Norwegian B788 at Rome on Aug 10th 2019, engine spits parts, hits person and vehicles on ground

Last Update: October 28, 2019 / 16:06:21 GMT/Zulu time

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Incident Facts

Date of incident
Aug 10, 2019

Classification
Incident

Flight number
DY-7115

Aircraft Registration
LN-LND

ICAO Type Designator
B788

A Norwegian Long Haul Boeing 787-8, registration LN-LND performing flight DY-7115 from Rome Fiumicino (Italy) to Los Angeles,CA (USA), was in the initial climb out of Rome's runway 16R when an engine (Trent 1000) failed emitting debris onto the ground below. The crew stopped the climb at 3000 feet, secured the engine and returned to Rome for a safe landing on runway 16R about 23 minutes after departure.

The Mayor of Fiumicino reported 25 vehicles and 12 houses were damaged by debris falling off the aircraft, one man on the ground was hit too. The man was just frightened and remained uninjured however.

Local residents reported glowing pieces of metal rained down in the hundreds.

The airline reported the aircraft returned to Rome due to a technical problem.

Italy's ANSV have dispatched investigators on site.

On Aug 12th 2019 the ANSV reported following immediate operational inspection by investigators the ANSV have opened a safety investigation into the occurrence rated a serious incident.

On Sep 4th 2019 the ANSV released three safety recommendations explaining the motivation for those recommendations were:

the borescope inspection of the engine Trent 1000 G/01A SN 10166, performed after the IFSD event occurred to the B787-8 registration marks LN-LND, highlighted the fracture of two IPT blades. One of these is attributable to the same corrosion fatigue fracture mechanism that was responsible for ten previous cases of IFSD in the Trent 1000 fleet. In one of those cases, in addition to IFSD the blade release also caused damage on the LPT drive arm, proving further negative effects on safety could be possible as a consequence of a IPT blade fracture beside what happened in the B787-8 marks LN-LND event, in which damages to the aircraft and to objects on the ground were recorded. Indeed, for this matter EASA has already recognized the need to maintain fleet safety and has mandated several Rolls-Royce recommended safety actions in the last two years through 6 ADs, the latest and only live action being issued in NMSB 72-AK186, which instructs a hard life for pre-modification blades and is mandated by EASA AD 2019-0135. However, the in-flight IPT blade failure of the Trent 1000 G/01A SN 10166 happened 200 flight cycles before the hard life limit, demonstrating this not sufficient to avoid detrimental effects on safety.

The ANSV recommends to EASA:

Safety Recommendation ANSV-9/1147-19/1/I/19.

To take immediate actions to achieve an higher level of safety, also taking in consideration, but not limiting EASA initiatives to, defining different and more stringent time limits for the Trent 1000 pre-mod 72-H818 IPT blades.

Safety Recommendation ANSV-10/1147-19/2/I/19.

To re-evaluate the whole validity of the service management adopted by the manufacturer for the Trent 1000 pre-mod 72-H818 IPT blades, endorsed by the AD 2019-0135.

Safety Recommendation ANSV-11/1147-19/3/I/19.

To 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 DIFSD.

The ANSV reports that at about 1200 feet and 200 knots over ground climbing out of runway 16R the left hand engine vibration warning activated followed by “EEC MODE L”, “LOSS OF TPR L”, “ENG L EGT RED” (UTC 14.46.14), “ENG LIMIT EXCEED L” (UTC 14.46.16) and “OVERHEAT ENG L” (UTC 14.46.20) EICAS fault messages. The crew shut the engine down and returned to Fiumicino Airport. About 4kg of debris was recovered.

The ANSV released following preliminary data analysis:

Following the event, data were downloaded on site from the Engine Monitoring Unit (EMU) and from the Continuous Parameter Log (CPL). The Enhanced Airborne Flight Recorders (EAFR, picture 11) were downloaded at the ANSV laboratories.

The preliminary analysis of the EAFR data shows that at 14.46.05 UTC (about 6 s before the “Eng1_Vib_Warn” discrete parameter activation) an abrupt decrease of left engine N1 (from 90% to less than 60%, figure 4). At the same time, left engine N2 and N3, oil temperature and pressure slightly increased (figure 5). From the point onward the overall vibration level of the left engine increased (figure 6/7). The left engine IFSD was commanded by the crew at 14.48.06 UTC. The engine manufacturer reviewed the EMU (5 Hz sampling rate) data, confirming the above evidence as well as highlighting, in addition, that the behavior of the engine was compatible with an Intermediate Pressure Turbine (IPT) blade damage. In more detail, the EMU data shows that the drop in N1 happened after IP tracked order vibration increased (as a result of the IPT blade release). Therefore, the most likely sequence of events is (figure 8):

- IPT blade release resulting in IP tracked order vibration increase;
- IPT blade release causes downstream damage to the LP turbine and a reduction in LP shaft speed and increase in LP tracked order vibration;
- the engine control system then attempts to restore power before the pilot shuts down the engine.

No significant variations in the vibration level or other engine related parameters were recorded from the left engine prior to the event.

On Oct 28th 2019 Italy's ANSV released their preliminary report stating the engine failed at about 1200 feet AGL during initial climb. No debris was found within the airport perimeter. 4 kg (8lbs) of debris, mainly fragments of turbine blades, were recovered from the city of Fiumicino. The left engine did not show any external damage except for the last turbine stage. The ANSV wrote: "The aircraft showed multiple holes and impact marks underneath the n° 2 flaps, flap fairing and on the horizontal stabilizer. Some minor dents were also found on the fuselage. The left main landing gear tires deflated due to the hot-braking as a consequence of the overweight landing (photo 9). At the date this ANSV document is issued, the aircraft has not returned in service yet." The occurrence was rated a serious incident and is being investigated (with Germany's BFU, US NTSB, UK AAIB and Norway's SHT joining the investigation).

Analysis of the parameters as recorded by the FDR identify a blade release at the intermediate pressure turbine (IPT) as cause of the engine failure, that subsequently caused damage to the low pressure turbine downstream. A borescopic inspection revealed two adjacent blades at the IPT had failed confirming initial analysis based on the FDR data. The leading blades surface fracture is consistent with a progressive fracture, the trailing blade's fracture surface is consistent with an overload failure.
Incident Facts

Date of incident
Aug 10, 2019

Classification
Incident

Flight number
DY-7115

Aircraft Registration
LN-LND

ICAO Type Designator
B788

This article is published under license from Avherald.com. © of text by Avherald.com.
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