Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Miami, Florida
Sunday, October 5, 2003 EDT
NTSB Narrative Summary Released at Completion of Accident
Climbing through FL 230, an Edelweiss Airbus 330-243 experienced an uncontained engine failure of the No. 1 engine. The flight crew declared an emergency and returned to Miami International Airport, Miami, Florida, to execute an uneventful single-engine landing. Postincident examination revealed that an oil fire in the high pressure (HP)/intermediate pressure (IP) turbine bearing chamber internal oil vent tube of the No. 1 engine burned through the tube, allowing hot gases into the HP/IP turbine bearing chamber. The hot gases blew the oil past the oil seals, igniting the rear area of the bearing chamber and providing enough heat to fracture the IP turbine disk drive arm, which caused the disk to overspeed and release its blades through the IP turbine case. Some of the blades impacted the left wing and a portion of the fuselage. Due to the fire damage to the No. 1 engine and the loss of a significant portion of the internal vent tube and associated heat shield, the exact cause of the vent tube oil fire initiation is unknown. However, examination of the No. 2 engine's vent tube revealed that it was blocked with carbon deposits. Because both engines had the same operating time and history, it is likely that the event engine had a similar blockage of its vent tube and that the blockage contributed to the initiation of the oil fire.
At the time of the uncontained engine failure, Mobil Jet Oil (MJO) 291 was being used in the incident engines. MJO 291 was approved for use in Trent 700 engines in 1996 but Edelweiss was the only operator using that type of oil. The incident investigation revealed that the use of MJO 291 produced coking in the sister engine and, by inference, the incident engine's HP/IP bearing chamber internal oil vent tube which resulted in a catastrophic engine failure. There had been a demonstrated coking problem in the same area with another previously approved oil. A 1999 Rolls-Royce service bulletin (SB) removed ASTO 560 from the list of oils approved for use in Trent series 700 and 800 engines after it was found that significant carbon accumulation was confined to operations using ASTO 560. After the deletion of ASTO 560 from the list of approved oils, no significant buildup of carbon was found in engines over 10,000 hours. As a result, CAA and Rolls-Royce, based upon data available and mindful of the additional threat of a maintenance error associated with such inspections, deleted the 3,000-hour requirement for the on-wing inspection of the HP/IP bearing chamber internal oil vent tube for coking. If the 3,000-hour requirement to inspect for coking had remained in place, it is likely that the coking in the incident engines would have been found and the engine would not have suffered a failure. Each time a new oil is introduced, procedures should be developed and implemented to inspect those areas where engine testing or in-service experience has indicated carbon formation is possible - until such time as there is sufficient in-service engine data to support the case for no longer doing so.
The incident flight was on an ETOPS route, which, in the event of an engine shutdown, allows one engine operation for up to 180 minutes. It is recognized that if the flight crew did shut down one engine, the flight could have continued for that time with an unspecified risk for the remaining engine to fail. Since the sister engine had an unusual coke formation also, by both engines not being monitored after the induction of the new oil, it allowed for the potential of an erosion into the safety margin allowed by ETOPS. This investigation highlights that engine manufactures should take into account the level of risk associated with approving new engine/oil combinations. Operators also need to take into account the introduction of new oils into their fleets and ensure that sufficient evidence exists to support their use.
NTSB Probable Cause Narrative
an uncontained engine failure that resulted from the coking (carbon build-up) in a vent tube which led to a fire and the subsequent liberation of the IP turbine blades. Contributing to the cause of the uncontained engine failure was the absence of measures to adequately monitor the in-service performance of a new engine/oil combination.
Event Information
| Type of Event | Incident |
| Event Date | 10/5/2003 |
| Event Day of the Week | Sunday |
| Time of Event | 0 |
| Event Time Zone | Eastern Daylight Time |
| Event City | Miami |
| Event State | FLORIDA |
| Event Country | -- |
| Zipcode of the event site | -- |
| Event Date Year | 2003 |
| Event Date Month | 10 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | -- |
| Event Location Longitude | -- |
| Event Location Airport | -- |
| Event Location Nearest Airport ID | MIA |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | -- |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Pilot |
| Time of the weather observation | |
| Direction of event from weather observation facility (degrees) | -- |
| Weather Observation Facility ID | -- |
| Elevation of weather observation facility | -- |
| Distance of event from weather observation facility (units?) | -- |
| Time Zone of the weather observation | -- |
| Lighting Conditions | -- |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | -- |
| Sky Condition for Lowest Ceiling | -- |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | -- |
| Air Temperature at event time (in degrees celsius) | -- |
| Dew Point at event time (in degress fahrenheit) | -- |
| Wind Direction (degrees magnetic) | 280 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 15 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Unknown |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | -- |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | None |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 183 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 19782 |
| NTSB Notification Source | Rolls Royce |
| NTSB Notification Date | Oct 5 2003 12:00AM |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | Apr 25 2006 11:00AM |
| User who most recently changed record | NTSB\JOHB |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | HB-IQZ |
| NTSB Number | DCA04IA002 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Non-U.S., Commercial |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | Yes |
| Damage | Minor |
| Aircraft Fire | In-flight |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Airbus Industrie |
| Aircraft Model | A330 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | -- |
| Certified Max Gross Weight | -- |
| Aircraft Category | Airplane |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | -- |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | -- |
| Date of Last Inspection | -- |
| Airframe hours since last inspection | -- |
| Airframe Hours | -- |
| ELT Installed | -- |
| ELT Activated | -- |
| ELT Aided Location of Event Site | -- |
| ELT Type | -- |
| Aircraft Owner Name | -- |
| Aircraft Owner Street Address | -- |
| Aircraft Owner City | -- |
| Aircraft Owner State | -- |
| Aircraft Owner Country | -- |
| Aircraft Owner Zipcode | -- |
| Operator is an individual? | No |
| Operator Name | Edelweiss Air AG |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | 1211 Avenue of the Americas |
| Operator City | New York |
| Operator State | NY |
| Operator Country | USA |
| Operator Zip code | 10036 |
| Operator Code | -- |
| Owner has at least one certificate | -- |
| Other Operator of large aircraft? | -- |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | Scheduled |
| Indicates Domestic or International Flight | International |
| Operator carrying Pax/Cargo/Mail | Passenger Only |
| Type of Flying (Per_Bus / Primary) | -- |
| Second Pilot on Board | -- |
| Departure Point Same as Event | No |
| Departure Airport Code | MIA |
| Departure City | Maimi |
| Departure State | FL |
| Departure Country | USA |
| Departure Time | 0 |
| Departure Time Zone | EDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | -- |
| Destination City | Zurich |
| Destination State | -- |
| Destination Country | SZ |
| Specific Phase of Flight | Climb - to cruise |
| Report sent to ICAO? | -- |
| Evacuation occurred | No |
| Date of most recent change to record | Apr 11 2006 9:30AM |
| User who most recently changed record | DELI |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | -- |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |