In-flight uncontained engine failure Airbus A380-842, VH-OQA, overhead Batam Island, Indonesia, on 4 November 2010

Interim report released 18 May 2011

This interim report details factual information established in the investigation’s evidence collection phase and has been prepared to provide timely information to the industry and public. Interim reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this interim report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

The Australian Transport Safety Bureau is investigating an occurrence involving a Qantas A380 aircraft that experienced an uncontained engine failure over Batam Island, Indonesia on 4 November 2010. The aircraft landed safely in Singapore having returned with the aircraft's No 2 engine shut down. There were no injuries.

The investigation team has inspected the damaged engine and components and determined the sequence of events that led to the failure of the engine disc.

The investigation is also examining the airframe and systems damage that resulted from the engine disc burst to understand its effect on those systems and the impact on flight safety. That includes their effect on the aircraft's handling and performance and on crew workload. A flight simulator program was used to conduct a number of tests in a certified A380 flight simulator. Analysis of the flight simulation test data is ongoing.

Preliminary report released 3 December 2010

This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

On 4 November 2010, at 0157 Universal Coordinated Time (UTC), an Airbus A380 aircraft, registered VH-OQA (OQA), being operated as Qantas flight 32, departed from runway 20 centre (20C) at Changi Airport, Singapore for Sydney, New South Wales. On board the aircraft were five flight crew, 24 cabin crew and 440 passengers (a total of 469 persons on board).

Following a normal take-off, the crew retracted the landing gear and flaps. The crew reported that, while maintaining 250 kts in the climb and passing 7,000 ft above mean sea level, they heard two almost coincident 'loud bangs', followed shortly after by indications of a failure of the No 2 engine.

The crew advised Singapore Air Traffic Control of the situation and were provided with radar vectors to a holding pattern. The crew undertook a series of actions before returning the aircraft to land at Singapore. There were no reported injuries to the crew or passengers on the aircraft. There were reports of minor injuries to two persons on Batam Island, Indonesia.

A subsequent examination of the aircraft indicated that the No 2 engine had sustained an uncontained failure of the Intermediate Pressure (IP) turbine disc. Sections of the liberated disc penetrated the left wing and the left wing-to-fuselage fairing, resulting in structural and systems damage to the aircraft.

As a result of this occurrence, a number of safety actions were immediately undertaken by Qantas, Airbus, Rolls-Royce plc and the European Aviation Safety Agency. On 1 December 2010, the ATSB issued a safety recommendation to Rolls-Royce plc in respect of the Trent 900 series engine high pressure/intermediate pressure bearing structure oil feed stub pipes. In addition, the Civil Aviation Safety Authority issued a Regulation 38 maintenance direction that addressed the immediate safety of flight concerns in respect of Qantas A380 operations with the Trent 900 series engine. On 2 December 2010, Qantas advised that the requirements of Rolls-Royce plc Service Bulletin RB211-72-G595 would take place within the next 24 hours on engines in place on A380 aircraft currently in service, and before further flight on engines on aircraft not yet returned to service.

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.