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Summary

Summary

What happened

On 4 November 2010, while climbing through 7,000 ft after departing from Changi Airport, Singapore, the Airbus A380 registered VH-OQA, sustained an uncontained engine rotor failure (UERF) of the No. 2 engine, a Rolls-Royce Trent 900. Debris from the UERF impacted the aircraft, resulting in significant structural and systems damage.
The flight crew managed the situation and, after completing the required actions for the multitude of system failures, safely returned to and landed at Changi Airport.

What the ATSB found

The Australian Transport Safety Bureau (ATSB) found that a number of oil feed stub pipes within the High Pressure / Intermediate pressure (HP/IP) hub assembly were manufactured with thin wall sections that did not conform to the design specifications. These non-conforming pipes were fitted to Trent 900 engines, including the No. 2 engine on VH-OQA. The thin wall section significantly reduced the life of the oil feed stub pipe on the No. 2 engine so that a fatigue crack developed, ultimately releasing oil during the flight that resulted in an internal oil fire. That fire led to the separation of the intermediate pressure turbine disc from the drive shaft. The disc accelerated and burst with sufficient force that the engine structure could not contain it, releasing high-energy debris.

What has been done to fix it

Following the UERF, the ATSB, Rolls-Royce plc, regulatory authorities and operators of A380 aircraft with Trent 900 engines took a range of steps to ensure that HP/IP hub assemblies with non-conforming oil feed stub pipes were identified and either removed from service, or managed to ensure their safe continued operation. Rolls-Royce also released an engine control software update that included an IP turbine overspeed protection system (IPTOS) that is designed to shut the engine down before the turbine disc can overspeed, in the unlikely event that a similar failure occurs.

Rolls-Royce has also made a range of changes to their quality management system to improve the way in which they manage non-conforming parts, both during the manufacturing process and when it has been identified that parts had unknowingly been released into service with non-conformances.

Safety message

The ATSB identified a number of issues during the manufacture of Trent 900 HP/IP hub assemblies that resulted in their release into service with non-conforming oil feed stub pipes. Those issues highlighted the importance of providing clear procedures during the manufacturing process and of personnel complying with those procedures. Even though modern civil turbine engines are very reliable, and UERFs are very rare events, the resulting damage from such a failure can be significant and the potential effects catastrophic. This accident represents an opportunity for the regulatory authorities to incorporate any lessons learned into their certification advisory material to enhance the safety of future aircraft designs.

 

ATSB media release 27 June 2013

• Audio of media conference 27 June 2013 - [Download MP3 MP3 21MB

 
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