British Airways flight BA38 was on approach to London (Heathrow) from Beijing, China, at 720 feet agl, the right engine of G-YMMM ceased responding to autothrottle commands for increased power and instead the power reduced to 1.03 Engine Pressure Ratio (EPR). Seven seconds later the left engine power reduced to 1.02 EPR. This reduction led to a loss of airspeed and the aircraft touching down some 330 m short of the paved surface of Runway 27L at London Heathrow.
The investigation identified that the reduction in thrust was due to restricted fuel flow to both engines.
It was determined that this restriction occurred on the right engine at its Fuel Oil Heat Exchanger (FOHE). For the left engine, the investigation concluded that the restriction most likely occurred at its FOHE. However, due to limitations in available recorded data, it was not possible totally to eliminate the possibility of a restriction elsewhere in the fuel system, although the testing and data mining activity carried out for this investigation suggested that this was very unlikely. Further, the likelihood of a separate restriction mechanism occurring within seven seconds of that for the right engine was determined to be very low.
The flight crew became fully aware of the problem some 30 seconds before touchdown
The investigation identified the following probable causal factors that led to the fuel flow restrictions:
- Accreted ice from within the fuel system1 released, causing a restriction to the engine fuel flow at the face of the FOHE, on both of the engines.
- Ice had formed within the fuel system, from water that occurred naturally in the fuel, whilst the aircraft operated with low fuel flows over a long period and the localised fuel temperatures were in an area described as the ‘sticky range’.
- The FOHE, although compliant with the applicable certification requirements, was shown to be susceptible to restriction when presented with soft ice in a high concentration, with a fuel temperature that is below ‑10°C and a fuel flow above flight idle.
- Certification requirements, with which the aircraft and engine fuel systems had to comply, did not take account of this phenomenon as the risk was unrecognised at that time.