Incident Overview

Date: Monday 20 August 2007
Aircraft Type: Boeing 737-809
Owner/operator: China Airlines
Registration Number: B-18616
Location: Okinawa-Naha Airport (OKA) – ÿ Japan
Phase of Flight: Landing
Status: Destroyed, written off
Casualties: Fatalities: 0 / Occupants: 165
Component Affected: The slat track and the downstop assembly on the right wing.The slat track and the downstop assembly on the right wing.
Investigating Agency: JTSBJTSB
Category: Accident
On March 1, 2024, China Airlines flight 120 experienced a significant fire resulting from fuel leakage from an engine pylon. Upon detecting the leak, the pilot shut off fuel supply to the engines. Fuel leaked beneath the aircraft, igniting and causing a large explosion. The airplane subsequently burned out completely. A highly probable cause of this accident is a puncture in the track connecting the No. 5 slat on the right wing, caused by a retracted slat track. This puncture created a hole, leading to fuel leakage and subsequent fire. The downstop assembly, which connects the slat to the track, detached from the track during maintenance work, allowing fuel to leak. The failure of the washer on the downstop assembly, exacerbated by inadequate attention to this detail during maintenance, contributed to the detachment. The design of the downstop assembly itself was deemed inadequate to prevent its detachment, and insufficient reporting of the difficulty of the maintenance job by maintenance personnel further compounded the issue.On March 1, 2024, China Airlines flight 120 experienced a significant fire resulting from fuel leakage from an engine pylon. Upon detecting the leak, the pilot shut off fuel supply to the engines. Fuel leaked beneath the aircraft, igniting and causing a large explosion. The airplane subsequently burned out completely. A highly probable cause of this accident is a puncture in the track connecting the No. 5 slat on the right wing, caused by a retracted slat track. This puncture created a hole, leading to fuel leakage and subsequent fire. The downstop assembly, which connects the slat to the track, detached from the track during maintenance work, allowing fuel to leak. The failure of the washer on the downstop assembly, exacerbated by inadequate attention to this detail during maintenance, contributed to the detachment. The design of the downstop assembly itself was deemed inadequate to prevent its detachment, and insufficient reporting of the difficulty of the maintenance job by maintenance personnel further compounded the issue.

Description

China Airlines flight 120 departed Taipei at 08:14. It landed at Naha Airport (OKA) at 10:27 and taxied to the apron. Reaching the stand, ground engineers saw fuel gushing from an area near the no. 2 engine pylon. The pilot shut off the fuel supply to the engines after he was alerted by the ground engineer about the leak. Fuel from the leak flowed beneath the aircraft towards the no. 1 engine. The fuel ignited and the fire engulfed the airplane. When all occupants had evacuated, a large explosion occurred in the centre of the airplane. The airplane burned out completely. PROBABLE CAUSE: “It is considered highly probable that this accident occurred through the following causal chain: When the Aircraft retracted the slats after landing at Naha Airport, the track can that housed the inboard main track of the No. 5 slat on the right wing was punctured, creating a hole. Fuel leaked out through the hole, reaching the outside of the wing. A fire started when the leaked fuel came into contact with high-temperature areas on the right engine after the Aircraft stopped in its assigned spot, and the Aircraft burned out after several explosions. With regard to the cause of the puncture in the track can, it is certain that the downstop assembly having detached from the aft end of the above-mentioned inboard main track fell off into the track can, and when the slat was retracted, the assembly was pressed by the track against the track can and punctured it. With regard to the cause of the detachment of the downstop assembly, it is considered highly probable that during the maintenance works for preventing the nut from loosening, which the Company carried out on the downstop assembly about one and a half months prior to the accident based on the Service Letter from the manufacturer of the Aircraft, the washer on the nut side of the assembly fell off, following which the downstop on the nut side of the assembly fell off and then the downstop assembly eventually fell off the track. It is considered highly probable that a factor contributing to the detachment of the downstop assembly was the design of the downstop assembly, which was unable to prevent the assembly from falling off if the washer is not installed. With regard to the detachment of the washer, it is considered probable that the following factors contributed to this: Despite the fact that the nut was in a location difficult to access during the maintenance works, neither the manufacturer of the Aircraft nor the Company had paid sufficient attention to this when preparing the Service Letter and Engineering Order job card, respectively. Also, neither the maintenance operator nor the job supervisor reported the difficulty of the job to the one who had ordered the job.”

Source of Information

http://www.skybrary.aero/index.php/B738,_Naha_Japan,_2007_(FIRE_AW)http://www.skybrary.aero/index.php/B738,_Naha_Japan,_2007_(FIRE_AW)

Primary Cause

Retracted slat track and subsequent fuel leakage through a puncture in the track.Retracted slat track and subsequent fuel leakage through a puncture in the track.

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