Australian Transport Safety Bureau investigates A380 engine failure

The Australian Transport Safety Bureau is investigating an uncontained engine failure on a Qantas A380, which cut out over Bantam Island, Indonesia, on 4 November 2010.

The aircraft landed safely in Singapore, despite the plane’s No 2 engine having shut down. No injuries were reported.

The data gathering phase of the investigation is now complete and the team of Australian and international safety organisations, along with aircraft manufacturers, has commenced analysis of the data.

In order to ratify technical data on structural and systems damage resulting from the engine failure, representatives from the Air Accidents Investigation Branch of the United Kingdom (UK AAIB), France’s Bureau of Investigations and Analysis (BEA) and advisors from Airbus met with Australian Transport Safety Bureau (ATSB) investigators in Canberra from July to August 2011.

The examination of the Rolls-Royce Trent 900 engine data and a number of engine manufacturing processes is nearing completion.

In conjunction with the UK AAIB and Rolls-Royce, the ATSB is continuing its examination of any missed opportunities to detect the reduced wall thickness and offset counter bore of the oil feed pipe prior to, during and after the manufacture of the module 51 assemblies.

The ATSB has also reviewed the quality audits undertaken, and quality assurance system affecting the module 51 design and manufacturing process, and their effectiveness in detecting deficiencies in that process.

In the interim, Rolls-Royce has conducted a number of major internal investigations into its processes including the:

  • manufacture of oil pipes with reduced wall thickness
  • management of retrospective concessions of manufactured components
  • failure mode, effects and criticality analysis (FMECA) of previous component failures.

As a result of those investigations, Rolls-Royce has:

  • revised procedures for new structures that include feature verification and risk assessment during the design and manufacture process
  • introduced a revised, standalone procedure with appropriate supporting training to better manage the application of retrospective manufacturing concessions
  • revised its FMECA procedures to provide ‘best practice’ numerical justification for any assumptions made.

The investigation will monitor the progress of those initiatives.

More information can be found at atsb.gov.au.

[Image: Australian Government Transport Safety Bureau]