British Airways flight 38 from Beijing to London Heathrow on January 17, 2008 experienced a sudden and unexpected dual engine rollback just moments before landing, causing the pilots to crash-land the Boeing 777 short of the runway. Remarkably, all 152 passengers and crew survived the incident with only minor injuries.
The investigation revealed that the cause was a blockage in the fuel system, specifically at the fuel-oil heat exchanger (FOHE), caused by the sudden release of ice that had accumulated in the fuel lines during the flight. This ice buildup was the result of a unique confluence of low cruise fuel flow, high fuel flow during approach, and low fuel temperature - conditions that had not been adequately considered during the aircraft's certification process.
The solution was a simple design change to the FOHE, implemented by the engine manufacturer Rolls-Royce, to ensure that any ice would be melted on contact. This fix, along with recommendations for expanded use of fuel system icing inhibitors, has prevented any similar incidents since.
The crash of flight 38 serves as a stark reminder of the dangers of "unknown unknowns" - rare edge cases that push the boundaries of possibility. The extensive and costly investigation, while seemingly disproportionate to the ultimate fix, was crucial in uncovering this hidden vulnerability and preventing potentially catastrophic consequences in the future.
To Another Language
from source content
admiralcloudberg.medium.com
Key Insights Distilled From
by Admiral Clou... at admiralcloudberg.medium.... 04-06-2024
https://admiralcloudberg.medium.com/powerless-over-london-the-crash-of-british-airways-flight-38-7b2e20075f26Deeper Inquiries