Investigation number
200404214
Occurrence date
Location
Istem, (IFR)
State
International
Report release date
Report status
Final
Investigation type
Occurrence Investigation
Investigation status
Completed
Aviation occurrence type
Engine failure or malfunction
Occurrence category
Incident
Highest injury level
None

On 22 October 2004, at approximately 0510 Australian Eastern
Standard Time, an Australian registered (VH-EBU), Boeing Company
747-338 aircraft, was being operated on a scheduled passenger
service from Honolulu, in the United States of America, to Sydney,
Australia.  Near the instrument flight rules reporting point
ISTEM, located approximately 700 nautical miles north-east of
Sydney, the flight crew had been cleared by air traffic control to
climb from flight level (FL) 340 to FL360.  When the crew set
climb thrust on the engines, they reported that they felt a
vibration in the aircraft and the number-3 engine airborne
vibration monitor lights illuminated, indicating that the number-3
engine had an abnormal vibration level.  The crew shut down
the number-3 engine and continued to Sydney.

A subsequent engineering examination of the number-3 engine
indicated that a low pressure turbine (LPT) second stage blade had
failed.  The engine, a Rolls-Royce RB211-524D4 turbofan,
serial number 12682, was removed from the aircraft and the
recovered LPT blade fragments were sent to the Australian Transport
Safety Bureau (ATSB) for detailed examination.  At the time of
the failure, the engine had a recorded time in service of 71,200
hours and 11,221 cycles since new and 14,787 hours and 2,513 cycles
since repair. The ATSB examination revealed that the LPT blade had
failed as a result of high cycle fatigue cracking (HCF),
originating at an anomalous inclusion in the blade material.
Details of the failed LPT blade examination are contained in the
Technical Analysis report (Appendix A).

Previous LPT blade failures

The engine manufacturer reported that there had been three
previous LPT blade failures in this engine type.  Two of the
events were attributed to engine fuel mal-distribution and
subsequent blade excitation, leading to HCF and failure. 
There was no detail provided on the third event. The failure of
this blade type was a rare event, given that the engine type has
accumulated in excess of 25 million flight hours in service.

LPT blade life monitoring

The LPT blades in the Rolls-Royce RB-211 series engines do not
have a defined blade retirement life and are maintained on
condition; being monitored throughout their service life by
inspection and engine trend analysis.  Once the engine LPT
performance parameters change to pre-determined levels, the engine
is removed for overhaul or repair.  During engine overhaul,
the LPT blades are subject to inspections to determine if they meet
the dimensional requirements for continued service.  LPT
blades may be exchanged between various engines during this
process.

The engine manufacturer's Time Limits Manual for RB211-524
series engines specified that LPT blades are 'Group B' parts and
states that it is 'considered necessary to life mark or maintain
life records of Group B parts'. While it was evident that engine
serial number 12682 had been overhauled in accordance with the
manufacturer's requirements, the individual LPT blades' service
lives were not recorded and so the age and life history of the
failed blade could not be determined.

Aircraft Details
Manufacturer
The Boeing Company
Model
747
Registration
VH-EBU
Serial number
23223
Operation type
Air Transport High Capacity
Departure point
Honolulu, USA
Departure time
1100 UTC
Destination
Sydney, NSW
Damage
Nil