The Australian Transport Safety Bureau released the final report of its investigation into the uncontained engine failure involving a Qantas Airbus A380 over Batam Island, Indonesia on 4 November 2010.
The accident occurred shortly after the aircraft took off from Singapore. At about 7,000 ft above Batam Island, one of the aircraft’s Rolls-Royce Trent 900 engines failed, sending debris into the aircraft’s left wing and fuselage, and onto Batam Island. There was significant damage to the aircraft’s electrical, hydraulic and other systems. The crew managed the multitude of system failures before safely returning and landing the aircraft.
The ATSB found that the engine failure was the result of a fatigue crack in an oil feed pipe. The crack allowed the release of oil that resulted in an internal oil fire. The oil fire led to one of the engine’s turbine discs separating from the drive shaft. The disc then over-accelerated and broke apart, bursting through the engine casing and releasing other high energy debris.
The ATSB also found that the oil pipe, together with a number of similar pipes in other engines, had been made with a thin wall section and did not comply with the design specifications. The thin wall substantially increased the likelihood of fatigue cracking.
The ATSB, Rolls-Royce, aviation regulators, and operators of Trent 900-powered A380s took a range of steps to ensure that engines with incorrectly manufactured oil feed stub pipes were removed from service or managed to enable the aircraft to continue to operate safely.
Rolls-Royce also introduced software that would automatically shut down a Trent 900 engine before its turbine disc over speeds, in the unlikely event of a similar occurrence. As well, Rolls-Royce had improved their quality management system and management of non-conforming parts.
Read the ATSB investigation report AO-2010-089
MP3 audio of media conference 27 June 2013
Source: ATSB – Media release