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| Title: | Uncontained engine failure, Aircraft Accident Report, Garuda Indonesia Flight GA 880, Boeing B747-200 PK-GSD, In flight (21 minutes after takeoff from Denpasar, Bali), 23 November 2001 |
| Micro summary: | This Boeing 747-200 experienced an uncontained engine failure shortly after entering cruise. |
| Event Time: | 2001-11-23 at 1426 UTC |
| File Name: | 2001-11-23-ID.pdf |
| Publishing Agency: | National Transportation Safety Committee (NTSC) |
| Publishing Country: | Indonesia |
| Report number: | KNKT/01.27/03.01.009 |
| Pages: | 99 |
| Site of event: | 21 minutes after takeoff from Denpasar, Bali |
| Departure: | Ngurah Rai — Bali International, Denpasar, Bali, Indonesia |
| Destination: | Soekarno-Hatta International, Jakarta, Indonesia |
| Airplane Type(s): | Boeing 747-200 |
| Flight Phase: | Cruise |
| Registration(s): | PK-GSD |
| Operator(s): | Garuda Indonesia |
| Type of flight: | Revenue |
| Occupants: | 148 |
| Fatalities: | 0 |
| Serious Injuries: | 0 |
| Minor/Non-Injured: | 148 |
| Other Injuries: | 0 |
| Executive Summary: | On 23 November 2001, a Garuda Indonesia Boeing B747-200 aircraft registration PK-GSD was on a scheduled passenger flight from Denpasar to Jakarta. At 14.26 UTC, approximately 21 minutes after takeoff from Ngurah Rai Airport, the aircraft experienced an engine failure on the #2 engine. The flight crew decided to descend from FL390 to FL310 and proceed with N-1 condition to Jakarta, where an uneventful landing was accomplished. No injuries to crew or passengers were reported. The National Transportation Safety Committee conducted the investigation according to the standards and recommended practices of Annex 13 to the Convention on International Civil Aviation. On-ground inspection by the NTSC and Garuda Indonesia investigation team revealed that an uncontained engine failure had occurred on the #2 engine low pressure turbine. The debris ejected from the #2 engine had caused minor damages to the airframe and FOD to the #1 engine. The #2 engine was sent to Pratt & Whitney Facilities in Middletown, Connecticut, where an engine tear down was conducted. The tear down was witnessed by an accredited representative from The US National Transportation Safety Board and advised by a US Federal Aviation Administration officer, a team from Pratt & Whitney and a team from the NTSC. Metallurgical analysis was performed on several parts of the 5th stage LPT disk, specifically on the web, at the NTSB headquarters in Washington, D.C. The engine tear down revealed the blockage of the cooling air holes of the 5th stage rotating airseal by plasma coating material. This blockage has a significant impact on the 5th stage disk lives and resulted in uncontained disk fracture. Further investigations found that the process sheet of Windsor Airmotive Asia in Singapore where the airseal was repaired did not include the caution not permitting plasma coat in airseal holes. NTSC immediately issued recommendations to the Department of Communications and notified the Civil Aviation Authority of Singapore. The US FAA also issued a SAIB concerning the blockage of the 5th stage airseal cooling air holes, followed by an All Operators Wire from Pratt & Whitney. This final report contains the factual information, analysis, conclusions and recommendations from the accident investigation. An additional information on engine malfunction identification is attached as an appendix. |
| Learning Keywords: | Operations - Maintenance |
| Systems - Engine - Uncontained Engine Failure | |
| Consequence - Damage - Airframe or fuselage |
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