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B747-400

ENGINEERING

CONTINUATION TRAINING

Q3 & Q4 2015

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Contents:

1 Changes to the B747 Approval

2 B747-400 Landing Gear Door Incident

3 ADs

4 MOR review

5 B747-400 Gear Actuator fitted upside down (Serious Incident)

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1 Introduction / Changes to the B747 approval

The B747 approval has been reactivated. The approval being made active is reflected in MOE Part 1.9 as follows:

MAINTENANCE ORGANISATION EXPOSITION

1.9.3 Aircraft Type / Station Location Listing

Aircraft type listed in the table above includes passenger & freighter variants. The scope of work includes the APU relevant to the aircraft type within the scope permissible under the A1 rating. A shaded cell denotes a passive approval and as such is subject to the requirements of Technical Procedure 14 for monitoring and re-activation.

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2. B747 Landing Gear Door.

18th June 2015 (Memo)

B747-400 - Preventing Body Landing Gear Door / Tire Contact (Note to Engineers and Mechanics)

Hello Gents, Please be aware that a recent maintenance error involved contact between the body landing gear door and tire. As the aircraft was fuelled and loaded, the oleo extension was insufficient to guarantee clearance between the door and tires when the doors were closed post maintenance. There were a number of factors that led to the problem and this memo addresses the technical element of the error. The attached maintenance tip from Boeing clarifies the need to check the oleo extension prior to operation of the landing gear door ground release handle.

Many thanks in advance, Neil Shepherd Technical Director See over for maintenance tip on this subject

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Commercial MAINTENANCE TIP

Aviation Services CUSTOMER SUPPORT ENGINEERING . BOEING COMMERCIAL AIRPLANES . P.O. BOX 3707 SEATTLE . WASHINGTON 98124-2207

747 MT 32-052

747-400 MT 32-030

747-8 MT 32-001

28 February 2011

SUBJECT PREVENTING BODY LANDING GEAR DOOR / TIRE CONTACT

AND DAMAGE

APPLICABILITY All 747 Series Airplanes CONDITION Body landing gear inboard doors may contact the body gear outboard tires during door

opening/closing when the airplane is on the ground (i.e. not flying and not on jacks). Extension of the shock

struts when the airplane is flying or is on jacks provides additional clearance between the doors and tires and

contact should not occur. RECOMMENDED

ACTION

Prior to moving the landing gear doors by means of ground door release handle movement, normal gear

extension/retraction, or alternate extension, check that both body landing gear shock strut X dimensions (or

minimum exposed chrome dimensions, as applicable) meet the minimum requirement shown on the

placards. The placards are located on each large body gear strut door (refer to the Attachment which shows

the 747-8 example). If the X dimensions are not acceptable, offload weight from the airplane and/or service

the shock struts, per AMM 12-15-04, to achieve acceptable X dimensions before moving the main gear

doors.

Note: Concurrent servicing of the wing gear shock struts per AMM 12-15-03 may be necessary to achieve

minimum body gear X dimensions.

BACKGROUND Operating the body landing gear doors when the landing gear shock strut X dimension is

too small may result in the doors contacting the tires. This contact can result in damage to the body gear

inboard doors and body gear outboard tires. Also, landing gear doors opened when the airplane is lightly

loaded may not be able to be closed once the airplane weight is increased MAINTENANCE

MANUAL ACTION

Notes to ensure that landing gear shock strut X dimensions are acceptable (prior to door operation) currently

exist throughout the various AMM procedures. The AMMs are being reviewed again to ensure that all

affected procedures contain these notes and that the notes are clear. Any revisions that result from this

review will be included in the following Master AMM revisions:

747-Classic (-100/-200/-300) 5 October 2011

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747-400 Series 15 July 2011

747-8 15 July 2011 CMC/EICAS None. MESSAGE

Attachment: Typical X Dimension Placard – 747-8 Example

ATTACHMENT To: 747 MT 32-052

747-400 MT 32-030

747-8 MT 32-001

28 February 2011

Page 1 of 1

Typical X Dimension Placard – 747-8 Example

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3. B747-400 (PW4000) Airworthiness Directives

(Note that engine “shop” visit ADs are not listed) AD 2014-15-14

ATA 28 Fuel Inspecting certain fuel tank access doors for installation of impact-resistant doors, stencils and index markers

Manufacturer

The Boeing Company

Applicability This AD applies to The Boeing Company Model 747-100, 747-100B, 747-100B SUD, 747-200B, 747-200C, 747-200F, 747-300, 747-400, 747-400D, 747-400F, 747SR, and 747SP series airplanes; certificated in any category; as identified in Boeing Service Bulletin 747-28-2315, dated January 11, 2012.

Reason This AD was prompted by report of a standard access door installed instead of an impact-resistant access door and stencils missing from some impact-resistant access doors and adjacent wing skin. We are issuing this AD to prevent foreign object penetration of the fuel tank, which could cause a fuel leak near an ignition source (e.g., hot brakes or engine exhaust nozzle), consequently leading to a fuel-fed fire.

4. Maintenance Related MOR

The following are maintenance related MOR from the UK CAA MOR digest. As the information is protected and strictly controlled by the UK CAA, it is respectfully requested that this information is not circulated. B747-400 Forward drain mast heater wiring damaged and not connected. The aircraft was previously parked for D Check from 17 Oct 2014 to 16 Nov 2014. As report received from operator, the FWD Drain Mast Heater wiring was damaged and not connected, which resulted in the drain mast was being blocked and a lot of flooding in the galleys and toilets. The following actions have been taken by operator: Wiring reconnected with Blue Ray 20's 18 Gauge crimps and heat shrinks wraps, and earth wire connected to stand-off on skin. Defect rectified. The case is under investigation, details of which will be reported later. CAA Closure:

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The drain mast had been replaced at the previous D Check by a contracted foreign EASA Part 145 organisation, but the wiring had not been properly completed and connected to the aircraft at that time. The investigation established that the organisation did not raise a separate work card for the disconnect of the mast wiring therefore no closure action was carried out. The operator has recommended that the organisation issue a quality notice and training actions to address this issue.

B747-400 Electrical burning smell in the cabin. Cabin crew reported burning smell around seat 17A. Cabin crew were instructed to turn off IFE and Seat power switches in CSDs office. The smoke fire and fumes QRH was actioned. Utility power switches were turned off. Cabin crew reported smell lessening as soon as initial actions of QRH were completed. After discussion with Maintrol it was decided to re establish utility power with the IFE and Seat power isolated in the CSDs office. As soon as utility power was reselected the burning smell returned. Utility switches were turned off and remained off for the remainder of the flight. After discussion with Maintrol and Ops Control the flight continued. The passengers were moved from 17a and the adjacent seat and the seat was monitored for the remainder of the flight. CAA Closure: It is now confirmed post investigation that the chiller boost fan was defective, no further reports have been received since the chiller boost fan was made inoperative after the incident, so failure of the chiller boost fan is the most likely caused of the fumes and odours reported.

B747-400 Spoiler actuator rod end found detached. Report into outstation and back into main base of #9 spoiler not deploying. Subsequent inspection revealed rod end had detached from actuator causing actuator to fall and rub on fwd flap assy. Actuator assembly replaced, area of flap inspected iaw SRM. DD raised for corrective action to be carried out next 'A' Check. Actuator replacement c/o satisfactory. All function satisfactory iaw AMM. Off: P/N - 3320550-4, S/N 3376. Maintenance Engineers Report: Surprised to see rod end pulled from actuator, suggest fleet inspection. CAA Closure: Investigation revealed water ingress into the actuator rod threads leading to corrosion. AMM task 27-60-00-200-801 (spoiler actuator corrosion prevention) will be scheduled in for the other aircraft on the fleet at their next 1C check. Long Term Action; Known issue by OEM. Non flight safety. MOOG SIL-27-01 addresses this issue for awareness, for aircraft beyond 75,000 Hrs. Subject aircraft is at 86,000 flt hrs. NB This is the first of this failure modeof this type for the operator. OEM doing an investigation into the corrosion, and will provide any further preventative actions when this action is complete, as appropriate. OEM recommend application of sealant task in AMM 27-20-00-200-A01 at next convenient time such as the next C Check (24 mths).

B747-400 Gear lever would not move up after take-off.

Immediately after take-off, gear lever selected towards UP position but would not move past 'OFF'. 'Speed Intervene' selected and QRH actioned. As gear lever had moved from Down to Off, GEAR DISAGREE eicas message also displayed. Investigation : PLF/AHM showed multiple fault msgs related to the GEAR DISAGREE and GEAR MONITOR status msgs. This A/C has a recent history of landing gear problems, with the landing gear control lever being replaced twice and the PSEU once. It is understood these defects were related to FTD-32-01008. There had been no further landing gear related defects after the second landing gear lever replacement until this event. There had also been no previous reports of the landing gear lever not being able to be moved passed the Off position. Workpackage raised by TSG to troubleshoot the landing gear tilt indication system. Details as follows Aircraft HAD A RECENT EVENT WHERE BY THE CREW WERE UNABLE TO SELECT THE LANDING GEAR LEVER TO UP UNTIL THE SOLENOID OVERRIDE WAS OPERATED. THE AIRCRAFT GENERATED MULTIPLE LANDING GEAR RELATED CMC MSGS. THIS A/C HAS A HISTORY OF LANDING GEAR CONTROL DEFECTS. THE LANDING GEAR CONTROL MODULE HAS BEEN REPLACED TWICE AND THE PSEU HAS ALSO BEEN REPLACED. IN

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THE PREVIOUS EVENT THE GEAR MONITOR MSG WAS DISPLAYED AFTER LANDING. THEREFORE THIS DEFECT MAY BE UNRELATED. PLEASE CARRY OUT THE FOLLOWING: 1. WITH REFERENCE TO FTD-32-01008, CARRY OUT AN INSPECTION OF THE LANDING GEAR CONTROL MODULE, QUADRANT AND CONNECTING ROD FOR SIGNS OF INTERFERENCE OR BINDING. 2. CARRY OUT AN INSPECTION OF ALL WING AND BODY GEAR PRI AND ALT TILT PROX SENSORS FOR CONDITION, CLEANLINESS AND SECURITY. INSPECT ELECTRICAL CONNECTIONS AND HARNESSES AS FAR AS PRACTICAL. 3. REF SSM 32-61-04 AND FIM 32-61 FIGURE 103/32-61-00-990-801-001; CARRY OUT RESISTANCE, AND INDUCTANCE CHECKS (IF POSSIBLE,) OF THE SENSORS: 4. CARRY OUT A TEST OF THE TILT POSITION SENSORS AND THE GEAR LEVER SWITCH IAW AMM 32-61-00-705-001. 5. PLACE THE AIRCRAFT IN AIR MODE AND CARRY OUT FIM TASK 32-31 FIGURE 103/32-31-0-990-801/001 6. CARRY OUT A LANDING GEAR RETRACTION AND EXTENSION TEST IAW AMM 32-32-00-350-801. 7. RECORD ACCOMPLISHMENT OF THIS D7 IN THE AIRCRAFT LOG AS ATA 3230 STATING FINDINGS AND ACTION TAKEN WITH THIS D7 AS REFERENCE. D7 accomplished on the incident date and low insulation was found on left wing gear tilt switch S417. Switch S417 replaced and function satisfactory. Conclusions : Low insulation to ground on a gear tilt switch will cause the landing gear lever interlock to trigger. There are two tilt switches per gear so in this case the Crew through actioning the QRH would have been satisfied that the other left wing gear tilt switch was indicating normal position therefore would have overridden the gear lever lock. Preventative Actions Taken : This is an unusual finding therefore not considered a fleet issue. No further action necessary.

B747-400 Electrical smell from bread warmer in galley during cruise. Cabin Manager reported electrical fumes in Cabin Manager office. Flight crew started to action SFF checklist. Cabin Manager reported that fumes were positively identified by 3 crew members to be originating from the bread warmer, and that upon switching it off the fumes stopped. Confirmation was received from three crew members that the fumes had indeed stopped. SFF checklist halted and crew instructed to pull the CB for the bread warmer to prevent inadvertent switching on. Area monitored for remainder of flight. Engineering contacted on arrival and an AML pt 1 entry made.

B747-400 Aircraft arrived with two defects: 'Bleed 1 HP' EICAS warning and thrust reverser failed to deploy on engine nr1. On investigation found high pressure shut off valve (HPSOV) locked closed and thrust reverser motor isolated. Previous ADD 'bleed 1 overheat' had been actioned and ADD believed closed as log entry stated HPSOV returned to open position. No existing ADD was listed in on ADD sheets. When HPSOV and T/R reinstated, all Ops were normal.

B747-400 APU firebottle faulty due to cut wiring. During electrical test of APU fire simulation which auto fires the APU fire extinguisher when fire detected we were unable to get the necessary squib discharge voltage at the bottle. Extensive fault finding found 3 wires cut inside lower P6 panel in the flight deck at the diode block TD314F module M3991. This would have prevented the auto discharge of the APU firebottle should there have been a fire when the APU was running but the aircraft was not being monitored.

B747-400 MCP Altitude selector malfunctioned.

During approach, MCP Altitude selector jumped to unrequested values several times. Auto pilot reacted to unrequested level off and vertical modes were required to be reselected. Additionally amber minimum speed bar ( hockey stick) appeared to generate unusually high minimum speeds above FL200. This recovered to normal figures below FL200. Previous sector had some issues of a similar nature.

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B747-400 Potential for Cat B Mandatory overrun on engine parts. During a review of Life Limited Parts data, it was noted that engine 13382 did not have any LLPs fitted to the 04 Module on the maintenance database. These parts have finite lives limited by Chapter 5 and hence there is a potential for a Cat B Mandatory overrun. The missing components are HPC Rear Rotor Shaft Assy, HPC Rotor St.1&2 discs, HPC Rotor Disc St.3, HPC/T Joint Support Disc, HPT Disk. CAA Closure: A subsequent review of the event identified that the engine did not have any LLPs installed on it on the maintenance database subsequent to its data build, which was due to staff error. The LLPs have now been installed correctly on the database and no overrun has occurred as the units all have adequate life remaining. A 100% review of all this fleet's config checks has been carried out to confirm that there are no similar errors and config checks on all the other fleet types will be continually monitored.

B747-400 Nr4 engine vibration. Nr4 engine vibration (N1/BB) had been constant around 1.8 (slightly higher than norm). Aircraft entered light turbulence for 20 mins. Vib increased to max 3.3. When clear of turbulence vib reduced to 2.5. Maintrol contacted. Vib monitored for remainder of flight. F350 maintained. Vib reduced during flight as weight and EPR reduced. 9 hrs into flight, vib 1.9, wgt 248, EPR 1.51. Previous sector reported high vib Eng 4. Engineer suspected cause to be a strut for holding the eng cowling open, which he found to be loose. He tightened this and requested further reports. CAA Closure: After arrival, MCDs, scavenge and pressure filters were removed and inspected along with an inspection of the inlet and exhaust, with all found satisfactory. Due to the history of this engine having erratic and higher than average LP vibration, further tasks were actioned which included: 1. Remove the LP fan blades. Clean and inspect blade roots and chocking pads. Replace as required. Also inspect the fan disc chocking pads for security/displacement. Replace as required. 2. Clean and re-lube blade roots. Ensure all previous applications of Dry Film Lube on the dovetail flank faces is removed. 3. Inspect annulus fillers. Replace as required. 4. Inspect spinner P-Seal. Replace as required. 5. Re-install the LP Fan Blades. 6. Carry out Test 11 vibration survey and if necessary Test 16 Fan Trim Balance in order to achieve vibration level below 0.8 A/C units. Subsequent vibration survey carried out resulting in a peak vibration of 0.4 units. A review of engine vibration trend monitoring data since this rectification work shows that this engine's vibration level continues to be low and stable. This engine's LP vibration was most likely due to wear of dry film lubricant and/or loss of chocking pad security within the fan system. The actions taken were effective at addressing these potential causes.

B747-400 Discharge nozzle found disconnected from fire bottle valve assembly. Investigation not disclosed

B747-400 Landing gear could not be selected up. On the call of " positive rate ' the landing gear leaver could not be moved past the off position and hence the gear could not be retracted. The autopilot was engaged and the departure continued to be flown. The weather was poor in the area with significant Cb activity. ATC did not respond to a PAN call or the subsequent MAYDAY call. A second attempt to select the gear up was attempted and although there was some resistance around the off position, the gear lever was moved to the up position and the gear retracted normally. No EICAS messages were received during this event. Once the gear had been successfully retracted, two status messages remained, Gear Disagree and Gear Monitor. The flight continued.

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B747-400 Uncommanded thrust reduction to idle on engines nr2,3,4.

At flap 5, as thrust was commanded to reduce from TO thrust (1.72) to climb1 (1.52), the thrust reduced asymmetrically with no1 thrust lever reduced to climb1, and thrust levers 2,3,4 continuing aggressively towards idle. The FMAs were normal, showing THRUST REF/ LNAV / VNAVSPD AT was disconnected, full TO thrust restored, and climb out and clean up continued. In the resultant GA there was an EGT exceedance on no3 engine (max 744 degrees), and an N2 exceedance on eng1 ( max 106.5 ) aircraft has history of a similar event happening a few days earlier, 29/1/2015, tech log entry, passing FL270, the aircraft reduced thrust, uncommanded, to idle on engines 2,3, and 4.

B747-400 Emergency lights inoperative. Emergency light defect raised during routine 2a check. G2 lights and dr2r exit signs inop. Powered from battery pack. After extensive investigation supply and ground wires found connected together with jiffy quick release splices and exit sign fly leads connected together. Note, short to earth was 0.5 ohms and didn’t always blow the battery pack fuse immediately. Exit sign would never have worked from fit.

B747-400 On arrival of aircraft, loaders reported aft cargo door would not open.

The Ground Crew attended and manually wound the latch and hook actuators and the door then opened electrically on the lift actuator, revealing a four section seal depressor protector still partially attached to the aft seal depressor. Full inspection of seal depressor, door mid span latches and switches revealed no obvious damage. Door closes fully electrically with no visible damage to door or misalignment. Inspection from inside with door closed actioned satis, seal/depressor as required. Due to door opening issue a/c despatched with aft hold empty.

B747-400 Rejected take-off due to hydraulic system failure. RTO due hydraulic system failure msgs. During take-off at approximately 130kts 'HYD PRESS ENG 1' eicas msg followed shortly after by 'HYD PRESS DEM 1' eicas msg. 'STOP' called and uneventful RTO carried out iaw with QRH. Initial checks completed and runway vacated. Brake cooling time assessed and aircraft towed to remote stand. Passengers informed frequently. Passenger mood generally good.

B747-400 EICAS Brake Limiter and Antiskid Off. In cruise Brake Limiter and Antiskid Off Eicas messages with associated Status messages plus Park Brake Valve status message. Park brake valve not in fully open position during flight caused the messages. QRH actioned and Maintrol contacted. No further information was gained from Maintrol. Precautionary PAN was declared with London ATC. Landing and taxi in normal.

B747-400 Ring spanner found in RH landing gear bay. During routine inspections in the right hand wing landing gear bay a 5/8" Snap-on open ended / ring spanner was found on top of panel beneath the #3 tank aft override/jettison pump. The spanner doesn't have any ownership identification markings on it whatsoever other than the manufacturers trademark.

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B747-400 Fire risk from damaged mobile phone (PED) crushed in seat mechanism. Fire risk from damaged mobile phone. During the cruise, a passenger moved his seat and heard a crunching sound. Realising he had dropped his phone into the seat mechanism he asked a crew member for help. The seat was moved back and as the phone became visible the passenger attempted to pick it up. However it was extremely hot. The crew member picked it up with an eye shade and quickly placed it in an ice bucket. The phone had become so hot that the SIM card had melted. Had the phone not been quenched so quickly there could have been a fire risk. Pax stated to crew member that had lost his mobile phone. Proceeded to recline his flat bed seat. Phone was jammed on the side of the seat and was cracked by this action. Phone turned very hot and was placed in cold water (inside an ice bin) by main crew member AAA, possibly avoiding a dangerous situation (PED/lithium battery fire).

B747-400 Open Tech Log entry on arrival. Nr1 engine thrust reverser not open and collared iaw procedures. Aircraft dispatched with the #1 REV locked out. Entry 04, page 1529325 not signed. Not done IAW 78-31-01, under maintenance item 2A, CB's ENG #1 TR/IND and ENG #1 T/R CONT not open and collard. Engine T/R lockout plates found fitted correctly.

B747-400 Kruger flap top edge moulding detached from RH wing on initial climb.

The A/c arrived at maintenence base with following defect. No 16 Kruger Flap has top edge moulding missing. The missing part was deferred using MEL 05. The Boeing 747 CDL does contain some relief for the Inboard Strut seal but imposes a number of performance penalties. A review of the IPC suggests that the part specified is not that covered by the CDL. There appears to be nothing in the AMM, SRM or CDL to allow dispatch in this condition therefore it would appear that design authority would be required.

B747-400 Suspected incorrect installation lead to discovery of main battery charger (+) terminal burned and incomplete.

The aircraft returned to stand with a Main Battery Discharge advisory message. On attempting to replace the main battery charger the crimp tag on the positive terminal was found to be burned and incomplete. The stud, washers and nut on the charger showed no overheating or other damage what so ever. Also the damaged tag end showed signs of rework with a file. As a hydraulic crimp tool was not available an aircraft change was called. The aircraft was then made safe and passed to night shift/PRT team. The indications are that someone knowingly fitted a new charger with the crimp in this condition and may . or may not, be the person who 'reworked' the crimp.

B747-400 Incorrectly fitted passenger service units.

During routine maintenance it was discovered that the overhead PSU's including oxygen, between 42-44 HJK, had been incorrectly fitted in such a way as to prevent the deployment of the oxygen masks in an emergency. All PSUs removed and refitted correctly. No damage. CAA Closure: Despite enquires and technical documentation review it was not been possible to identify beyond doubt exactly where the incorrect installation of the PSUs may have occurred. The Tech Log review did not reveal any PSU related work preceding this finding and from the account of the rectifying engineer the incorrectly fitted panels would be easily noticed by anybody in the vicinity. Statement received from the reporting engineer in relation to the work carried out to rectify the finding. No recurrence of this type of incident since.

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B747-400 Passenger Oxygen Units (PSUs) failed flow checks. Passenger Oxygen Units (PSUs) failed flow checks when AMM Oxygen Mask Drop Test carried out. PSU No Flow Passenger Cabin (No of mask failures unknown). PSUs sent for investigation and pre-test. CAA Closure: Workshop investigation and test identified that 17 of 34 defective masks operated normally at 5 PSI (ground pressure) and that all other masks operated within 20 PSI, which is acceptable per CMM test parameters for normal operation. During disassembly, no abnormal internal defects were noted with the PSUs and masks other than 11 of 34 units were suffering from kinked PSU to mask hoses that may have further limited flow to the affected masks. Hose kinking is typically indicative of masks having been subject to in-service uncommanded deployment that have subsequently been repacked not per the AMM instructions. However, a review of the aircraft technical history since last PSU replacement did not record any widespread uncommanded PSU deployments for the affected positions. As the PSU / masks had all been overhauled in 2009, all operated within CMM specifications and no abnormal conditions were noted with the manifold assemblies, it is considered that these PSU/mask equipment would have worked when subject to operation at altitude as opposed to simulated altitude testing on the ground. As remedial action, this event and its findings are to be discussed further with Boeing to review the possible benefits of using a valve seal lubricant to enhance the PSU's operational reliability. It was also considered necessary to publish a Technical News document to highlight the importance of correct PSU mask packing per the AMM to prevent damage to the masks and hoses after in-service deployment.

B747-400 Flaps Drive' message on selecting F20 to F30 during approach. Inboard trailing edge flaps jammed. Go -around flown.

On selecting F30 a "flaps drive" caution was received. Inboard trailing edge flaps jammed. Go around flown and QRH actioned. Aircraft reconfigured for F25 vref30 + 25 and another R/W requested. Rnav approach and landing made. CAA Closure: It is concluded that insufficient lubrication and possibly a marginal RVDT was the cause of this event. As this is a repeat ASR a repetitive defect history record raised to control and monitor this defect.

B747-400 Fuselage dented from falling control lock during maintenance and aircraft returned to service without rectification. The aircraft was AOG from 6-Apr to 8-Apr due to a rudder actuator leak. During rectification of this defect, a control lock fell from height onto the aft fuselage causing severe dent/crease damage at a stringer location. The aircraft was returned to service with no assessment/damage report performed and flew with the damage unrepaired and unapproved. Details of Occurrence: The subject aircraft became AOG upon arrival. The initial defect was reported as a ‘centre rudder actuator leaking beyond limits.’ This defect did not require FTM Structures involvement, however we monitor AOG events regardless in case our input becomes necessary. The initial Tech. Ops AOG Update Alert was received at 0256 on 7-Apr. Further updates were received through the day and into the following morning Wednesday 8-Apr. At 0636 on 8-Apr, an update was received by FTM Structures which reported: “RUDD LOCK FELL OUT DURING A/C MOVE. ASSESSMENT TO BE C/O PER SRM.” /CONT ON ATTACHED SHEET/Immediate Corrective Actions Taken: None. Currently AOG on arrival awaiting detailed damage evaluation and structural repair. CAA Closure: This incident occurred in the immediate aftermath of change of service provider. Post this incident ‘Organisational Change’ is now included in Risk Log to ensure non recurrence of similar situations where the change programme may be implemented. The operator instigated a period of oversight of the service provider by provision of engineering staff to support the transition and provide additional training on their process and procedures. It was confirmed by the service provider that the area of impact was inspected prior to aircraft departure. However, the extent and findings of the preliminary damage assessment were not adequately documented by engineering staff. Additional training on the operator's systems and process provided by way of recurrence prevention.

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B747-400 Brake temperature warning due to dragging brakes. Dragging brakes on right hand side reported by crews on previous x 3 sectors in tech log. Engineering found no faults. Aircraft required power to maintain taxi-speed of 10kts. Taxi-out longer than usual as 18L in use, 17R was closed. Taxi-out completed with gear EICAS page selected to monitor brake temps. At RWY hold, brake temps on RHS ranged between 0 and 2, all LHS temps 0. Crew brief amended to include leaving the gear down after take-off to cool brakes. During take-off roll gear EICAS left displayed to monitor brakes. The rear left wheel on the RHS body gear was seen to increase rapidly to 3 then 4, during latter stage of the take-off run, once airborne the indication on this wheel increased to 5 which triggered an EICAS "brake temp" message. QRH actioned, wheels left down & clarified with ATC Tower Controller that this was intentional. On approach Fire service put on local standby as precaution. Autobrake 2 selected + Max available reverse thrust, 1+4 (no 3 REV U/S), all runway used for gentle deceleration. Brake temps from 0 to 1 on taxi. Brake temps are slowly rising during taxi-out due to dragging brakes but this isn't shown on B.T.M.S as per Ops FRCOM. The system doesn't show accurate temps for 10-15 mins after brake application. An RTOW even from a slow speed would cause fuse plugs to melt on several wheels & there is great potential for brake fire. Please don't dispatch A/C again until fault is found & fixed. CAA Closure: During investigations, Tech Log entries indicated that the correct troubleshooting was undertaken between each sector and the aircraft deemed serviceable. The final piece of troubleshooting identified that the defect was attributed to worn cables and pulleys which were subsequently replaced and the aircraft made serviceable. No further recurrence since rectification and considered an isolated incident.

B747-400 Inspection not carried out when stated.

Notification was raised. The text of the notification stated that it had to have a 4A repeat inspection for further corrosion. the 4A check was accomplished 175 days previous and this inspection was not carried out. I was approached by EMM who had been contacted by core Planning. The Aircraft was on its return leg so we called the Inspection on its arrival. This caused an A/C change and a night stop to complete the Inspection.

B747-400 Double EEC failure. During cruise in IMC (mid southern Atlantic in warm moist conditions, with surrounding CB activity and static discharge) ENG 2 EEC MODE master caution annunciated, followed by eng2 and eng3 EPR gauges failing. QRH actioned and flight continued without event CMC interrogated, which showed failure of both 2 & 3 EECs; Maintrol advised via satphone, due to no dispatch allowable with 2 EECs u/s. Pitot static icing suspected due to atmospheric conditions. Crew briefed wrt possible A/S unreliable, and subsequent actions required if necessary. Engineer at GRU was alerted by maintrol and immediately inspected pitots on arrival; also suspected ice accretion. Supplementary Rep 29/06/15 From the above investigation it can be concluded that the EEC failure on engines 1 and 2 was as a result of an ice crystal event which blocked the P2.0/T2.0 probe line on these engines. As the EEC uses readings from this probe to calculate EPR, the EEC MODE EICAS message was displayed as the EECs could no longer compute EPR. The EEC were therefore placed into alternate mode and the aircraft flown in N1 reversion mode. There is a known problem with TAT probes icing on all fleets, which is under investigation with Boeing. The icing events normally occur above convective cloud formations mainly in equatorial areas, however BA has seen some events in the North Atlantic and Europe. Very small ice crystals (approximately 70microns in diameter) are formed above convective cloud formations, they are too small to disperse from the TAT / T2 probe and therefore build up and this causes it to freeze.

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B747-400 Engine vibration during initial climb.

Shortly after T/O there was an engine VIB pop up. No. 4 engine indicated an N3 VIB of 2.8 which also caused a CMC printout. The vibration was monitored in the climb and the P3 advised engineering. The N3 and BB VIB initially reduced to 1.3-1.5 in the cruise but after 2 hrs with the a/c level at FL350 the N3 VIB increased to 2.9. Maintrol updated and a report and manual snap shot sent. Supplementary 05/07/15: Tech log report of on taxi out eng 4 did not respond to lever movement. EICAS msgs Elec Gen off 4. EGT rose to 680 deg C. Oil pressure fell to 6 PSI followed by Eng 4 Autostart EICAS. Maintrol informed. Eng 4 started manually with Autostart selected off. During initial climb vib pop up Eng 4 indicated an N3 Vib of 2.8. In cruise the vib was from 2.2 to 2.9. Boroscope inspection completed for high stage compressor. Multiple blade damage found. Engine replacement required.

B747-400 Fuel fumes in cabin after engine start. After engine start the cabin crew reported smell of fuel in cabin in the vicinity of the forward part of c zone (just aft of csd's office). Smoke fire fumes QRH actioned which led to an improvement. Aircraft returned to stand after consulting maintrol. Supplementary Rep 21/07/2015 Leak traced to LWR RH corner of centre fuel tank FWD face. Fuel was found to be leaking from CWT LWR R/H side sta1000 STR39. Bolt was removed from the bathtub fitting. Upon further investigation the bolt hole was found to be badly scored. Bathtub fitting will have to be replaced before further flight. Bath tub fitting replaced leak checks with full centre tank carried out, no leaks noted. A/c back into service with no further reports.

B747-400 External power receptacle found severely damaged by overheating.

On landing for an input into MC, panel P36 was inspected prior to application of external power. Power receptacle No1 was seen to be severely damaged by overheating . On closer examination, the C phase pin of the receptacle was found to be loose and therefore compromising the airtight seal. The surrounding area was also showing the effects of heat. Receptacle No2 appears normal.

B747-400 Alternate gear extend switch inadvertantly activated on stand.

While on stand and engineering were investigating a "No Land 3" msg the Nose/Body Altn Gear Extend switch was activated. Activation of switch caused Nose and Body gear doors to open. Engineering contacted and after father investigation and after ensuring the area around gear was clear Hyd 1 & 4 were pressurised and gear doors retracted. Supplementary Rep 16/7/2015 I was tasked to attend a report of an EICAS Status MSG "NO LAND 3" On arrival at the aircraft, I noticed that the nose gear and body gear doors were open. I discussed with the Captain the "NO LAND 3" msg and the fact that the gear doors were open. He mentioned that an engineer had been on the flight deck earlier and pressed the "ALTN GEAR EXTEND (NOSE/BODY)" switch located on panel P2-3. I called the T5BS satellite office to find out why the gear doors were open. The office was unable to answer my question The refueller arrived on the flight deck and expressed his concerns that the gear doors had been opened during refuelling and he had not been informed. I received a call from the AMS in charge of the aircraft. We discussed that the doors had

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been opened by use of the "ALTN GEAR EXTEND (NOSE/BODY)" switch. After confirming the area was clear of personal and equipment, we closed the gear doors, with all indications returning to normal. The AMS left the aircraft to attend to other duties. Shortly afterwards a B1 FMA arrived to certify log entry AK1304931. I had a brief discussion with the LMA technician who had pressed the "ALTN GEAR EXTEND (NOSE/BODY)" switch. I concluded that he had been in contact with the T5BS satellite office and was trying to clear the "NO LAND 3" status msg. I was not on the flight deck whilst he was doing this, so I am not aware of the conversation he had. The result of the conversation was that the "ALTN GEAR EXTEND (NOSE/BODY)" switch was pressed. He was not aware that the doors had opened. Pressing the "ALTN GEAR EXTEND (NOSE/BODY)" switch results in the nose and body gear doors opening. These doors would have opened without warning, which CAN CAUSE INJURY TO PERSONS OR DAMAGE TO EQUIPMENT. Furthermore, if the hydraulic system had been pressurised when the aircraft was in this configuration, then the doors would have closed without warning which CAN CAUSE INJURY TO PERSONS OR DAMAGE TO EQUIPMENT.

B747-400 MAYDAY declared due to tailpipe fire on shutdown following 'Engine Fuel valve 3' message.

Eng fuel valve 3 message on shutdown followed by brief tailpipe flame. As fuel control was already at cut-off the fire handle was pulled on advice from engineer on headset who was visual with the engine. Flame extinguished. Mayday declared until fire was confirmed extinguished by the fire crew. Fire crew remained in attendance until passengers all disembarked. Maintrol briefed on sat phone after event. No engine limits exceeded - max temp estimated 580C. Supplementary Rep 23/7/15 : On arrival during engine shut down at 2030 crew had EICAS 73755 eng 3 fuel press active and 73756 engine 3 Fuel metering unit shut off valve followed by a tail pipe fire flame observed by ground engineer Crew pulled the fire handle as cut off had already been selected and flame extinguished without blowing the fire bottles. Tail pipe fire checks actioned satis. Check start aborted due to large fuel leak reported, Engine fuel system visually inspected with no obvious defects and blown through and collector tank drained. Check start attempted but large amount of fuel again. FMU change required. Work party sent to investigate/rectify as this is an agency station. Subsequently have had verbal report from C&C that this engine had been shutdown on the fire handle prior to the service. . B747-400 Incorrect securing of wire loom. Wire loom adjacent to the ram air exit door position switch S572 found to be laced onto a drain pipe contrary to BSWPM.

B747-400 Nr3 engine 'OVHT STRUT' EICAS message in cruise. Prior to departure, the aircraft was carrying MEL item 73-21-01 also STRUT OVHT LP B. During the cruise OVHT ENG 3 STRUT EICAS occurred with STRUT OVHT LP A status msg. QRH actioned but OVHT ENG 3 STRUT did not clear so Eng 3 operated at idle thrust for remainder of flight. FMC ENG OUT page reviewed and clearance obtained to reduce speed to M82, maintaining FL370, via CPDLC from Gander. Flight continued and ILS to R/W 27L carried out for auto land. Diversions were available in the event of a second engine malfunction. Lengthy consideration given to declaring a PAN but not required. Fuel balancing carried out resulting in equal fuel distribution across tanks on landing. Pax and crew not informed as situation contained. Engineering advised by ACARS message and again by VHF on arrival. CMC reviewed, all Eng parameters were normal. Post-flight review carried out on flight deck.

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5. B747-400 Gear Actuator fitted upside down (Serious Incident)

Aircraft Type and Registration: Boeing 747-443, G-VROM No & Type of Engines: 4 General Electric CF6-80C2B1F turbofan engines Year of Manufacture: 2001 (Serial no: 32339) Date & Time (UTC): 29 December 2014 at 1334 hours Location: Near London Gatwick Airport Type of Flight: Commercial Air Transport (Passenger) Persons on Board: Crew - 18 Passengers - 447 Injuries: Crew - None Passengers - None Nature of Damage: Damage to right wing landing gear door and strike board Commander’s Licence: Airline Transport Pilot’s License Commander’s Age: 47 years Commander’s Flying Experience: 12,279 hours (of which 9,771 were on type) Last 90 days - 162 hours Last 28 days - 95 hours Information Source: AAIB Field Investigation Synopsis of Serious Accident. Shortly after take-off from London Gatwick Airport for a scheduled flight to Las Vegas and following retraction of the landing gear, low quantity and pressure warnings occurred on hydraulic system 4, due to a hydraulic fluid leak. The required checklists were completed and the aircraft returned to land at London Gatwick Airport. As the landing gear extended during the approach, the right wing landing gear struck the gear door, preventing the gear leg from fully deploying. The crew carried out a go-around and, following a period of troubleshooting and associated preparation, a non-normal landing was successfully completed. It was subsequently determined that the hydraulic retract actuator on the right wing landing gear had been incorrectly installed. This incident resulted in several Safety Recommendations being issued.

Synopsis of Pre-flight Maintenance Activity G-VROM had a history of hydraulic fluid leakage from the gear actuator piston rod gland seal on the right wing landing gear. In order to rectify this, a Technical Services Work Order (TSWO) was raised by the operator’s engineering department. The actuator removal and installation was scheduled to be carried out in the operator’s hangar at London Gatwick Airport, during the day shift on Sunday 28 December. The certifying engineer who led the day shift team stated that he spent considerable time trying to locate the fishpole hoist specified in the AMM, but in the end obtained a hoist designed for installation/removal of the aircraft Auxiliary Power Unit (APU) from the tool store. He reported difficulty in sourcing the correct tooling for other elements of the task as well and raised a Ground Occurrence Report (GOR) to highlight this to the operator’s safety department. However, the team stated that the unserviceable actuator was eventually removed from the aircraft without using either the sling or hoist. They identified that the AMM did not contain instructions on how to use the sling or how to use the hoist and sling combination to maneuver the actuator. Once the unserviceable actuator had been removed from the aircraft, the associated fittings were transferred to the replacement actuator on the work bench. Delays caused by the late arrival of the aircraft to the hangar and a requirement for additional parts to be sourced for the

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replacement actuator, meant that it could not be installed by the day shift team, so the task was handed to the night shift team who came on duty that evening. An additional engineer, with some experience of installing a landing gear actuator, was reassigned to assist due to the additional workload this task placed on the team. The night shift team reported that the task handover provided by the day shift team was “excellent”. The installation procedure commenced at approximately 2145 hrs and began with the team positioning a set of steps and a lifter platform, carrying the replacement actuator, underneath the aircraft. In order to install the actuator it had to be passed through a section of structure in the wing. The team positioned spill bags to prevent damage from any contact between the actuator and the wing structure. The sling and hoist were not used by the team, who instead manhandled the actuator between the two technicians standing in the lifter and the engineer standing on the steps. The weight of the actuator was then supported by the two technicians, while the engineer attempted to install the pin which secured the actuator to the hanger. After 20 minutes of unsuccessful effort, the team’s positions were rotated and they tried again to locate the pin for a further 10 minutes. Eventually the actuator was successfully secured in place by one of the technicians. The team then continued to work through the night to reconnect the hydraulic hoses and leak check the hydraulic system. The AMM did not require a full operational test of the landing gear actuator following replacement, just a selection of the gear lever up with the gear locking pins in place, to check the gear leg began to move before being restrained by the locking pin and to check for leaks. The aircraft was then prepared and released for service that morning.

Fig 1 Damaged hydraulic port on landing gear actuator – Note distorted hydraulic port boss fitting and damage

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Fig 2 Wing landing gear actuator

Fig 3 Initial aircraft inspection

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Post Incident detailed inspection of the wing landing gear The aircraft was recovered from the runway and towed to the operator’s hangar for further investigation. The damaged wing landing gear door was removed and the right wing landing gear leg fully extended. The right wing landing gear actuator was found installed 180° out of alignment. The hydraulic port boss fitting on the head end of the actuator was distorted and damaged (see Figure 1). For a full description of this serious Incident refer to the complete report document which can be found in the useful folder section.

End