Aviation safety investigations & reports

Engine power loss and low speed rejected take off, involving Airbus A320-232, registered VH-VFF Brisbane Airport, Queensland, on 23 October 2020

Investigation number:
AO-2020-058
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final report

Download Final report
[Download  PDF: 1.19MB]
 

What happened

On the morning of 23 October 2020, an Airbus A320-232 was being operated by Jetstar Airways on a flight from Brisbane to Cairns, Queensland. As power was being applied for take-off, the crew reported feeling a vibration and hearing a ‘popping’ noise that rapidly increased in frequency and volume. At the same time, the aircraft diverged to the right of the runway centreline despite the pilot flying applying full left rudder pedal deflection. The captain immediately selected reverse thrust and brought the aircraft to a stop.

Some passengers onboard, a Brisbane air traffic tower controller, and flight crew of a following aircraft all reported momentarily seeing flames coming out the right engine. The aircraft was taxied back to the airport gate. Engineers then reported finding metallic debris in the tailpipe of the right engine.

On disassembly of the engine, it was discovered the high-pressure compressor (HPC) had sustained significant damage and a screwdriver tip was found in the combustion section.

What the ATSB found

The screwdriver tip was determined to have been in the engine for over 100 flights. The ATSB concluded the tool bit had been left in the engine after maintenance and when the engine was running, it entered the HPC leaving dents and nicks in numerous rotor blades and stator vanes. At least two of these defects initiated fatigue cracks that resulted in a blade failing during the occurrence take-off. The liberated blade caused greater damage to the HPC and the engine surged.

What has been done as a result

As a result of the occurrence Jetstar Airways issued a Safety Alert to their maintenance engineers, which highlighted the need for all tooling to be accounted for. They also conducted a risk assessment to better understand the on-going risk.

Safety messages

Tool control is an important part of maintenance processes that ensures they do not lead to foreign object damage. Small and seemingly insignificant tool components can, and have, caused significant incidents or accidents. Tool control should extend to pseudo consumable items such as screwdriver tips and drill bits.

Modern training methods include the use of high-fidelity training devices such as full motion flight simulators. Their design aims to maximise the realism of an artificial environment. However, there is a limit to their ability to replicate extreme events. Flight crew should be aware that the noise and vibration from an actual engine failure may be greater than, or different to, that experienced during simulator training and this could contribute to the effects of startle.

Download Final report
[Download  PDF: 1.19MB]
 
 
 

The investigation

General details
Date: 23 October 2020   Investigation status: Completed  
Time: 10:00 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Brisbane Airport   Investigation phase: Final report: Dissemination  
State: Queensland   Occurrence type: Engine failure or malfunction  
Release date: 16 August 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus  
Aircraft model A320-232  
Aircraft registration VH-VFF  
Serial number 5039  
Operator Jetstar Airways  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Minor  
Departure point Brisbane, Queensland  
Destination Cairns, Queensland  
Last update 16 August 2021