B788, vicinity Rome Fiumicino Italy, 2019

B788, vicinity Rome Fiumicino Italy, 2019

Summary

On 10 August 2019, the left Rolls Royce Trent 1000 engine of a Boeing 787-8 just airborne from Rome Fiumicino suddenly malfunctioned and was shut down. A MAYDAY was declared and the flight returned for an overweight landing during which both left main gear tyres deflated. The underlying cause of the engine failure was found to have been intermediate pressure turbine blade detachment attributable to previously-identified serviceability issues. Wider concerns were identified in relation to the key underlying engine certification standards and to the hazard created by the ejection of large quantities of engine debris into a densely populated area.

Event Details
When
10/08/2019
Event Type
AW, FIRE, LOC
Day/Night
Day
Flight Conditions
VMC
Flight Details
Type of Flight
Public Transport (Passenger)
Flight Origin
Intended Destination
Actual Destination
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Take Off
Location - Airport
Airport
General
Tag(s)
Air Turnback, Extra flight crew (no training), Ineffective Regulatory Oversight
FIRE
Tag(s)
Landing Gear Overheat
LOC
Tag(s)
Loss of Engine Power
EPR
Tag(s)
MAYDAY declaration, Precautionary Rapid Disembarkation
AW
System(s)
Engine - General
Contributor(s)
Component Fault in service, Corrosion/Disbonding/Fatigue, Ejected Engine Failure Debris
Outcome
Damage or injury
Yes
Aircraft damage
Minor
Non-aircraft damage
Yes
Non-occupant Casualties
No
Off Airport Landing
No
Ditching
No
Causal Factor Group(s)
Group(s)
Aircraft Technical
Safety Recommendation(s)
Group(s)
Aircraft Airworthiness
Investigation Type
Type
Independent

Description

On 10 August 2019, a Boeing 787-8 (LN-LND) being operated by Norwegian Air Shuttle on a non-scheduled passenger flight from Rome Fiumicino to Los Angeles as DY7115 was passing 1000 feet agl having just taken off in day VMC when its left engine suddenly malfunctioned and was shut down. A MAYDAY was declared and the flight made an overweight landing back at Fiumicino thirty minutes later after dealing with the immediate issue and preparing for the approach and landing whilst following the ground track shown below. During the landing roll, all four left main gear tyres deflated resulting in a small fire which was quickly extinguished by the airport fire service with no hazard to the occupants. A non-emergency passenger disembarkation then followed before further movement of the aircraft. The engine failure was subsequently found to have resulted in the ejection of a large quantity of engine debris which then fell onto a densely populated area causing relatively minor damage but no injuries. Quite extensive but minor impact damage was caused to the airframe structure by ejected engine debris.

B788-vic-Rome-2019-ground-track

The aircraft ground track. [Reproduced from the Official Report]

Investigation

An Investigation was carried out by the Italian ANSV. The available evidence on what had happened included recorded flight data from the two EAFRs installed at different locations in the aircraft together with data recorded in the NVM in the Engine Monitoring Units (EMU). The EMU data were particularly valuable given that a significant number of the 2000 recorded parameters on these units helped to fully understand how the turbine blades has degenerated to a point where complete in-situ failure had occurred without any readily available prior warning as well as comparing the status of the two engines in terms of the possibility of dual failure.

It was found that the operating flight crew consisted of a 49 year-old Captain, an Austrian National with a total of 12,093 flying hours including 1,393 hours on type and a 37 year-old First Officer, a Danish national with a total of 2,882 flying hours experience including 953 hours on type. A 37 year-old Relief First Officer, a German national with a total of 8,356 hours including 673 hours on type, was occupying the flight deck supernumerary crew seat and actively assisted the operating crew following the engine failure.

What Happened

Passing 1,000 feet agl half a minute after the aircraft had taken off from runway 16R with the First Officer acting as PF, the left engine N1 abruptly decreased from 90% to 60% just before strong airframe vibrations began. A series of EICAS messages all relating to the left engine occurred in a rapid sequence over 12 seconds in the order ‘EEC MODE L’, ‘ENG1 VIB WARN’, ‘LOSS OF TPR L’, ‘ENG L EGT RED’, ‘ENG LIMIT EXCEED L’ and ‘OVERHEAT ENG L’. The crew responded by maintaining directional control and preparing to shut down the engine concerned. 

Having been about to check in with radar when the failure occurred, the crew then did so, initially advising “an engine problem” and, having made the initial right turn onto heading 240° to follow the assigned SOSIV 6B SID, requested to continue on that heading. Two minutes later, the crew declared a MAYDAY advising “engine out” and requesting radar vectors to prepare for landing back on 3,902 metre-long runway 16R. A right turn onto downwind heading 320° was given climbing to 3000 feet QNH and when higher terrain was approached, ATC advised that orbits would need to be made until ready for base leg and two to the right were conducted.

Once ready, ATC provided radar vectors towards and onto base leg for runway 16R. With the aircraft remaining in VMC with the airport in sight, ATC then provided a closing heading to the ILS LOC which resulted in alignment with the extended runway centreline at 16 nm out with the subsequent transfer to TWR with 6½ nm to run. As per the crew’s previously-advised intention, the aircraft cleared the runway once at taxi speed and came to a stop on the final RET taxiway ‘AH’ and the right engine was shut down. The Airport RFFS were waiting at this location and having observed a fire starting in the left MLG, they proceeded immediately to extinguish it. An orderly passenger disembarkation to buses followed after which the aircraft was towed to a suitable remote parking position.

The left engine showed no obvious signs of externally-visible damage except for two of the last stage turbine blades and one seriously damaged vane. Numerous fragments were found in the exhaust cone and the final stage of turbine damage was visible (see the illustration below). Multiple small holes and debris-impact marks were visible on the underside of the left wing, its flap fairing and on the left horizontal stabilizer as well as several small impacts on the mainly carbon fibre fuselage. All four left main gear tyres deflated (see the first illustration below) due to the high temperature created during braking following the overweight touchdown. 

A borescope inspection of the failed engine once the aircraft had been towed to a remote parking position found that the origin of the failure had been the detachment of one of the engine’s Intermediate Pressure Turbine (IPT) blades which had then caused the detachment of the trailing blade (see the second illustration below) which together had both led to considerable further engine damage.

B788-vic-Rome-2019-deflated-LMG-tyres

The deflated left main gear tyres. [Reproduced from the Official Report]

B788-vic-Rome-2019-fracture-detachment-IPT-blades

The fracture surface of the primary damage - the detachment of an IPT blade which led to the breakage of the adjacent one. [Reproduced from the Official Report]

Most of the recovered engine debris was found in the area over which the aircraft was passing at the time the first (‘ENG1 VIB WARN’) indications of a problem were annunciated. Although only around 4 kg of debris, mainly fragments of turbine blades ejected from the left engine, was recovered from this area, an analysis of the left engine made by the manufacturer concluded that almost ten times this weight of debris had been ejected. Impact damage included to vehicles - mainly broken windows (see below) and bodywork dents and to buildings (mainly holes in awnings). The larger fragments found weighed about 100 g.

B788-vic-Rome-2019-vehicle-damage

Typical impact damage to a parked vehicle. [Reproduced from the Official Report]

Why It Happened

Both engines installed on the aircraft were Trent 1000 package ‘B with pre-mod SB72-H818 IPT blades (such engines were allowed a limited number of cycles on wing before being modified to remove this limit). There was no evidence that the risk of turbine blade detachment could have been detected either during maintenance or engine operation. It was noted that the Rolls Royce Trent 1000 engine which failed was a three-shaft turbofan with a high bypass ratio of approximately 10:1 with the IPT located as shown in the cross section below.

B788-vic-Rome-2019-RollsRoyceTrent1000-engine

The Rolls Royce Trent 1000 engine. [Reproduced from the Official Report]

In this engine, the low pressure shaft connects the LP compressor to a six-stage Low Pressure Turbine (LPT) which during take-off provides 80% of the thrust. The intermediate pressure shaft connects the 8 IP compressor stages to the single stage IPT turbine where the failure occurred. The IPT blade detachment was found to have been the consequence of progressive corrosion fatigue with initiation favoured by the methodology and type of blade coating and the base material composition of the blade. This problem had already been identified and a programme to replace the blades on all on-wing affected engines (those with pre-mod 72-H818 IPT blades) was already under way based on action being taken ahead of a hard life of 200 cycles as mandated by the EASA under AD 2019-0135. However, the IPT detachment under investigation was found to have occurred 200 cycles ahead of the mandatory limit which was therefore determined to be inadequate with two Interim Safety Recommendations issued (see below under Safety Recommendations).These proposed both a re-assessment of the appropriate on-wing limit for pre-mod engines and a re-evaluation of OEM service management of this problem.

The Investigation checked the status of the right engine, which was at the same modification standard as the failed engine but had functioned normally and found that it had even less cycles remaining (103) and it was found that the majority of its IPT blades were exhibiting sign of deterioration which would eventually lead to blade failure. Since the IPT hard life mandate was clearly inadequate, it was considered that there was at least a possibility that this engine could also have failed and in the absence of any AD to prevent aircraft operation with two pre-mod engines installed. A third Interim Safety Recommendation was therefore issued (again see below) to implement mandatory action to limit the extent to which continued aircraft operation with two pre-mod engines installed would be permitted. 

Uncontained High Energy Debris

It was noted that the CS-E has no clear definition of which “hazardous engine effects” are required to have a probability of occurrence (i.e. failure rate) below 10‾⁷, whereas the FAA equivalent specification in AC33.75 does explicitly recognise that “the release of significant numbers of blades will likely include fragments exiting with high energy and would therefore result in a hazardous engine effect”. It was also noted that the EASA CM-21.A-A-001 concludes that “there are no unsafe conditions currently and in the long-term for the population on ground” because of the absence of cases of death or serious injury due to Parts Detached from Aeroplanes (PDA). This conclusion was considered to be “highly questionable” since it is based on hourly failure rates at any stage of flight whereas “the exposure to risk for PDA of those who live near an airport is clearly higher", especially in the case of those under initial climb flight tracks since “engine stress is typically higher during takeoff and initial climb”

Engine Reliability

The Investigation noted that engine certification standards “have remained unchanged since they were defined more than 40 years ago” and that since engine reliability has significantly improved over that time, the concept of continuous improvement would support periodic review of the minimum level of reliability rather than continuing to use an obsolete standard.

The Cause of the investigated Serious Incident was formally determined as “the failure of intermediate pressure turbine blade number 79 in the left engine induced by a progressive corrosion-fatigue phenomenon made possible by an improvable blade design (which then) induced damage to other parts of the engine, to the aircraft and on (the) ground in the area Fiumicino”.

Contributory Factors in respect of weakness in terms of the regulatory framework for engine certification, given that ten previous similar cases had already occurred beginning in October 2015, were identified as: 

  • An absence of any effective risk assessment for people on the ground due to Parts Detached from Aircraft (PDA) in European Union Aviation Safety Agency Certification Memorandum CM-21.A-A-001.
  • The absence of a clear and more comprehensive definition of what constitutes ‘high energy debris’. 
  • The absence of any plan to review and potentially revise the maximum allowable ‘probabilities of occurrence’ used in the parts of the European Union Aviation Safety Agency (EASA) Certification Specifications and in the Federal Aviation (FAA) Part 21 Certification Procedures for Products and Articles. 

Three Interim Safety Recommendations were made whilst the Investigation was in progress to address the immediate risk of recurrence as follows:

On 29 August 2019:

  • that the European Union Aviation Safety Agency (EASA) takes immediate actions to achieve an higher level of safety, also taking into consideration, but not limiting their initiatives to, defining different and more stringent time limits for the RR Trent 1000 pre-mod 72-H818 IPT blades.
  • that the European Union Aviation Safety Agency (EASA) re-evaluates the whole validity of the service management currently being adopted by the manufacturer of the Trent 1000 pre-mod 72-H818 IPT blades, endorsed by the AD 2019-0135.

On 19 September 2019:

  • that the European Union Aviation Safety Agency (EASA) evaluate provisions relevant to the de-pairing of pre-mod 72-H818 engines, avoiding two engines of the same pre-mod status being installed on the same aircraft, thus further lessening the possibility of a double in flight engine shutdown.

Five Additional Safety Recommendations were issued upon completion of the Investigation in January 2022 as follows:

  • that the European Union Aviation Safety Agency (EASA) evaluates the opportunity to revise the risk assessment related to people on the ground being hit by Parts Detached from Aircraft (PDA), considering in the most conservative way the different specific scenarios for each phase of flight for the improvement of safety. Special attention should be given to people living nearby the airports (and) the results should be taken into account for the next (revision to) certification requirements. [10/1147-19/4/I/21]
  • that the European Union Aviation Safety Agency (EASA) evaluates a revision of the CS-E in order to provide a clear definition of high energy debris including what constitutes a risk for the aircraft and people on board, but also for people on the ground in the framework of the different phases of flight. Special attention should be given to people living near airports. [10/1147-19/5/I/21]
  • that the Federal Aviation Administration (FAA) evaluates a revision of AC33.75 in order to provide a clear definition of high energy debris including what constitutes a risk for the aircraft and people on board, but also for people on the ground in the framework of the different phases of flight. Special attention should be given to people living near airports. [10/1147-19/6/I/21]
  • that the European Union Aviation Safety Agency (EASA), taking into account the actual accident and incident statistics, the actual volume of traffic of the commercial transportation and the actual technology state of the art, evaluates a periodic revision of the maximum allowable probabilities of occurrence used in the CS-E, establishing clear calculation methods. This should have the aim of improving safety by setting achievable standard levels of reliability which are compatible with the actual state of the art. [12/1147-19/7/I/21]
  • that the Federal Aviation Administration (FAA) taking into account the actual accident and incident statistics, the actual volume of traffic of the commercial transportation and the actual technology state of the art, evaluates a periodic revision of the maximum allowable probabilities of occurrence used in FAA Part21 (AC25 25.1309-1A, AC33-75, AC3908), establishing clear calculation methods. This should have the aim of improving safety by setting achievable standard levels of reliability which are compatible with the actual state of the art. [12/1147-19/8/I/21]

The Final Report was published in an English language translation and in the definitive Italian language on 26 January 2022. 

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