Qantas A380 uncontained #2 engine failure
(...) pointed out that pictures from the vertical fin mounted camera suggested a fluid leak from the left hand wing
Clearly they where not immediately aware of what was happening and even dispatching someone in the cabin did not give comprehensive information about the situation.
Given the size of the 380 the relative weight & cost would be minimal.
Thoughts ?
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atakacs,
Engines don't usually come apart....
Even with a birdstrike, I don't think there's not much to see after the initial surge and ball of fire.
But yes, I'd have expected a couple more cameras, one for each wing, to view all the droop-down and pop-up bits which do occasionally malfunction.
Engines don't usually come apart....
Even with a birdstrike, I don't think there's not much to see after the initial surge and ball of fire.
But yes, I'd have expected a couple more cameras, one for each wing, to view all the droop-down and pop-up bits which do occasionally malfunction.
Old and Horrified:
Your post recalls to mind the old "sub safe" program Admiral Rickover had established back in the 60's to reduce the chance of incorrectly manufactured parts being istalled in nuclear submarines.
Identifying which parts have critical characteristics, and proper inspection processes for ensuring they are within tolerance strikes me as standard Quality Engineering practices in any precision industry ... .like jet engine manufacture.
IF that failed tube is what led to the problem (oil fire?) that led to the disc coming off of / out of the engine, then perhaps reclassifying certain parts and their critical characteristics (and QA oversight, etc) is part of the remedy to restore confidence in that remarkable, precision-made machine: RR's Trent 972 engine.
Your post recalls to mind the old "sub safe" program Admiral Rickover had established back in the 60's to reduce the chance of incorrectly manufactured parts being istalled in nuclear submarines.
Identifying which parts have critical characteristics, and proper inspection processes for ensuring they are within tolerance strikes me as standard Quality Engineering practices in any precision industry ... .like jet engine manufacture.
IF that failed tube is what led to the problem (oil fire?) that led to the disc coming off of / out of the engine, then perhaps reclassifying certain parts and their critical characteristics (and QA oversight, etc) is part of the remedy to restore confidence in that remarkable, precision-made machine: RR's Trent 972 engine.
I'm quite impressed with the balanced discussions in the last 24 hours. Even those that seemingly take opposite views.
IMO there is room and need to learn from this and to improve standards in several areas to make it even less likley that similar failure combinations will occur and result in the loss of an aircraft.
I do suspect that a lot of folks miss the importance of the lessons learned of what did work to make this in the end a safe outcome (it's more than just the pilots
. It's easy to find fault but much harder to find solutions.
Some nits
To me one should not just say the aircraft was overwhelmed by three 1/3rd fragments beyond the design and regulatory assumptions until such time that the facts are displayed in the ATSB report of what pieces did which damage.
Yes QA should be examined, but more importantly prioritized against critical parts under the presumption that one can not spend the same amount of QA resources on all parts. So yes I am in favor of reexamining the criticality of the parts involved generically across the industry.
And I don't think that we need to change any rules, since there is plenty of room in the current rules to accept lessons learned interpretations.
IMO there is room and need to learn from this and to improve standards in several areas to make it even less likley that similar failure combinations will occur and result in the loss of an aircraft.
I do suspect that a lot of folks miss the importance of the lessons learned of what did work to make this in the end a safe outcome (it's more than just the pilots
. It's easy to find fault but much harder to find solutions.Some nits
To me one should not just say the aircraft was overwhelmed by three 1/3rd fragments beyond the design and regulatory assumptions until such time that the facts are displayed in the ATSB report of what pieces did which damage.
Yes QA should be examined, but more importantly prioritized against critical parts under the presumption that one can not spend the same amount of QA resources on all parts. So yes I am in favor of reexamining the criticality of the parts involved generically across the industry.
And I don't think that we need to change any rules, since there is plenty of room in the current rules to accept lessons learned interpretations.
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For the first time in a long time, I see the Beeb's concern. They are the same engine. The TRENT 700 and the TRENT 900 are quite similar. To be dismissive of public concern when they are confronted with what appears to be unsettling disclosures and emergency landings is not well tolerated. The Industry has no one to blame but within its own walls. The Public Relations that come from these fossils is insulting, and confusing. At a time when public concern is high, the Players should be scolded for showing such an inept face to the masses. The mysterious nature of the BA038 incident remains, oddly enough, centered on a tubesheet, and tubes that plugged. There is no real relationship, but when odd balls like Joyce, Gourgeon, and others muddy things up firms lose money. What people worry about is their own ignorance of machinery, so instead of front and center with CEO's, perhaps someone will charge some tech people to translate for the Passengers.
The IPT was not the cause, it was one of the results. From the information divulged, it is at least premature to label the IPT as the problem, Any fail/chain starts with some identifiable procuring cause.
The focus now is on this oil tube. A year has elapsed since rather rigorous regulatory commands were given, in the form of AD'S. They receive no mention of late, instead a bleat of "Recent Key Findings", and "After Further Research". Just now we have the "trail" id'ed? The RB211 deserves better than this.
Rant off, much respect,
bearfoil
The IPT was not the cause, it was one of the results. From the information divulged, it is at least premature to label the IPT as the problem, Any fail/chain starts with some identifiable procuring cause.
The focus now is on this oil tube. A year has elapsed since rather rigorous regulatory commands were given, in the form of AD'S. They receive no mention of late, instead a bleat of "Recent Key Findings", and "After Further Research". Just now we have the "trail" id'ed? The RB211 deserves better than this.
Rant off, much respect,
bearfoil
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bearfoil
Has it occurred to anyone what Alan Joyce and Tony Hayward, former CEO of BP, have in common?
No doubt honest individuals, they have the talent of making a bad situation appear extremely fishy if they dare open their mouths.
"We take safety (yawn) as number one priority (yawn) ....."
No doubt honest individuals, they have the talent of making a bad situation appear extremely fishy if they dare open their mouths.
"We take safety (yawn) as number one priority (yawn) ....."
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Pipe burst contra splines wear
Now it seems that all interest is concentrated on the discovered error in counter-boring. What about earlier AD:s about splines wear?
At the end of the list of warnings there is a message about avionics bay overheat. Should that not trigger some attempt to land ASAP or is rather normal?
Although I am no pilot (but have a background in nuclear accident analysis safety) I find this tread and the ATSB report quite interesting and educating.
Regards
At the end of the list of warnings there is a message about avionics bay overheat. Should that not trigger some attempt to land ASAP or is rather normal?
Although I am no pilot (but have a background in nuclear accident analysis safety) I find this tread and the ATSB report quite interesting and educating.
Regards
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I think there is note taken of this "new" trail, Diversification, in the other thread. Whether it's in the nature of the beast to hyperfocus, or it serves some ulterior motive, the AD's are the key to this mess. With a year gone relative to the safety concern about malfunctioning engines, the broad view is the best one. An attempt to "Dovetail" the tube and oiling issues with prior work would raise the threat level, cannot have that.
ECAMS? Avionics Bay OH. I'm sure that was taken seriously, but like all the others, it turned out not to have brought this a/c down.
"No Harm, No Foul?"
bear
ECAMS? Avionics Bay OH. I'm sure that was taken seriously, but like all the others, it turned out not to have brought this a/c down.
"No Harm, No Foul?"
bear
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Impaseo - Once again I am in general agreement with your comments, but the final paragraphs concerning criticality are a bit difficult.
A Critical Part is one the failure of which could cause Catastrophe. I do not believe the Requirements or Regulations provide for levels of criticality. Parts are either Critical or not,and the lifing and manufacturing processes are applied accordingly.
If the safety assessment indicates that a non-disc type part such as an oil pipe could fail in a manner likely to lead to Catastrophe a redesign would be necessary. Hence engines have few Critical parts other than discs or shafts.
I also have difficulty with your view that the current rules are sufficiently robust to be able to encompass 'lessons learned'. My experience indicates that if your really believe safety needs to be enhanced then the only certain fix is a change to the Rules. Tinkering with advisory material seldom works.
It has to be said that the whole arena of safety assessments is an absolute nightmare when it comes to agreeing compliance, since there are so many different ways in which the job can be done. This inevitably leads to inconsistency of approach between constructors and between regulators.
Perhaps it is time to stop assuming that everything on the aircraft is correct to drawing and adopt a more pragmatic approach that recognises human falibility, such as is the case I believe with CRM in operational affairs.
Trouble is, Regulators are not very imaginative when their fundamental assumptions are challenged.
Sorry this is a bit rambling, but it's quite interesting, isn't it?
A Critical Part is one the failure of which could cause Catastrophe. I do not believe the Requirements or Regulations provide for levels of criticality. Parts are either Critical or not,and the lifing and manufacturing processes are applied accordingly.
If the safety assessment indicates that a non-disc type part such as an oil pipe could fail in a manner likely to lead to Catastrophe a redesign would be necessary. Hence engines have few Critical parts other than discs or shafts.
I also have difficulty with your view that the current rules are sufficiently robust to be able to encompass 'lessons learned'. My experience indicates that if your really believe safety needs to be enhanced then the only certain fix is a change to the Rules. Tinkering with advisory material seldom works.
It has to be said that the whole arena of safety assessments is an absolute nightmare when it comes to agreeing compliance, since there are so many different ways in which the job can be done. This inevitably leads to inconsistency of approach between constructors and between regulators.
Perhaps it is time to stop assuming that everything on the aircraft is correct to drawing and adopt a more pragmatic approach that recognises human falibility, such as is the case I believe with CRM in operational affairs.
Trouble is, Regulators are not very imaginative when their fundamental assumptions are challenged.
Sorry this is a bit rambling, but it's quite interesting, isn't it?
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The Australian Transportation Safety Board Preliminary Report contains two items which have so far not been commented on.
First, it seems that the cabin crew were unable to talk to the flight deck:
"The customer service manager (CSM) reported attempting to contact the flight crew, including through the use of the EMERGENCY contact selection on the cabin interphone system, which activated the flight deck warning horn. However, that selection had no associated ECAM message and the flight crew stated that they associated the emergency contact warning horn with the continuously-sounding warnings from the ECAM system and so cancelled the horn."
It therefore seems that, assuming the CSM has no way of actually entering the cockpit in these strengthened door days, there was no way for the cabin crew to inform the flight deck about any possible injuries to passengers from engine debris.
Second, it seems that even in the most modern of passenger aircraft the length of the recording on the CVR is utterly inadequate:
"The CVR contained over 2 hours of cockpit audio but, due to the continued running of the No 1 engine in Singapore, the audio at the time of the disc failure was overwritten. The available audio commenced during the landing approach and continued during the subsequent ground operations"
Therefore there is unfortunately no recording of the flight crew's handling of this incident, a recording which would have proved invaluable for future cockpit crew training. The period before over-writing on the CVR is stupidly short.
First, it seems that the cabin crew were unable to talk to the flight deck:
"The customer service manager (CSM) reported attempting to contact the flight crew, including through the use of the EMERGENCY contact selection on the cabin interphone system, which activated the flight deck warning horn. However, that selection had no associated ECAM message and the flight crew stated that they associated the emergency contact warning horn with the continuously-sounding warnings from the ECAM system and so cancelled the horn."
It therefore seems that, assuming the CSM has no way of actually entering the cockpit in these strengthened door days, there was no way for the cabin crew to inform the flight deck about any possible injuries to passengers from engine debris.
Second, it seems that even in the most modern of passenger aircraft the length of the recording on the CVR is utterly inadequate:
"The CVR contained over 2 hours of cockpit audio but, due to the continued running of the No 1 engine in Singapore, the audio at the time of the disc failure was overwritten. The available audio commenced during the landing approach and continued during the subsequent ground operations"
Therefore there is unfortunately no recording of the flight crew's handling of this incident, a recording which would have proved invaluable for future cockpit crew training. The period before over-writing on the CVR is stupidly short.
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bearfoil - I'm not sure that I understand the thrust of your latest thoughts.
Are you implying that the defective oil tube is in some way connected with the spline and other ADs.
I cannot for the life of me work out what you are saying. Perhaps it's a European thing. Would it be possible to do a translation for those of us in the Old World?
Are you implying that the defective oil tube is in some way connected with the spline and other ADs.
I cannot for the life of me work out what you are saying. Perhaps it's a European thing. Would it be possible to do a translation for those of us in the Old World?
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Twenty years ago I purchased a SONY video machine. I used it for Plant security. Video and Audio for six hours, it cost one thousand dollars.
CAAAD
No "Link" is implied. The AD's stand alone. The Bearing Case was noted as having Lubrication problems. These problems involved "Clogged Restrictor Vanes". Scavenge problems were identified, to include "coking" and Carbon deposition. One year in effect, the AD was relaxed by modification. QF32 has explosive disintegration, uncontained. Uncontained explosion said to be the result of Oil Fire. Oil in the bearing cavity fed this fire. From Pictures, the IPT exploded with such force it suffered Drive arm collapse and fold back onto the aft face of the IPT. The Aft face was peppered with molten metal. Picture of "Oil Tube" is released, drawing hyperfocus from a curious World. RR was done in by duff part alone, AD's take back seat, 'One-Off' is suggested. All is well then? Yes, What have we learned, Class?
respect from fellow Old guy,
bear
CAAAD
No "Link" is implied. The AD's stand alone. The Bearing Case was noted as having Lubrication problems. These problems involved "Clogged Restrictor Vanes". Scavenge problems were identified, to include "coking" and Carbon deposition. One year in effect, the AD was relaxed by modification. QF32 has explosive disintegration, uncontained. Uncontained explosion said to be the result of Oil Fire. Oil in the bearing cavity fed this fire. From Pictures, the IPT exploded with such force it suffered Drive arm collapse and fold back onto the aft face of the IPT. The Aft face was peppered with molten metal. Picture of "Oil Tube" is released, drawing hyperfocus from a curious World. RR was done in by duff part alone, AD's take back seat, 'One-Off' is suggested. All is well then? Yes, What have we learned, Class?
respect from fellow Old guy,
bear
Last edited by bearfoil; 3rd Dec 2010 at 19:55.
Twenty years ago I purchased a SONY video machine. I used it for Plant security. Video and Audio for six hours, it cost one thousand dollars.
I think the civil reqt is only for 2 hours of CVR (used to be only 30mins), but I tend to agree it should be alot longer in this day and age.
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Believe me my question is NOT intended in any way to provoke any sort of argument because I am totally ill equipped to have an argument with anyone . But I do wonder sometimes if Rolls Royce make aero engines these days or just assemble them --they seem to buy in bits from all over the world. Does this strain quality control?
When I was a kid the impression was that they made everything -even all nuts and bolts--from alloys they made themselves in their own foundries. They had, it seemed, total control.
Who made the apparently crude oil pipe for them?
When I was a kid the impression was that they made everything -even all nuts and bolts--from alloys they made themselves in their own foundries. They had, it seemed, total control.
Who made the apparently crude oil pipe for them?
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bearfoil - Ah, I see, I think. Your interpretation of events may not coincide with mine. In particular the term 'explosion' is a bit loose.
This is the general progression of the failure as I understand it.
1. The oil pipe failed and oil found itself where it shouldn't be, in an environment condusive to combustion.
2. Oil caught fire and burned with sufficient ferocity as to degrade the material of the IP shaft or coupling. Although fairly exciting, there was no explosion.
3. Shaft or coupling failed, disconnecting turbine disc from its compressor.
4. IP turbine disc oversped to burst in classic tri hub fashion. It did not explode, it burst. The effects were similar to those of an explosion. But the professionals use the expression 'burst'.
Is it your belief that there was some kind of explosive phenomenon taking place in the bearing chamber which in some way 'exploded' the disc?
This is the general progression of the failure as I understand it.
1. The oil pipe failed and oil found itself where it shouldn't be, in an environment condusive to combustion.
2. Oil caught fire and burned with sufficient ferocity as to degrade the material of the IP shaft or coupling. Although fairly exciting, there was no explosion.
3. Shaft or coupling failed, disconnecting turbine disc from its compressor.
4. IP turbine disc oversped to burst in classic tri hub fashion. It did not explode, it burst. The effects were similar to those of an explosion. But the professionals use the expression 'burst'.
Is it your belief that there was some kind of explosive phenomenon taking place in the bearing chamber which in some way 'exploded' the disc?
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oldchina
"Has it occurred to anyone what Alan Joyce and Tony Hayward, former CEO of BP, have in common?
No doubt honest individuals, they have the talent of making a bad situation appear extremely fishy if they dare open their mouths.
"We take safety (yawn) as number one priority (yawn) ....."
Still better than a lot of airlines, and at least when something does go wrong the people up front know how to handle it and get the plane down pulling the years of experience together to get a positive outcome.
OK, they are commercially focused but this and the oxygen bottle were on Qantas planes but could have occurred on any airline.
I would still fly QF over other airlines for the reason of having experience up front.
.
"Has it occurred to anyone what Alan Joyce and Tony Hayward, former CEO of BP, have in common?
No doubt honest individuals, they have the talent of making a bad situation appear extremely fishy if they dare open their mouths.
"We take safety (yawn) as number one priority (yawn) ....."
Still better than a lot of airlines, and at least when something does go wrong the people up front know how to handle it and get the plane down pulling the years of experience together to get a positive outcome.
OK, they are commercially focused but this and the oxygen bottle were on Qantas planes but could have occurred on any airline.
I would still fly QF over other airlines for the reason of having experience up front.
.
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Don't understand why some of our friends in Oz are so negative about their flag carrier? Go easy. Remember being amongst the first to fly the A380 also makes the statistics for others to follow.
I think there should be a few gongs being awarded to the crew. Not quite clear though what awards are given for civilian aircrew who achieve the almost-impossible.