Bundesstelle für

Flugunfalluntersuchung

German Federal Bureau of

Aircraft Accident Investigation

Investigation Report
Identification
Type of Occurrence: Serious incident

Date: 1 March 2010

Location: Near Stuttgart

Aircraft: Airplane

Manufacturer / Model: Cessna Aircraft Company

Cessna 525A

Injuries to Persons: No injuries

Damage: Minor damage to aircraft

Other Damage: None

Information Source: Investigation by BFU

State File Number: BFU 7X001-10

Factual Information

History of the Flight

On 1 March 2010 at 0803 hrs1 the airplane took off from Stuttgart Airport for a ferry
flight to Bremen. No other persons besides the pilots were on board. The pre-flight
check, engine start-up, and take-off were uneventful. Simultaneously with the
retraction of the flap from 15° to 0° the pilot noticed unusual vibrations and a strong

1 All times local, unless otherwise stated.

 Investigation Report BFU 7X001-10

left yawing moment. Immediately afterwards he heard the acoustic warning Left
Engine Fire. He stated that at that moment the inter-turbine temperature (ITT) was far
in the red area. Therefore, the thrust lever was pulled into Idle and immediately
afterwards into shutoff position. Then the left Engine Fire Switched was pushed. After
a few seconds the fire warning stopped so that the Engine Fire Bottles were not
actuated. The pilot stated that at that time the vibrations were only slightly noticeable.
The indication for N2 showed zero and for N1 approximately 20%. In the further
course of the flight the vibrations increased again.

The airplane returned to Stuttgart Airport and landed at 0822 hrs without further
incident.

Personnel Information
The 46-year-old Pilot in Command (PIC) held an Airline Transport Pilot Licence
(ATPL(A)) initially issued in 1987 and valid until 20 December 2014. His class 1
medical certificate was valid until 20 June 2010. He had a type rating as PIC for
Cessna 525 valid until 27 February 2011. He also had valid ratings for the aircraft
type CLRJ 100 and for single and twin engined piston land aircraft.

His flying experience:

Total Approx. 21,000 hours

On the type: Approx. 300 hours

In the last 90 days: 128 hours

In the last 30 days: 52 hours

Aircraft Information
The aircraft Cessna 525A is a twin-engine low-wing airplane. It is called Citation Jet
2+ (CJ2+). The airplane has six seats. Both engines are installed at the tail section.

The last Airworthiness Review Certificate (ARC) was issued on 30 July 2009 and
valid until 29 July 2010. The aircraft had a valid German Certificate of Registration
and was operated by a German air operator.

At the time of the serious incident total operating times of airplane and engines were
1,223 flight hours and 1,161 cycles.

-2-
 Investigation Report BFU 7X001-10

Manufacturer: Cessna Aircraft Company

Year of manufacture: 2007

Serial number: 525A-0358

MTOM: 5,613 kg

Engines: Williams International FJ44-3A-24

Serial number: 216118

The engine FJ44-3A-24 is a two-shaft turbofan engine. The two-stage Low Pressure
Turbine (LPT) powers a single-stage fan and a three-stage axial Intermediate
Pressure Compressor (IPC). The single-stage centrifugal High Pressure Compressor
(HPC) is powered by the single-stage High Pressure Turbine (HPT). The engine has
an annular combustor. An annular jet distributes the fuel in the area of the rotor
shafts outward into the combustion chamber.

Meteorological Information
According to the Meteorological Aviation Report (METAR) of Stuttgart, time of issue
0820 hrs (0720 UTC), the following weather conditions prevailed:

Wind: 120° / 03 kt

Visibility: More than 10 km

Precipitation: None
Clouds: 1/8 – 2/8 in 2,000 ft.

Temperature: 5°C

Dewpoint: -1°C

Air Pressure: 1,009 hPa

Radio Communications
Radio communications with the air traffic control unit at Stuttgart Airport had been
established.

-3-
 Investigation Report BFU 7X001-10

Aerodrome Information
Stuttgart Airport is an international airport. The airport has one runway with the
direction 074°/254° which has a length of 3,345 m and a width of 45 m.

Flight Recorders
The airplane was not equipped with a Flight Data Recorder (FDR) or a Cockpit Voice
Recorder (CVR). These recording devices were not mandatory.

Wreckage and Impact Information

After the landing it was determined that the aft outer side of the left engine cowling
had been destroyed. The engine had been damaged in this area. The engine cowling
showed evenly spread puncture traces.

The engine examination was conducted at facilities of the engine manufacturer

Williams International under supervision of the US National Transportation Safety
Board (NTSB). The fan and the two compressors did not show any apparent
damages. The diffuser case and skirt did not show any thermal distress. But the inner
diameter of the skirt was sooted. The brazed forward end of the skirt was cracked
between the 9:30 and 8:00 o'clock2 position. The diffuser skirt had multiple axial
cracks at the rear edge and several circumferential cracks radiating from the axial
cracks.

The skirt was missing a section from the aft edge between the 2:00 and 3:00 o’clock
position. The missing section had the size of 106 mm x 108 mm x 60 mm x 34 mm. It
was found in the back of the combustor cover.

The hole in the diffuser skirt for the fuel manifold tube was ovalized and the clockwise
side of the hole on the outer diameter had raised metal. The outer diameter of the
fuel manifold tube showed abrasion signs.

The combustion cover showed holes and soot traces.

The fuel manifold tube fractured at the brazed outer edge to the diffuser housing.

2
All locations on the engine, or directions, as referenced to the clock, will be as viewed from the aft
looking forward, unless otherwise specified.

-4-
 Investigation Report BFU 7X001-10

Damages were also determined on the high and low pressure turbines and the
exhaust pipe. The low pressure turbine case was burned away between the 6 and
9 o’clock position.

The engine manufacturer also conducted a microscopic examination of the fuel pipe
and the cracks on the diffuser. But this examination was limited to the fracture
features which had not been obliterated. The forward and aft cracks on the diffuser
showed clear signs of fatigue fractures. The investigated fracture surfaces on the fuel
manifold tube also showed signs of fatigue fractures. They originated in the brazed
joint fillet radius in the fuel manifold assembly and continued into the area of the tube.

Fire
The engine cowling and the pylon showed signs of fire.

Additional Information
During two previous flights the odour of smoke had been noticed in the cabin. It could
be eliminated by selecting the Air Source switch to the right engine. During the
previous six months it was observed that the turbine temperature of the left engine
was about 20° - 30°C higher. On 11 November 2010 and on 7 December 2009
boroscope inspections of the left engine were conducted.

At the time of the engine examination the engine manufacturer stated that so far no
fractures on the diffuser of the FJ44-3A-24 model had occurred. There were however
17 cases in the entire FJ44-3A program. The diffuser was reinforced in combination
with the development of the FJ44-4 model. Gradually, the FJ44-3A and FJ44-3A-24
models should be re-fitted with this diffuser. Williams International issued the Service
Bulletin (SB) FJ44-72-093 for that purpose.

On 5 April 2010 Williams International informed all operators of this engine about the
serious incident and described three signs for diffuser damages:

 a persistent bleed odour

 a sudden increase in inter-turbine temperature (ITT) or in the ITT split between

engines of 30°C

 difficulty removing the start fuel nozzle adapter or igniter.

-5-
 Investigation Report BFU 7X001-10

The engine manufacturer stated that by January 2015 almost all FJ44-3A-24 engines
had been refitted with the modified diffuser. So far the engine manufacturer has not
received any information about fractures on the modified diffuser.

Analysis
The diffuser cracks were caused by naturally occurring airflow buffeting and vibratory
modes of the inner flow path within the engine run range. The cracks at the forward
end of the diffuser inner flow path allowed the inner flow path to separate and move
aft until contacting the fuel manifold tube which subsequently failed due to vibration.
The fracture of the fuel manifold tube allowed an uncontrolled amount of fuel to enter
the combustion zone which resulted in the burn-out of the combustion cover. All other
damages were secondary damages.

The firewall of the airplane prevented the fire from affecting the aircraft structure. The
intensity of the fire was so low that the shut-off of the engine was sufficient to
extinguish the fire. Therefore the use of fire extinguishers was not necessary.

The noticed smells of the bleed air and the increased inter-turbine temperature (ITT)
of the left engine can be viewed as first signs of damage.

The pilot correctly carried out the actions necessary to cope with this situation.

The engine manufacturer's corrective action by refitting the engine model with the
modified diffuser turned out to be effective because the fractures on the diffuser have
not occurred again.

Conclusions
The serious incident was caused by fatigue fracture on the diffuser.

Safety Recommendations
Safety recommendations were not issued due to the manufacturer's corrective action.

Investigator in charge: Karge

Braunschweig: 11 November 2015

-6-
 Investigation Report BFU 7X001-10

Appendices

Destroyed engine

Damaged engine cowling and turbine Photos (2): Operator

-7-
 Investigation Report BFU 7X001-10

Location of the fracture and cracks in the engine Source: Engine manufacturer/BFU

-8-
 Investigation Report BFU 7X001-10

This investigation was conducted in accordance with the regulation (EU) No. 996/2010 of
the European Parliament and of the Council of 20 October 2010 on the investigation and
prevention of accidents and incidents in civil aviation and the Federal German Law
relating to the investigation of accidents and incidents associated with the operation of
civil aircraft (Flugunfall-Untersuchungs-Gesetz - FlUUG) of 26 August 1998.

The sole objective of the investigation is to prevent future accidents and incidents. The
investigation does not seek to ascertain blame or apportion legal liability for any claims
that may arise.

This document is a translation of the German Investigation Report. Although every effort
was made for the translation to be accurate, in the event of any discrepancies the original
German document is the authentic version.

Published by:

Bundesstelle für
Flugunfalluntersuchung
Hermann-Blenk-Str. 16
38108 Braunschweig

Phone +49 531 35 48 - 0

Fax +49 531 35 48 - 246

Mail [email protected]
Internet www.bfu-web.de

-9-