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Recommendations

Summary

Initial recommendation for misaligned stub pipe counter-boring that led to reduced wall thickness

Safety Issue

Misaligned stub pipe counter-boring is understood to be related to the manufacturing process. This condition could lead to an elevated risk of fatigue crack initiation and growth, oil leakage and potential catastrophic engine failure from a resulting oil fire.

As a result of the identified critical safety issue, the Australian Transport Safety Bureau issues the following safety recommendation:

Safety Recommendation AO-2010-089-SR-012

The Australian Transport Safety Bureau recommends that Rolls-Royce plc address the safety issue and take actions necessary to ensure the safety of flight operations in transport aircraft equipped with Rolls-Royce plc Trent 900 series engines.


 

Airframe certification standards in the case of an uncontained engine rotor failure - EASA

Safety Issue

The evolution of the current advisory material relating to the minimisation of hazards resulting from uncontained engine rotor failures was based on service experience, including accident investigation findings. The damage to Airbus A380-842 VH-OQA exceeded the modelling used in the UERF safety analysis and, therefore, represents an opportunity to incorporate any lessons learned from this accident into the advisory material.

ATSB safety recommendation AO-2010-089-SR-039

The Australian Transport Safety Bureau recommends that the European Aviation Safety Agency, in cooperation with the US Federal Aviation Administration, review the damage sustained by Airbus A380-842, VH-OQA following the uncontained engine rotor failure overhead Batam Island, Indonesia, to incorporate any lessons learned from this accident into the advisory material.


 

Airframe certification standards in the case of an uncontained engine rotor failure - US FAA

Safety Issue

The evolution of the current advisory material relating to the minimisation of hazards resulting from uncontained engine rotor failures was based on service experience, including accident investigation findings. The damage to Airbus A380-842 VH-OQA exceeded the modelling used in the UERF safety analysis and, therefore, represents an opportunity to incorporate any lessons learned from this accident into the advisory material.

ATSB safety recommendation AO-2010-089-SR-040

The Australian Transport Safety Bureau recommends that the US Federal Aviation Administration, in cooperation with the European Aviation Safety Agency, review the damage sustained by Airbus A380-842, VH-OQA following the uncontained engine rotor failure overhead Batam Island, Indonesia, to incorporate any lessons learned from this accident into the advisory material.

 
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