Investigation update 17 August
2012
The investigation team is being led by the
Australian Transport Safety Bureau (ATSB), with the assistance of
accredited representatives from the Bureau d'Enquêtes et d'Analyses
(BEA), the Air Accidents Investigation Branch of the United Kingdom
(UK AAIB), the Air Accident Investigation Bureau of Singapore (AAIB
Singapore) and the National Transportation Safety Committee of
Indonesia (NTSC). In turn, those investigation agencies are being
assisted by advisors from Rolls‑Royce, Airbus, SAFRAN Sagem,
Honeywell (USA and UK), Aerolec UK and Singapore Aero Engine
Services Private Limited.
Since the last update, the investigation has
spent considerable time working with a number of stakeholders
clarifying and further exploring several factors in the development
of the accident. These factors came to light during the analysis
and initial drafting of the final investigation report. Additional
factual information was sought, allowing the investigation to fully
understand the technical and other implications.
Unfortunately, this effort has slowed the
progress of the draft final report and it is now likely to be
forwarded to directly involved parties (DIP) towards the end of
October 2012. In accordance with Annex 13 to the Convention on
International Civil Aviation Aircraft Accident and Incident
Investigation, the ATSB is planning a 60-day DIP period in which
the parties will be able to comment on the factual accuracy of the
report and provide other input.
In the meantime, the ATSB has been working to
address an evolving safety issue in relation to the lack of a
documented procedure to enable airport rescue and fire fighting
services (RFFS) personnel to safely shut down an uncontrolled
running engine, as occurred in this accident (see the Preliminary
and Interim reports at
/publications/investigation_reports/2010/aair/ao-2010-089.aspx).
This has involved discussions with the International Civil Aviation
Organization (ICAO) and the provision to the ICAO Rescue and Fire
Fighting Working Group (RFFWG) of supporting documentation. The
issue was discussed in an RFFWG meeting in Montreal, Canada in July
and will be pursued further as part of a working group member's
visit to Australia shortly.
The ATSB will continue to work with the RFFWG in
an effort to resolve the safety issue and any safety action in
response will be included in the final investigation report.
The final report is anticipated for public
release in the first quarter of calendar year 2013.
Investigation update 19 January
2012
The investigation team is being led by the
Australian Transport Safety Bureau (ATSB). With the assistance of
accredited representatives from the Bureau d'Enquêtes et d'Analyses
(BEA), the Air Accidents Investigation Branch of the United Kingdom
(UK AAIB), the Air Accident Investigation Bureau of Singapore (AAIB
Singapore), the National Transportation Safety Committee of
Indonesia (NTSC), and advisors to those investigation bodies
including Rolls-Royce, Airbus, SAFRAN Sagem, Honeywell (USA and
UK), Aerolec UK and Singapore Aero Engine Services Private Limited,
the data gathering phase of the investigation is complete and the
team has commenced analysing that data.
During the period July to August 2011,
accredited representatives from the BEA and UK AAIB and advisors
from Airbus met with ATSB investigators in Canberra, Australia to
ratify relevant A380 technical data in respect of the structural
and systems damage sustained by the aircraft as a result of the
uncontained engine failure. The examination of relevant Rolls-Royce
Trent 900 engine data and a number of engine manufacturing
processes is nearing completion.
The ATSB has met with Rolls-Royce and Qantas
Airways to update those parties on the progress of the
investigation. In accordance with international protocol and ATSB
policy and procedures, those and other relevant stakeholders will
be involved in the development of the investigation findings and
final report.
In conjunction with the UK AAIB and Rolls-Royce,
the ATSB is continuing its examination of the circumstances and
missed opportunities with the potential to have detected 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.
Aircraft response to the disc
failure
The examination of airframe and systems damage that resulted from
the engine disc burst has been completed. That examination did not
reveal any significant or critical safety issues.
The continuing repair of the aircraft in
Singapore has allowed the examination of relevant removed/replaced
aircraft components at the ATSB's technical facilities in Canberra.
Those components have included a number of wiring looms, elements
of the aircraft's airframe and a number of sub-components.
Airbus proactive safety
action
As part of its ongoing examination of this event, Airbus has
commenced working with a number of airport and rescue and
firefighting agencies to develop an agreed safe means for those
agencies to externally shut down engines on Airbus aircraft - as
became necessary in this case. Any agreed procedures will be
incorporated in the Airbus Aircraft Rescue and Fire Fighting Chart
and be made available to airports and fire crews on line in
document and poster form.
Ongoing investigation
activities
The investigation is continuing and has progressed to the analysis
of the large amount of complex factual information that has been
gathered during the investigation. The drafting of the
investigation report has commenced and will include extensive
liaison with domestic and international stakeholders. In accordance
with international protocol, that will include a 60-day
consultation period for international parties to the
investigation.
The information contained in this web update is released in
accordance with section 25 of the Transport Safety Investigation
Act 2003 and is derived from the initial 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 web
update. As such, no analysis or findings are included in this
update.
