The Australian Transport Safety

Bureau (ATSB) is an independent ATSB TRANSPORT SAFETY

Commonwealth Government statutory
Agency. The Bureau is governed by a Aviation Occurrence Investigation AO-2010-066
Commission and is entirely separate
from transport regulators, policy
Final

Uncontained engine failure and air turn-back

makers and service providers. The
ATSB's function is to improve safety
and public confidence in the aviation,
marine and rail modes of transport

Near San Francisco Airport, USA

through excellence in:

• independent investigation of
transport accidents and other

30 August 2010
safety occurrences
• safety data recording, analysis
and research
• fostering safety awareness,
knowledge and action.
VH-OJP, with 213 passengers and 18 crew,
The ATSB does not investigate for the
purpose of apportioning blame or to Abstract departed San Francisco International Airport for a
provide a means for determining

On 30 August 2010 at approximately 2330 Pacific scheduled passenger service to Sydney, Australia.
liability.

The ATSB performs its functions in

accordance with the provisions of the Daylight Time, a Qantas Boeing 747-438 aircraft, Around 15 minutes into the flight, as the aircraft
Transport Safety Investigation Act
2003 and, where applicable, relevant
registered VH-OJP, departed San Francisco climbed through 25,000 ft above mean sea level,
international agreements. International Airport on a scheduled passenger severe vibrations were felt through the aircraft.
When the ATSB issues a safety service to Sydney, Australia. As the aircraft passed Cockpit indications received by the flight crew
recommendation, the person,
organisation or agency must provide a through 25,000 ft, the aircraft's number-4 engine were consistent with severe damage to the
written response within 90 days. That
response must indicate whether the failed, resulting in the puncturing of the engine number-4 engine; however, there were no
person, organisation or agency
accepts the recommendation, any casing and nacelle and the release of debris. The indications of an engine fire. The flight crew
reasons for not accepting part or all of
the recommendation, and details of
engine was shut down and the flight crew completed the appropriate non-normal checklist
any proposed safety action to give returned the aircraft to San Francisco items (NNC)2, and after the engine was shut
effect to the recommendation.
International Airport. There were no injuries. down, requested a return to San Francisco
© Commonwealth of Australia 2012

In the interests of enhancing the value An investigation conducted by the engine International Airport (the nearest available
of the information contained in this
publication you may download, print, manufacturer found that the engine failure was airport). They did not declare an emergency at
reproduce and distribute this material
initiated by the fatigue fracture of a single stage-2 that time.
acknowledging the Australian
Transport Safety Bureau as the
source. However, copyright in the
low pressure (LP) turbine blade. The ensuing rotor When contacted, the cabin crew reported that
material obtained from other agencies, imbalance caused the LP turbine bearing to fail, sparks and flames were emanating from the
private individuals or organisations,
belongs to those agencies, individuals which ultimately resulted in the uncontained number-4 engine exhaust. One of the flight crew
or organisations. Where you want to
use their material you will need to release of debris. then confirmed this observation, but reported the
contact them directly.

Australian Transport Safety Bureau As a result of this occurrence, the engine situation ‘not too bad’.
PO Box 967, Civic Square ACT 2608
Australia
manufacturer released non-modification service Regardless of airspeed changes made by the
bulletins NMSB72-AG729 and NMSB72-AG800; flight crew as directed by the NNC, significant
1800 020 616 instructing operators of RB211-524 engine airframe vibrations continued for the remainder of
+61 2 6257 4150 from overseas variants to fit a more robust LP turbine bearing, so the flight.
www.atsb.gov.au as to reduce the likelihood of catastrophic engine
Publication Date: 16 April 2012 failure resulting from rotor imbalance. The crew obtained a clearance for the aircraft to
ISBN 978-1-74251-254-9 enter a holding pattern at 20,000 ft, where
Released in accordance with section
FACTUAL INFORMATION 70,000 kg of fuel was jettisoned over a period of
25 of the Transport Safety
Investigation Act 2003 about 34 minutes to bring the aircraft under
History of the flight maximum landing weight.

On 30 August 2010, at approximately 2330 PDT 1,

a Qantas Boeing 747-438 aircraft, registered
2 The operator’s Flight Crew Operations Manual contained a
series of checklists for dealing with ‘non-normal’
1 Pacific Daylight Time (PDT) was Coordinated Universal conditions – that is, conditions outside normal operating
Time (UTC) –7 hours. parameters – such as an engine failure.

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A PAN 3 radio call was made by the flight crew on several smaller punctures through the left side
completion of the fuel jettison, and clearance (Figure 3).
obtained to return to San Francisco, where
emergency services were requested to be on Figure 1: Right side of number-4 engine
standby.

The aircraft landed without incident on runway

28R at approximately 0050; holding on a taxiway
while the engine was inspected by emergency
services. The aircraft subsequently proceeded to
the gate for passenger disembarkation. At this
time, the flight crew were informed by ground
personnel that ‘holes’ were present in the
number-4 engine nacelle.

There were no reported physical injuries to

passengers or crew.
Debris ejected through the hole in the right side
Commencement of the investigation (outboard) of the engine had impacted the
underside of the wing, producing superficial nicks
Upon receiving notification of the occurrence, two and scratches to the wing skin. There was a
Australian Transport Safety Bureau (ATSB) puncture through the composite, leading-edge,
investigators travelled to San Francisco to variable-camber flaps and the associated torque
commence an investigation into the event. As the tube was slightly bent. Operation of the flaps was
engine failure occurred over international waters, not affected.
responsibility for the investigation fell to the State
of (aircraft) Registry under the provisions of Annex Figure 2: Perforation in the engine nacelle,
13 to the Convention on International Civil right side
Aviation (ICAO Annex 13). Once on-site,
investigators conducted a preliminary examination
of the engine and aircraft, in conjunction with
representatives from the aircraft operator and
engine manufacturer.
Aircraft information
The Boeing 747-438 aircraft, serial number
25545, registered VH-OJP, was manufactured in
1992 and first registered in Australia at that time.

Aircraft propulsion was generated by four Rolls-

Royce RB211-524G2-T, high bypass, three-shaft,
turbofan engines.
Damage to the aircraft
The number-4 engine had ruptured through the
left and right sides of the turbine case and
fairings, producing a large perforation in the right
side of the engine nacelle (Figures 1 and 2) and

3 An internationally-recognised radio call announcing an

urgency condition which concerns the safety of an aircraft
or its occupants, but where the flight crew does not
require immediate assistance.

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Figure 3: Punctures in nacelle, left side (Figure 5). Figure 6 shows the general layout of
the RB211-524 engine and Figure 7 shows the
turbine section in detail.

Figure 4: Engine serial number: 13247

Figure 5

Figure 5: IP and stage 1 LP turbine discs

LP stage 1

IP turbine

There was no airframe damage inboard of the

number-4 engine. Despite the several small
punctures in the left (inboard) side of the engine,
the released debris did not have sufficient energy
to contact the fuselage.
Engine disassembly
After removal from the aircraft, the engine was
shipped to an overhaul facility in Hong Kong for
systematic disassembly and inspection. ATSB
investigators and representatives from the engine
manufacturer, aircraft operator and airframe
manufacturer oversaw the examination.

Figure 4 presents the subject engine with the

fairings removed. During the early stages of the
examination, it was evident that the internal turbo-
machinery had been significantly disrupted, with
extensive damage sustained by the intermediate-
pressure (IP) and low-pressure (LP) turbine rotors

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Figure 6: RB211-524 engine

Figure 7

Figure 7: RB211-524 turbine section

LP stage-3
LP stage-2
LP stage-1
IP turbine
HP turbine

Speed
probes

LP turbine LP turbine IP turbine IP shaft separation

bearing shaft shaft point (Figure 8)

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Disassembly of the LP/IP turbine module revealed stage-2 LP blade fracture surface showed two
the LP turbine bearing, phonic wheel4 and speed distinct morphologies; consistent with high-cycle
probe assembly had been destroyed in the failure fatigue crack progression followed by ductile
sequence. overstress fracture (Figure 11). The origin of the
fatigue crack was at the trailing-edge corner of the
The IP turbine shaft was severed towards the aft
blade root, between the blade platform and fir
end and there was evidence of heavy rotational
tree.
wear on the inner and outer surfaces (Figure 8).
The damage was consistent with the shaft having Figure 10: Stage-2 LP turbine disc showing
contacted adjacent components, including the LP fractured blade root
turbine shaft (Figure 9).

Figure 8: Composite image showing IP turbine

shaft damage and separation

Figure 11: Stage-2 LP turbine blade root.

Fatigue crack origin arrowed
Figure 9: LP turbine shaft showing evidence of
contact with IP shaft

Engine Information
The number-4 engine, serial number 13247, was
All of the IP turbine blades had separated from
configured as an RB211-524G2-T-19/15. The last
the disc. Apart from a single stage-2 LP turbine
overhaul was completed in May 2009 and the
blade that had fractured through the blade root
engine had accumulated 5,059 hours and 518
(Figure 10), all blades from the three LP turbine
cycles since overhaul, which was within the IP/LP
stages had either fractured through the airfoil
turbine module build target of 26,000 hours and
section or separated entirely from the disc. The
3,000 cycles.

At the time of the last overhaul, the LP turbine

roller bearing (part number LK30313, serial
4 A geared wheel that induces an electric current in the number PBC019) was inspected as per the engine
adjacent speed probe by varying magnetic flux. The
maintenance manual and subsequently refitted to
magnitude of the current generated gives an indication of
the engine. The bearing had accumulated 71,885
engine speed.

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hours total time in service (TTIS) and 9,026 cycles failure event had been overwritten and as such,
since new (CSN). the CVR contained no pertinent information.

Also at the time of the last overhaul, the set of 68, Engine manufacturer
stage-2 LP turbine blades (P/N: UL20899) were
overhauled at an approved blade repair station A number of engine components were retained for
and refitted to the engine. The blades were testing and analysis by specialists from the engine
estimated to have accumulated around 80,000 manufacturer. That examination was overseen by
hours TTIS and 10,000 CSN. Physical, representatives from the UK Air Accident
dimensional and crack inspections were Investigation Branch (AAIB), acting as Accredited
conducted as part of the overhaul process. Representatives to the investigation (State of
Manufacture – Engines).
Both the LP turbine bearing and turbine blades
were maintained according to standards
Engine failure sequence
published in the engine maintenance manual.
Neither part had a specified maximum service life The manufacturer’s completed investigation
and were maintained on-condition5. findings were provided to the ATSB, where it was
concluded that the engine failure was most likely
Recorded information
the result of the following sequence of events:
The aircraft was fitted with the mandatory Flight • Fatigue failure and release of a stage-2 LP
Data Recorder (FDR) and Cockpit Voice Recorder turbine blade resulted in secondary blade
(CVR) as well as an optional Wireless Quick releases and causing engine imbalance.
Access Recorder (WQAR) which is used by the
aircraft operator for flight data and aircraft system • Imbalance in the engine overloaded the LP
monitoring. The FDR and CVR were downloaded at turbine roller bearing, which subsequently
the ATSB’s facilities in Canberra and a copy of the failed.
WQAR data was provided to the ATSB by the • Failure of the LP turbine bearing allowed the
operator. LP turbine shaft to orbit, contacting and
eventually severing the IP turbine shaft.
Data from the FDR and WQAR confirmed the
sequence of events as detailed in the flight crew • Separation of the IP turbine shaft allowed the
reports. The vibration level of the number-4 IP turbine disc to overspeed slightly, losing its
engine N1 reached 5 (maximum) and the exhaust axial and radial location. The loss of location
gas temperature 780 degrees C. Although there allowed the disc and blades to contact
were recorded abnormal engine indications adjacent engine components, resulting in the
associated with the failure event, there were no blades being released from the disc (as per
precursor indications leading up to the event that the design intent to prevent a disc burst). The
may have alerted the flight crew of an impending entanglement of released blades and stage 1
engine failure. LP turbine nozzle guide vanes resulted in the
turbine casing rupture and release of debris.
The FDR contained the most recent 25 hours of
flight data. Number-4 engine data from previous
flights showed no abnormal engine indications. LP turbine bearing

The CVR recorded data on a continuous-loop The mechanism of breakdown of the LK30313 LP
principle and retained the most recent 2 hours of turbine bearing could not be fully determined from
audio information. Due to the duration of the examination of the bearing debris recovered from
return to San Francisco and aircraft ground the engine.
operations after landing, the recording of the Three standards of LP turbine bearing were
available for installation on RB211 engines. The
LK30313 and UL29651 bearings were of a two-
piece, riveted roller-cage design. The FB500000
5 A preventative maintenance regime, where a bearing comprised a single piece cage
determination of the continued serviceability of a construction and had a significantly greater load
component is based on appropriate periodic inspections. carrying capacity than the two-piece cage design.

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Due to supply continuity issues with the LK30313 the LP turbine support bearing, which was the
and UL29651 bearings, in 1995 the FB500000 riveted-cage design. IP/LP inter-shaft rub was
bearing was introduced (service bulletin SB-72- observed as a result of the bearing breakdown,
B540) as an optional alternative to the earlier but there was no shaft separation.
parts.
Two occurrences of riveted-cage bearing damage
were reported on older, RB211-524D4 engines,
Stage-2 LP turbine blade related to blade release events. However, the
Detailed examination of the turbine blade root bearings did not completely break down and there
found no evidence of material defects or other was no inter-shaft contact.
anomalies that may have contributed to the There were therefore no previous occurrences of
fatigue crack initiation. The manufacturer’s finite turbine shaft separation as a result of LP turbine
element stress analysis showed that the fatigue bearing breakdown. There have also been no in-
crack origin coincided with the peak stress service issues related to the FB500000 bearing.
location within the blade.

The engine manufacturer’s analysis of the ANALYSIS

circumstances contributing to the blade failure
found that a flutter vibration phenomenon could With respect to the engine failure, the ATSB
contribute to reduced fatigue endurance of the concurred with the findings of the engine
stage-2 LP turbine blades at engine speeds above manufacturer, which indicated that the most likely
100% N1 6. Flutter stress levels were found to sequence of events was initiated by the fatigue
increase in an almost linear fashion up to the N1 failure of a stage-2 LP turbine blade. The
operational limitation of 110.5%. The amount of consequence of the turbine blade failure was
accrued blade damage would therefore depend increased by the subsequent LP bearing failure,
on the type of engine operation in addition to the which ultimately resulted in the uncontained
blade service hours. engine failure.

The stage-2 LP turbine blade part number FINDINGS

UL20899 was superseded in 1992. Many high life
blades remained in service after that time, as Context
typically, only about 5% of the total engine
inventory of stage-2 LP turbine blades would be From the evidence available, the following
replaced during any given engine overhaul. findings are made with respect to the uncontained
engine failure on the Boeing 747-438 aircraft,
registered VH-OJP, and should not be read as
Previous occurrences
apportioning blame or liability to any particular
The engine manufacturer reported that the failed organisation or individual.
stage-2 LP turbine blade from the event engine Contributing safety factors
was the only stage-2 blade to have failed by a
fatigue cracking mechanism in the RB211- • High service time stage-2 LP turbine blades
524G/H-T service history (totalling around 40 were susceptible to a reduction in fatigue
million hours service over 23 years). However, endurance as a result of vibratory stresses
there have been five IP turbine and two stage-3 LP sustained during operation at speeds close to
turbine blade release events, all of which resulted the maximum. [minor safety issue]
in in-flight engine shut downs (one aborted
• It was likely that as a result of the reduced
takeoff). One of the stage 3 LP turbine blade
fatigue endurance limit, a single stage-2 LP
release events, in 1995, resulted in breakdown of
turbine blade fractured and separated from
the LP disc during engine operation.
• LP turbine support bearings (part numbers
6 In a 3-spool turbine engine, N1 refers to the LP shaft LK30313 and UL29651) showed increased
speed, expressed as a percentage of the maximum rated susceptibility to breakdown and collapse under
speed. N2 and N3 refer to the IP and HP shaft speeds
respectively.

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 vibratory stress conditions associated with LP Action taken
turbine blade release. [minor safety issue]
As a result of this occurrence and to minimise the
• It was likely that vibratory stresses from the LP risk of potentially hazardous complications
turbine blade loss resulted in the LP turbine associated with blade release events, the engine
support bearing collapse, allowing contact manufacturer released non-modification service
between the LP and IP turbine shafts. bulletins NMSB72-AG729 for RB211-524G/H-T
• The IP turbine shaft severed as a result of engines, and NMSB72-AG800 for RB211-524
contact between the IP and LP turbine shafts, ‘Classic’ engines. The service bulletins instructed
which ultimately resulted in the uncontained fitment of a more robust LP turbine bearing, part
failure event. number FB500000, during the next maintenance
visit where the turbine module is removed. At the
Other key findings time of writing, the FB500000 bearing had
already been installed in over 68% of the RB211-
• Cockpit voice recorder audio of the engine
524G/H & -T worldwide engine fleet.
failure event was not available to the
investigation, as it had been overwritten as a High service time stage-2 LP turbine blades
result of the time elapsed during aircraft return
Safety Issue
and ground operations subsequent to the
event. High service time stage-2 LP turbine blades were
susceptible to a reduction in fatigue endurance as
SAFETY ACTION a result of vibratory stresses sustained during
operation at speeds close to the maximum.
The safety issues identified during this
investigation are listed in the Findings and Safety Action taken
Actions sections of this report. The Australian The manufacturer is recommending that
Transport Safety Bureau (ATSB) expects that all
operators replace high service time stage-2 LP
safety issues identified by the investigation should
turbine blades.
be addressed by the relevant organisation(s). In
addressing those issues, the ATSB prefers to
encourage relevant organisation(s) to proactively
initiate safety action, rather than to issue formal
Civil Aviation Safety Authority
safety recommendations or safety advisory CVR audio of the event was overwritten
notices.
Cockpit voice recorder audio of the engine failure
All of the responsible organisations for the safety event was not available to the investigation, as it
issues identified during this investigation were had been overwritten as a result of the time
given a draft report and invited to provide elapsed during aircraft return and ground
submissions. As part of that process, each operations subsequent to the event.
organisation was asked to communicate what
safety actions, if any, they had carried out or were Action taken
planning to carry out in relation to each safety
Although not directly related to this occurrence, on
issue relevant to their organisation. 25 March 2011 the Australian Civil Aviation Safety
Rolls-Royce Authority (CASA) amended Civil Aviation Order
(CAO) 82.5 ‘Conditions on Air Operators’
LP Turbine support bearing breakdown Certificates authorising regular public transport
Safety Issue operations in high capacity aircraft’. Section 12 of
the amendment included a requirement for Air
LP turbine support bearings (part numbers Operator Certificate holders to preserve for 30
LK30313 and UL29651) showed increased days CVR or FDR records for immediately
susceptibility to breakdown and collapse under reportable matters such as engine failures.
vibratory stress conditions associated with LP
turbine blade release.

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SOURCES AND SUBMISSIONS
Sources of Information
The aircraft operator

The engine manufacturer

VH-OJP crew reports

References
Figures 6 and 7 courtesy of Rolls-Royce
Submissions
Under Part 4, Division 2 (Investigation Reports),
Section 26 of the Transport Safety Investigation
Act 2003, the ATSB may provide a draft report, on
a confidential basis, to any person whom the
ATSB considers appropriate. Section 26 (1) (a) of
the Act allows a person receiving a draft report to
make submissions to the ATSB about the draft
report.

A draft of this report was provided to the aircraft

operator, the engine manufacturer, the aircraft
manufacturer, the UK Air Accidents Investigation
Branch (AAIB), the US National transportation
Safety Board (NTSB), and the Civil Aviation Safety
Authority (CASA).

Submissions were received from the aircraft

operator, the engine manufacturer, the aircraft
manufacturer, the UK Air Accidents Investigation
Branch (AAIB) and the Civil Aviation Safety
Authority (CASA). The submissions were reviewed
and where considered appropriate, the text of the
report was amended accordingly.

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