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.

Abstract

At about 1303 on Saturday 22 May 2010, freight train 7MP7 collided with a young male child on the track adjacent to a level crossing near Nantawarra in the mid-north of South Australia. The child was fatally injured as a result of the collision. The investigation found that prior to the collision the child had wandered away from the family home and had unknowingly placed himself in a place of extreme danger on the railway track and there was little the train drivers could do to avoid the collision.

On 31 October 2010, a Cessna Aircraft Company TU206C, registered VH-EAL (EAL), was being operated on a parachute flight overhead the South Grafton aeroplane landing area (ALA), New South Wales.

Just prior to the parachute drop, the pilot heard broadcasts from an aircraft on the ground at South Grafton and an inbound aircraft. The pilot of EAL requested that both aircraft remain clear of the drop zone. After the parachute drop was completed, the pilot descended the aircraft and continued to converse with the pilots of the other aircraft until the parachutists were on the ground.

The aircraft joined the circuit on crosswind for runway 08.  Due to a preceding aircraft, the pilot of slowed the aircraft down and conducted a wider circuit. The aircraft was turned onto final and shortly after, the engine went quiet. The pilot changed the fuel tank selection and applied full throttle, but the engine did not respond. The aircraft landed about 300 m from the runway and sustained serious damage.

The pilot reported that he had been distracted by the other aircraft operating in the area at the time and did not change the fuel tank selection during the descent or on downwind, as per his normal procedure.

Pilot distractions occur frequently; some can be minimised or removed, while others cannot be avoided. This accident is a prime example of how distractions impact aircraft operations and a reminder that distractions are not unique to any one type of operation and that no pilot is immune.

After lift off, the helicopter was climbed vertically to a height of about 80 feet. As the pilot attempted to commence forward flight, a main rotor low speed warning alert was received and confirmed by the main rotor tachometer. The pilot attempted to land on a road adjacent to the helipad. After touchdown, the main rotor collided with the wall of a building.

On 1 November 2010, an Airbus A330-302, registered VH-EBF (EBF), departed Phuket, Thailand on a scheduled passenger flight to Sydney, New South Wales.

When the aircraft was approaching overhead Kuala Lumpur International Airport, Malaysia, in icing conditions, the aircraft systems indicated a loss of total air temperature (TAT) data. This resulted in the loss of autopilot and autothrottle capabilities. The crew attempted to resolve the fault but were unable to restore the auto-flight capabilities.

The crew conferred with company operational and maintenance personnel and elected to divert to Singapore. The aircraft landed in Singapore without further incident.

Analysis of the data from the flight data recorder indicated that both TAT probes failed during the incident flight, triggering the loss of autoflight capabilities. The manufacturer suspected that the TAT probes failed due to icing.

A new TAT probe was certified for the A330 aircraft and issued through an optional Service Bulletin in 2008. As of November 2010, there had been no reported events of multiple failures involving the new TAT probes. At the time of the incident, EBF was not fitted with one of the new TAT probes.

On 23 October 2010, a Partenavia P.68B aircraft, registered VH-IYI (IYI) and an Avions Pierre Robin R-2160 aircraft, registered VH-JXY, were inbound to Jandakot Airport, Western Australia. The pilot of IYI made an inbound call at the visual flight rules (VFR) inbound reporting point of Boatyard prior to the pilot of JXY. However, JXY was in front of IYI. Both aircraft then tracked towards the VFR reporting point Adventure World.

Prior to reaching Adventure World the Jandakot Tower Airport controller instructed the pilot of IYI to track as number one and cleared them for runway 24R at Jandakot. The pilot of IYI did not continue to track to Adventure World but headed directly for the downwind leg of the circuit.

The pilot of JXY continued onto Adventure World and was instructed by the controller to track for downwind. The pilot of JXY informed the controller on a number of occasions that they could not see IYI. When both aircraft were on their downwind legs the controller informed the pilot of JXY that IYI was below them.

When IYI turned onto base the pilot observed JXY fly over the top of their aircraft, with about 100 ft separation. The pilot of JXY did not see IYI.

This incident highlights the importance of air traffic control and pilots maintaining situational awareness and an accurate mental picture of the location of other traffic in the alerted see and avoid environment. To assist pilots in maintaining situational awareness air traffic control need to provide timely traffic information to aircraft to ensure they are aware of the proximity of other aircraft.

On 23 October 2010, the student pilot of a Cessna Aircraft Company 152, registered VH-HCC (HCC) was conducting solo circuit training at Bankstown aerodrome, New South Wales (NSW). At the same time, a flying instructor and student pilot were conducting dual training circuits in a Piper Aircraft Corporation PA-28-161, registered VH-XSN (XSN).

While on the base leg of the circuit, the pilot of HCC reported sighting another aircraft at a 90^º angle to his right. He noted that this aircraft was a long way from the aerodrome and decided to continue flying his circuit as normal. At the same time, when on final for runway 29L, the student pilot of XSN observed a Cessna 152 aircraft turn in front, and below his aircraft. The instructor initiated a go-around and advised air traffic control (ATC).

The distance between the two aircraft was estimated at 100 m horizontally and 100 ft vertically.

It is important that pilots apply the principles of 'see-and-avoid' by maintaining a constant lookout for other traffic in the circuit and actively listen to the radio to ensure that separation with preceding aircraft is maintained. If there is any doubt as to the position of other aircraft, contact ATC or make a broadcast.

On 23 October 2010, a De Havilland Canada DHC-2 MK 1 floatplane, registered VH-PCF, was being operated on a charter passenger flight from Green Island to Cairns, Queensland.

During the take-off, the pilot applied right rudder to counteract the aircraft's engine torque component and right aileron to compensate for the crosswind. Immediately after becoming airborne, the aircraft began turning to the left. The pilot rejected the take-off and the aircraft landed heavily, sustaining serious damage. The pilot could not recall if the aircraft had encountered a gust of wind after becoming airborne.

Shortly after, a boat arrived from Green Island and the passengers were assisted to shore. None of the aircraft occupants received injuries.

At the time of the accident, the wind conditions experienced at Green Island were close to the maximum operational limitations stipulated by the aircraft operator.

This accident is a reminder of the challenging conditions that pilots operating in an open water environment may be faced with. It is crucial that pilots have an appreciation of the existing wind conditions prior to the take-off, and in the event of unexpected wind gusts during the take-off, the pilot responds appropriately. Under these circumstances, it is important for pilots to not only be aware of aircraft and operator limitations, but also their own personal limitations.

Preliminary report released December 2010

The information contained in this Preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the ongoing investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this Preliminary report. As such, no analysis or findings are included in this report.

Abstract

At approximately 0710 on 23 October 2010, 15 wagons on freight train 3PW4 derailed near Wodonga, Victoria. There were no injuries but serious damage to rolling stock and track infrastructure was sustained during the derailment.

On 13 October 2010, a Boeing 717-200 (717), registered VH-NXD, was being operated by Cobham Aviation Services Australia, on a scheduled passenger flight from Perth to Kalgoorlie, Western Australia. On board were 97 passengers, three cabin crew and two flight crew.

During the approach to land on runway 29 at Kalgoorlie Airport, the stick shaker activated. The copilot, who was the pilot flying, reduced the aircraft's pitch angle and continued the turn onto final. About a minute later, the approach was no longer stabilised, and the flight crew conducted a go-around. On the second approach to land and after turning onto final, the copilot noted that the aircraft was below the required profile. As the copilot increased the aircraft's pitch attitude, the stick shaker activated for about 2 seconds. Following recovery actions, a go-around was conducted. The third approach was conducted by the pilot in command at an airspeed that was about 15 kts higher than the previous approaches.

The investigation found that the stick shaker activations were primarily a result of an incorrect approach speed. The approach speed generated by the flight management system (FMS) was based on a landing weight that was 9,415 kg less than the aircraft's actual weight. Prior to departure, the flight crew had inadvertently entered the aircraft's operating weight in lieu of the aircraft's zero fuel weight (ZFW) into the FMS. The data entry error also influenced the aircraft's take-off weight (TOW) in the FMS. The error went unnoticed and did not manifest as an operational problem until the approach into Kalgoorlie.

The investigation identified several organisational issues that had the potential to adversely affect the safety of future operations. Those issues related to the format of the aircraft load sheet, the verification check by the flight crew of the TOW against the load sheet and the lack of an independent validation check of the FMS-generated landing weight. In response, the operator has made a number of enhancements to the format of the 717 load sheet, the FMS weight data entry and verification procedures, the weight validation checks and the 717-simulator training in respect of recovery from stick shaker activation.

The application of correct operating data is a foundational and critical element of flight safety. In January 2011, the ATSB released a research report titled Take-off performance calculation and entry errors: A global perspective.