Investigation number
200100445
Occurrence date
Location
Melbourne, Aero.
Report release date
Report status
Final
Investigation type
Occurrence Investigation
Investigation status
Completed
Occurrence category
Serious Incident
Highest injury level
None

Local safety action

As a result of the investigation, the manufacturer, together
with the UK CAA, implemented the following requirements for all
Trent 800 series engine installations:

  • Mandatory `once round the fleet' inspection for blade root
    cracking (Service Bulletin RB.211-72-D344).
  • Mandatory periodic non-destructive inspection of the blade
    root. Mandatory service bulletin RB211.72-344 specifies the
    interval for repeat non-destructive inspection of the blade root on
    the basis of engine rating, aircraft category and blade root
    standard. In the case at hand (B777-300, Trent 892 with undercut,
    dry film lubricant and standard blade root), the threshold for
    inspection and re-lubrication was set at 600 cycles, with a repeat
    every 80 cycles.
  • Mandatory periodic re-lubrication of the blade roots. Mandatory
    service bulletin RB211.72-D347 specifies re-lubrication intervals
    with frequency dictated by engine rating, aircraft category and
    blade root standard.

In addition, Service Bulletin RB.211-72-D672 specifies a revised
blade design incorporating a re-work to the undercut blade and
re-defining the surface anti-galling system to incorporate the
`Metco 58' interface layer. The service bulletin was undergoing
review by the UK Civil Aviation Authority at the time of release of
this report.

Australian Transport Safety Bureau safety
action

As a result of the investigation, the Bureau issues the
following Safety Advisory Notice:

Safety Advisory Notice SAN20010222

The Australian Transport Safety Bureau advises airlines that
Passenger Entertainment Landscape Camera systems have the potential
to cause passenger distraction during non-normal and emergency
situations.

Emergency procedures should ensure that the system is operated
in a way that will not divert passengers' attention from
instructions given by the flight or cabin crew in such
situations.

Aircraft Details
Manufacturer
The Boeing Company
Model
777
Registration
A6-EMM
Operation type
Air Transport High Capacity
Departure point
Melbourne, VIC.
Destination
SINGAPORE
Damage
Minor