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  • AT72, vicinity Budapest Hungary, 2016 (Synopsis: On 16 March 2016, an engine fire occurred to an ATR 72-200 departing Budapest and after declaring a MAYDAY, it was landed in the reciprocal direction on the departure runway without further event. The Investigation found that the failure had been initiated by the fatigue-induced failure of a single blade in the power turbine assembly but with insufficient evidence to ascribe a cause for this. A number of almost identical instances of engine failure initiated by failure of a single turbine blade were noted. Opportunities for both ATC procedures and flight crew response to mandatory emergency procedures were also identified.)
  • B773, Abu Dhabi UAE, 2016 (Synopsis: On 27 September 2016, the left engine of a Boeing 777-300 failed on takeoff from Abu Dhabi after it ingested debris resulting from tread separation from one of the nose landing gear tyres and a successful overweight return to land then followed. The Investigation found that FOD damage rather than any fault with the manufacture or re-treading of the tyre had initiated tread separation and also noted the absence of any assessment of the risk of engine damage and failure from such debris ingestion which it was noted had the potential to have affected both engines rather than just one.)
  • C525, vicinity Bournemouth UK, 2019 (Synopsis: On 13 April 2019, an experienced Cessna 525 pilot almost lost control shortly after takeoff from Bournemouth when a recently installed performance enhancement system malfunctioned. After a six minute flight involving a potentially hazardous upset and recovery of compromised control, the turn back was successful. The Investigation found that although the pilot was unaware of the supplementary procedures supporting the modification, these did not adequately address possible failure cases. Also, certification flight tests prior to modification approval did not identify the severity of some possible failure outcomes and corresponding Safety Recommendations were made to the system manufacturer and safety regulators.)
  • A319, vicinity Zurich Switzerland, 2014 (Synopsis: On 17 October 2014, two recently type-qualified Airbus A319 pilots responded in a disorganised way after a sudden malfunction soon after take-off from Zurich required one engine to be shutdown. The return to land was flown manually and visually at an excessive airspeed and rate of descent with idle thrust on the remaining engine all the way to a touchdown which occurred without a landing clearance. The Investigation concluded that the poor performance of the pilots had been founded on a lack of prior analysis of the situation, poor CRM and non-compliance with system management and operational requirements.)
  • A320, vicinity Dublin Ireland, 2015 (Synopsis: On 3 October 2015, an Airbus A320 which had just taken off from Dublin experienced fumes from the air conditioning system in both flight deck and cabin. A 'PAN' was declared and the aircraft returned with both pilots making precautionary use of their oxygen masks. The Investigation found that routine engine pressure washes carried out prior to departure have been incorrectly performed and a contaminant was introduced into the bleed air supply to the air conditioning system as a result. The context for the error was found to be the absence of any engine wash procedure training for the Operator's engineers.)
  • DC93, en-route, north west of Miami USA, 1996 (Synopsis: On 11 May 1996, the crew of a ValuJet DC9-30 were unable to keep control of their aircraft after fire broke out. The origin of the fire was found to have been live chemical oxygen generators loaded contrary to regulations. The Investigation concluded that, whilst the root cause was poor practices at SabreTech (the maintenance contractor which handed over oxygen generators in an unsafe condition), the context for this was oversight failure at successive levels - Valujet over SabreTech and the FAA over Valujet. Failure of the FAA to require fire suppression in Class 'D' cargo holds was also cited.)