2.6

2.2.7 The engine oil leak was due to a magnetic plug that loosened during operation as it was not torqued and secured with a safety locking wire as per the applicable AMM procedures.

2.2.8 The aircraft was initially issued with Certificate of Airworthiness (C of A) on 18 August 2015 with an expiry date of 17 August 2019. The Certificate of Registration (C of R) was issued on 19 August 2015.

3. Appendices

3.1 Appendix 1: Starter Servicing (Oil drain/Fill) 3.2 Appendix 2: Magnetic Plug Housing Installation

4. On-going Investigation

4.1 The SACAA investigation is on-going and we will be looking into operator and AMO systems which lead to this incident.

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Appendix 1

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Appendix 2

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