The Australian Transport Safety Bureau has finalised its 2.5-year investigation into a Qantas plane whose engine exploded on a flight from Singapore to Sydney in November 2010.
The ATSB’s massive report includes some extraordinary photos of the damage.
Here’s exactly what happened:
Qantas was due to ferry 5 flight crew, 24 cabin crew and 440 passengers from Singapore’s Changi Airport to Sydney’s Kingsford Smith on QF32. The Airbus A380 took off seconds before 9.57am, Singapore time.
ATSB reported that the crew retracted the landing gear and flaps after a normal take-off, and set the plane to climb.
Four minutes after take-off, the crew reported hearing two ‘loud bangs’ about half a second apart. The aircraft was about 7000 feet above sea level at the time.
Captain Richard de Crespigny immediately switched on systems that would normally have automatically maintained the plane’s altitude and direction, but the systems weren’t working, so he had to adjust its speed manually.
QF32’s electronic centralised aircraft monitoring system (ECAM) initially warned the crew that the plane’s No.2 engine turbine was overheating.
It soon began displaying multiple warning messages, including a fire warning that only lasted for 1 to 2 seconds.
The crew transmitted an emergency, ‘pan-pan’ message to Singapore air traffic control at 10.02am. They decided to shut down the No.2 engine.
During the shutdown procedure, the ECAM warned that the engine had failed. The crew was unable to discharge either of the engine’s two fire extinguisher bottles normally.
ATSB reports that the crew continued following engine failure procedure by initiating a fuel transfer process.
The ECAM then warned that the No.2 engine had failed, No.1 and 4 engines were degraded, and No.3 was operating in an ‘alternate mode’.
ATSB reports that the flight crew did not initially respond to emergency warnings from the cabin crew while they were focused on the ECAM.
The bureau observed that the location of the cabin emergency call light and tone of the warning horn was not conspicuous enough, although ‘this did not result in an unsafe situation’ in this circumstance.
The ATSB reports that the seat belt sign was on at the time of the engine failure, and all cabin crew and passengers were seated.
Passengers and cabin crew noticed that the plane’s left wing was damaged and there was fuel leaking out from it. The damage was visible through windows and also through the live video that was displayed on the in-flight entertainment system.
The crew had been holding at about 7000 feet above sea level since the engine blast, and assessing ECAM messages and fuel levels throughout the ordeal.
They initially told Singapore’s air traffic control that they would need about 30 minutes to process ECAM messages and go through the relevant procedures and were advised to conduct a holding pattern at 7400 feet, just east of Changi Airport.
‘It took about 50 minutes for the flight crew to complete all of the initial procedures associated with the ECAM messages,’ ATSB reports.
The airport also told the crew that ‘a number of aircraft components had been found by residents of Batam Island, Indonesia’, ATSB reports.
News of the troubled flight spread quickly after one Indonesian resident posted a photo of a clearly marked Qantas engine part on Twitter.
Photos supplied by passengers to the ATSB indicate that some passengers did not turn off their portable electronic devices – including phones and cameras – despite being asked to do so.
‘A significant amount of debris from the aircraft fell over 1.5 square km on Batam Island,’ the ATSB reports. Falling engine components including part of a turbine disc and sections of engine cowling damaged several buildings and other property in Indonesia.
The flight crew told the airport that they would need emergency services on landing. Cabin crew and passengers were told that the plane could overshoot the runway and they should be prepared for emergency evacuation.
Despite a high number of system and flight control malfunctions, QF32 touched down at Changi Airport seconds before 11.47pm. Captain de Crispigny decided to fly the plane manually from about 800 feet down, after the autopilot malfunctioned twice.
QF32 came to a stop just 150m away from the end of the runway. The captain applied the brakes and selected reverse thrust on the No.3 engine to achieve this; the left brake reached temperatures higher than 900°C, ATSB reports.
All but one cockpit display went blank as the captain began shutting down engines. The flight crew also had trouble shutting down engine No.1: neither off switches nor fire extinguishers worked for that engine. It was eventually shut down about 3 hours after the aircraft landed.
Fuel was still leaking from the left wing and firefighters began laying a fire retardant foam blanket over the leaking fuel.
After weighing up options, the crew decided to have passengers exit the plane via a single door on the right of the aircraft. ‘Stairs arrived at the aircraft about 35 minutes after landing and the first bus arrived about 10 minutes later,’ ATSB reports.
Passengers began disembarking about 50 minutes after the aircraft touched down. All passengers left the plane within 10 minutes.
The A380 has 4 engines. QF32’s No.2 - the inner of two engines on the left side of the plane - was badly damaged thanks to a fire in the high pressure/intermediate pressure (HP/IP) bearing component.
The No.2 engine was a three-shaft, high-bypass ratio turbofan ‘Trent 900’ engine manufactured by Rolls Royce.
The HP/IP bearing component caught fire because of a pipe that cracked within it. The fractured oil feed stub pipe leaked oil into the bearing chamber. The temperature in the bearing chamber was 365-375°C: so hot that the oil caught fire.
ATSB said the pipe had developed a fatigue crack over time because the HP/IP hub assembly was misaligned and a section of the pipe wall was too thin.
Rolls Royce's manufacturing drawings were slightly different to design specifications but the parts passed inspection and were produced anyway because of 'ambiguity' in Rolls Royce's procedures, ATSB reports.
As oil leaked out of the pipe, the fatigue crack developed into a fracture. Part of the pipe broke off and was found about 30mm away.
The engine was coming apart.
The oil fire spread throughout the HP/IP component and distorted surrounding parts, causing some to come into contact with each other, which led to intense vibrations and more breakage.
The drive shaft overheated; a turbine disc separated from the shaft, started spinning too fast, and burst. Parts of the broken disc were shot out of the engine and damaged the aircraft, including the left wing.
Engine manufacturer Rolls Royce has since identified and either removed or fixed all affected HP/IP components and improved its quality management system, ATSB reports.
Two of the three broken disc sections from the faulty engine No.2 shot all the way through the left wing, entering through the base of the wing and flying out through the top. One exit hole was as large as 450 mm by 100 mm.
The remaining disc section went through the belly fairing, which is a cover that protects the bottom of the main body of the plane.
Passengers could see the damage through windows and a video stream on the in-flight entertainment system, which probably made for more thrilling viewing than they would have liked.
Engine parts damaged components within the left wing on their way through. The ATSB reports that damage was 'significant' but 'not considered to be major structural damage'.
However, debris wreaked havoc on electrical wires and severed fuel pumps on the base of the left wing.
Engine debris also severed wires at the base of the body of the plane.
The ATSB reports that a total of 650 wires in the left wing and belly fairing were damaged; this explains the many system malfunctions. As noted previously, the autopilot disengaged twice during landing.
Struts supporting the failed engine No.2 didn't fare too well either.
The ATSB reports that the No.2 engine pylon, which attached the engine to the left wing, was hit by engine debris and sustained 'bending, scratches and small gouges' as a result.
Typically, two 'thrust struts' transfer forces from the engine to the wing. Both of these were severed in the case of engine No.2.
Despite all the damage to the plane, the ATSB reports that there were 'no reported injuries to the crew or passengers', and no 'confirmed injuries' to people on Batam Island in Indonesia.
The highly experienced Captain Richard de Crespigny has been described as a hero in the media.
He kept a cool head during the flight, but was psychologically scarred for months after, later telling reporters that he was crying, exhausted and 'constantly reliving the flight' and eventually got help for post-traumatic stress. De Crispigny released a book about the incident last year.
In 2011, Rolls Royce reached a $95 million settlement with Qantas over disruption that followed the incident. The manufacturer now faces a lawsuit from 17 Qantas crew members who say they suffered psychological injury from the experience.
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