Aviation safety investigations & reports

Engine shut down in-flight involving Airbus A330-302, B-18358, Darwin Airport, 887 km ENE on 3 October 2013

Investigation number:
AO-2013-172
Status: Completed
Investigation completed

Final Report

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What happened

On 3 October 2013 at 1223 UTC[1] an Airbus A330-302, registered B-18358 and operated by China Airlines, departed Sydney Australia on a scheduled passenger transport flight to Taipei, Taiwan ROC. Approximately 4 hours into the flight, the flight crew completed a precautionary shutdown of the number one engine in response to a low oil pressure warning. The aircraft diverted to Cairns, Australia where it landed without further incident.

What the ATSB found

The model ATS200-61 air turbine starter from the number one engine sustained an uncontained failure. Released debris from the starter severed an adjacent oil sump scavenge pipe, resulting in the loss of oil from the engine and necessitating the in-flight shutdown.

The starter manufacturer’s investigation concluded that the starter failure resulted from failure of the output shaft bearing. Damage to the bearing was reported as being consistent with a transient loading event, typical of that resulting from crash engagement of the starter clutch during engine starts or from axial loads transferred from the horizontal driveshaft. There was no evidence in the recorded data from the most recent series of engine starts to indicate that a crash engagement had occurred, however, it was possible that the transient loading event had occurred outside this timeframe.

What's been done as a result

Following the occurrence, the starter manufacturer, the engine manufacturer and the operator made a number of changes to their procedures for starter oil level check and starter oil changes.

To eliminate the potential for future crash engagements, the starter manufacturer was phasing out the single pawl and ratchet clutches such as that in the model ATS200-61 to be replaced by a full range pawl and ratchet or sprag clutch. The engine manufacturer had initiated a design change in the horizontal driveshaft to eliminate this as a source of axial load on the bearing.

 

 

__________

  1. Coordinated Universal Time (abbreviated UTC) is the time zone used for civil aviation. Local time zones around the world can be expressed as positive or negative offsets from UTC.
Download Final report
[Download  PDF: 1.96MB]
 
 
Alternate: [Download  DOCX: 997KB]
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

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Safety Issue

Go to AO-2013-172-SI-01 -

Uncontained failure of air turbine starter led to loss of engine oil

Debris originating from the starter failure was not contained by the starter casing and severed the number one engine B-sump oil scavenge pipe. 

Safety issue details
Issue number: AO-2013-172-SI-01
Who it affects: All operators of engines fitted with Honeywell ATS200-61 model starters
Status: Adequately addressed
General details
Date: 03 October 2013   Investigation status: Completed  
Time: 1610 UTC   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Darwin, 887 km ENE (OPABA)    
State: International   Occurrence type: Abnormal engine indications  
Release date: 10 December 2015   Occurrence class: Technical  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus  
Aircraft model A330  
Aircraft registration B-18358  
Serial number 1346  
Operator China Airlines  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Sydney, NSW  
Destination Taipei, Republic of China  
Last update 14 November 2018