Final Report


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.

The occurrence


Safety analysis


Safety issues and actions

Sources and submissions