DCA09IA014

An accumulation of ice in the fuel system, which formed from the water normally present in jet fuel during commonly encountered flight conditions, which accreted and released, restricting the fuel flow at the right engine fuel-oil heat exchanger inlet face. Contributing to the incident were certification requirements (with which the aircraft and engine fuel systems were in compliance), which did not account for the possibility of ice accumulating and subsequently releasing in the aircraft and engine fuel feed system upstream of the fuel-oil heat exchanger.

About flight level 390 (about 39,000 feet), the airplane experienced an uncommanded thrust reduction (or “rollback”) of the right engine. The flight crew actions did not initiate or exacerbate the engine rollback. Although the flight crew expressed some questions about the applicable procedures, they reduced thrust as required and the right engine recovered and responded normally for the remainder of the flight. (Following the Delta incident, Boeing revised its engine response non normal procedure.) The flight did not encounter any severe weather or abnormally low temperatures aloft, and the fuel did not reach a low enough temperature to freeze or solidify. All relevant systems on the airplane were operating as designed and certified. The water content and chemical makeup of the fuel met all international test standards. Flight crew statements and recorded flight data indicated that the flight was normal from the departure from Shanghai until about 55 minutes before the engine rollback occurred; at which time, the right engine oil temperature began to increase relative to that of the left engine oil temperature with no corresponding thrust increase or other potential explanation. (A consistent small difference existed between the left and right engine oil temperatures, which was attributed to manufacturing tolerance variances.) This period of elevated oil temperature occurred because the inlet face of the fuel-oil heat exchanger (FOHE) was partially obstructed by ice, resulting in the fuel flowing through a reduced number of tubes in the FOHE, which reduced the oil cooling efficiency of the FOHE before and during the rollback. When the right engine fuel flow returned to normal after the ice blockage cleared, the engine oil temperature dropped, indicating that the FOHE oil cooling effectiveness was restored. Therefore, the oil temperature excursion is evidence that the FOHE was partially restricted for about 55 minutes before and during the engine rollback. The investigation determined that the following sequence of events occurred during the incident flight: ice formation from the normal amounts of entrained water in the fuel, ice accretion and subsequent release from the area of accretion (possibly at more than one distinct time), and ice travel through the fuel system to collect on, and obstruct the flow through, the FOHE inlet face. The recorded fuel temperature during the time period leading up to the engine rollback was -22° C. Extensive testing using Boeing 777 components in a cold fuel laboratory concluded that, jet fuel with normal amounts of entrained water could form ice crystals and that, when localised fuel temperatures are in the ‘sticky range’ (-5 to -20 °C), ice can accumulate along the internal components of the fuel system and that this ice could be released during higher fuel flows and subsequently travel downstream through the system. The testing further concluded that the Rolls-Royce Trent 800 FOHE inlet face could be obstructed by a concentration of ice sufficient to restrict the fuel flow to a value similar to that recorded during the incident flight. Testing also demonstrated that reducing the volume of the fuel flow through the FOHE allows the heat of the oil to melt the ice, allowing for a recovery to normal operation. Although the fuel system met certification requirements, the FAA determined that neither the FAA nor applicants anticipated ice accumulating in the aircraft and engine fuel feed system upstream of the FOHE or that, under certain conditions, the ice could release and cause a restriction at the FOHE that would limit fuel flow to the engines. Therefore, the FAA and European Aviation Safety Agency provided applicants revised acceptable methods of compliance to those applicable regulations to ensure that future designs are tolerant to the threat of ice concentrations.

HISTORY OF FLIGHT On November 26, 2008, about 1930 coordinated universal time, a Boeing B777-232ER (B777), N862DA, operated by Delta Air Lines as flight 18, experienced an uncommanded thrust reduction (or “rollback”) of the right Rolls-Royce RB211 Trent 895 engine during cruise flight at flight level (FL) 390 (about 39,000 feet). Following the rollback, the flight crew descended to FL310 and executed applicable flight manual procedures, after which, the engine recovered and responded normally. The flight continued to Atlanta-Hartsfield International Airport (ATL), Atlanta, Georgia, where it landed without further incident. The airplane was not damaged, and no injuries were sustained by the flight crew or passengers. The flight was a regularly scheduled passenger flight from Shanghai Pudong International Airport (ZSPD), Shanghai, People’s Republic of China, to ATL, operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121. Visual meteorological conditions prevailed for the flight, and an instrument rules flight plan had been filed. There were no reported anomalies in flight from the departure from Shanghai through the initial portion of cruise. While crossing the northern Pacific Ocean, just south of the Aleutian Islands, the airplane passed a low pressure area with some light to moderate turbulence. Shortly after entering U.S. airspace in the vicinity of Seattle, Washington, air traffic control cleared the flight to climb to FL370. The flight crew executed the climb using VNAV (vertical navigation) mode and the CLB (maximum climb) power setting. About 15 minutes after reaching FL370, the en-route flight crew was relieved by the incident flight crew. At that time, the airplane was in clear weather over an undercast layer, and all flight deck indications were reported as normal. Shortly after the flight crews changed, the flight was cleared to climb to FL390. The incident flight crew executed the climb using the VNAV and CLB settings, and flight deck indications were reported as normal. The first officer, who was the pilot flying, stated that, about 30 minutes after reaching FL390, he noted that the right engine pressure ratio (EPR) indication was “fluctuating” and that he saw corresponding fluctuations on the N1 and exhaust gas temperature (EGT) indications. He reported that his attention was drawn by the message, “ENG RESP,” displayed on the engine indicating and crew alerting system (EICAS); however, no message with this text exists on the B777. The flight crew reported that they were aware of a January 2008 accident involving a B777 at London Heathrow Airport that experienced engine rollbacks and, therefore, they suspected that “engine icing” was causing the indications. (Air Accidents Investigations Branch [AAIB] AAR 1/2010 “Report on the Accident to Boeing B777-236ER, G-YMMM, at London Heathrow Airport on 17 January 2008” is available on-line at http://www.aaib.gov.uk/sites/aaib/publications/formal_reports/1_2010_g_ymmm.cfm.) The ENG RESPONSE (engine response) non normal checklist in the Delta B777 Operations Manual Quick Reference Handbook (QRH) had been revised on October 31, 2008, as a result of recommendations issued by the AAIB during the investigation of the G YMMM accident. The revised U (unannunciated) ENG RESPONSE checklist stated that it was to be used when “One or both engine(s) did not reach commanded thrust or rolls back after performing the Cold Fuel Operations supplementary procedure or after operating at high thrust settings. Note: The objective of this procedure is to clear ice from the fuel system by reducing engine fuel flow while descending, then checking for proper engine response.” The first item on the checklist was to descend with the thrust levers closed. The flight crew reported that they had some questions about the applicability of the U ENG RESPONSE checklist to their situation because they were more than 3 hours from the top of the descent and had not yet performed the Cold Fuel Operations procedure, nor had they recently operated either engine at a high thrust setting. However, they retarded both thrust levers and executed a descent to FL310. The right engine recovered and responded normally for the remainder of the flight. The flight crew performed the rest of the U ENG RESPONSE checklist items after reaching FL310. The flight continued to ATL, where it landed without further incident. Review of the DFDR (digital flight data recorder) and QAR (quick access recorder) information indicated that about 45 minutes after reaching FL390, the right engine EPR dropped from approximately 1.25 to 1.1. The data showed that the measured fuel flow for the right engine reduced to approximately 5000 pounds per hour, consistent with the reduced thrust of the engine. All the engine parameters, including rotor speeds, burner pressure, and stator vane position, were consistent with the measured fuel flow, indicating that the engine was operating as would be expected for the measured amount of fuel flow. Recorded data showed that the engine control system attempted to increase fuel flow in response to autothrottle commands by driving the fuel metering valve (FMV) fully open, but this did not result in any increase in the fuel flow. The airplane’s Thrust Asymmetry Compensation (TAC) system automatically adjusted the rudder to compensate for the asymmetric thrust, caused by the reduced right engine power. The rollback condition persisted for about 23 minutes between the first indication of fuel flow reduction on the FDR data and the execution of the descent by the flight crew. The engine control system on the Rolls-Royce Trent 895 powered B777 is designed to display an ENG THRUST (sometimes termed “EPR shortfall”) caution message on the EICAS alerting the flight crew of a significant disagreement between the actual measured engine thrust and the commanded thrust. Examination of recorded engine controls data revealed that this message was not displayed on the EICAS (see Tests and Research section below.) FDR and QAR data further indicated that about 55 minutes prior to the rollback, the oil temperature of the right engine began to rise, eventually increasing by about 31º C relative to that expected based on the previous portions of the flight. During the rollback period, the oil temperature decreased, but it still remained at a higher than expected value. Following the recovery, the oil temperature returned to a value consistent with the previous portions of the flight. Note that a consistent small difference in the oil temperature between the two engines was evident throughout the nominal portions of the flight, which was not considered abnormal, due to variances in manufacturing tolerances. Recorded data indicated that, during the hour before the rollback, the outside (static) air temperature reached a minimum of -62º C and increased to about -57º C following the step climb to FL390. The total air temperature (due to the speed of the airplane) was about -25º C before the rollback, and it decreased slightly during the incident as the airspeed decreased. Main tank fuel temperatures went below 0° C about 3 hours into the flight and then progressively reduced to a minimum of -23° C. The airplane made four step climbs at fuel flows in excess of 11,000 pph before the restriction occurred. The third and fourth step climbs both occurred at fuel temperatures below 0° C. The third occurred shortly after the fuel temperature went below 0° C, and the fourth occurred just over 3 hours later when the fuel temperature was approaching -15° C. About 3 hours later, the airplane carried out a further step climb, with a maximum fuel flow of just over 11,000 pph. It was during this engine acceleration that the engine oil temperature was observed to rise, followed shortly thereafter by the rollback. Fuel temperature at the time of the rollback w