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QF32: what's been done to improve safety

By Martin Dolan, Chief CommissionerMartin Dolan

Our recently released report into the uncontained engine failure of a Qantas Airbus A380 (QF32) shows how accident investigations, along with good international cooperation, can make a real difference to improving aviation safety around the world.  

The accident occurred on 4 November 2010, shortly after the A380 took off from Singapore’s Changi Airport. At about 7,000 ft above Batam Island, Indonesia one of the aircraft’s Rolls-Royce Trent 900 engines failed, sending debris into the aircraft’s left wing and fuselage, and onto Batam Island. 

To the great credit of the crew, they successfully managed the multitude of system alarms and safely landed the A380 at Changi Airport under extremely difficult circumstances. None of the crew or passengers was injured. 

Our investigation found that the engine failure was a result of a fatigue crack in an oil feed pipe. The crack allowed the release of oil that resulted in an internal oil fire. The oil fire led to one of the engine’s turbine discs separating from the drive shaft. The disc then over-accelerated and broke apart, bursting the engine casing and releasing high-energy debris.

This was a complex and resource-intensive investigation that relied on the cooperation of international regulators, Rolls-Royce, and Airbus, as well as accredited representatives from the United Kingdom, Indonesian, Singaporean and French investigation agencies.

What we learned from this accident, and what’s been done in response, has resulted in major safety improvements for the aviation industry and travelling public as a whole.

Beyond the engine improvements, the investigation also uncovered concerns with the existing airframe certification standards for all aircraft. 

Early on in the investigation, all the parties involved took a range of steps to ensure that engines with incorrectly manufactured oil feed stub pipes were removed from service or managed to enable the aircraft to continue to fly safely.

Rolls-Royce also introduced software that would automatically shut down a Trent 900 engine before its turbine disc overspeeds, in the unlikely event of a similar occurrence. As well, Rolls-Royce had improved their quality management system and management of non-conforming parts. This reflected lessons learned during the investigation about where quality systems could be improved.

Beyond the engine improvements, the investigation also uncovered concerns with the existing airframe certification standards for all aircraft. These standards—which aim to minimise the hazards that result from an uncontained engine rotor failure—have been based on a limited range of accidents with older engine models. The QF32 engine failure revealed opportunities to improve the current standards. In response, the ATSB recommended that the United States Federal Aviation Administration and the European Aviation Safety Agency review and incorporate any lessons learned from this accident into their aircraft certification advisory material. 

I’m proud of the good work our investigators put into this complex and important investigation. Equally, I’m grateful for the level of cooperation and support we received from all the organisations involved. Maintaining and improving safety must be a cooperative effort, with an emphasis on learning lessons and putting the results into practice.

Read the investigation report AO-2010-089

Written by Martin Dolan, Chief Commissioner at 11:00 AM

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