Inquiry AO-2012-002: Airbus A320 ZK-OJQ, Bird strike and subsequent engine failure,

Wellington and Auckland International Airports, 20 June 2012

The Transport Accident Investigation Commission is an independent Crown entity established to
determine the circumstances and causes of accidents and incidents with a view to avoiding similar
occurrences in the future. Accordingly it is inappropriate that reports should be used to assign fault or
blame or determine liability, since neither the investigation nor the reporting process has been
undertaken for that purpose.

The Commission may make recommendations to improve transport safety. The cost of implementing
any recommendation must always be balanced against its benefits. Such analysis is a matter for the
regulator and the industry.

These reports may be reprinted in whole or in part without charge, providing acknowledgement is made
to the Transport Accident Investigation Commission.
 Final Report
Aviation inquiry 12-002
Airbus A320 ZK-OJQ
Bird strike and subsequent engine failure
Wellington and Auckland International Airports
20 June 2012

Approved for publication: May 2015

Transport Accident Investigation Commission

About the Transport Accident Investigation Commission

The Transport Accident Investigation Commission (Commission) is an independent Crown entity

responsible for inquiring into maritime, aviation and rail accidents and incidents for New Zealand, and
co-ordinating and co-operating with other accident investigation organisations overseas. The principal
purpose of its inquiries is to determine the circumstances and causes of the occurrences with a view to
avoiding similar occurrences in the future. Its purpose is not to ascribe blame to any person or agency
or to pursue (or to assist an agency to pursue) criminal, civil or regulatory action against a person or
agency. The Commission carries out its purpose by informing members of the transport sector, both
domestically and internationally, of the lessons that can be learnt from transport accidents and
incidents.

Commissioners

Chief Commissioner Helen Cull, QC

Commissioner Jane Meares

Key Commission personnel

Chief Executive Lois Hutchinson

Chief Investigator of Accidents Captain Tim Burfoot

Investigator in Charge Ian McClelland

General Counsel Cathryn Bridge

Email [email protected]
Web www.taic.org.nz
Telephone + 64 4 473 3112 (24 hours) or 0800 188 926
Fax + 64 4 499 1510
Address Level 16, 80 The Terrace, PO Box 10 323, Wellington 6143, New Zealand
Important notes

Nature of the final report

This final report has not been prepared for the purpose of supporting any criminal, civil or regulatory
action against any person or agency. The Transport Accident Investigation Commission Act 1990
makes this final report inadmissible as evidence in any proceedings with the exception of a Coroner’s
inquest.

Ownership of report

This report remains the intellectual property of the Transport Accident Investigation Commission.

This report may be reprinted in whole or in part without charge, provided that acknowledgement is
made to the Transport Accident Investigation Commission.

Citations and referencing

Information derived from interviews during the Commission’s inquiry into the occurrence is not cited in
this final report. Documents that would normally be accessible to industry participants only and not
discoverable under the Official Information Act 1980 have been referenced as footnotes only. Other
documents referred to during the Commission’s inquiry that are publicly available are cited.

Photographs, diagrams, pictures

Unless otherwise specified, photographs, diagrams and pictures included in this final report are
provided by, and owned by, the Commission.
 Airbus A320 – ZK-OJQ
(Courtesy of Colin Hunter)

International Aero Engines V2500 turbofan engine

 2

Legend

Wellington

Auckland

Location of incidents
Contents
Abbreviations ..................................................................................................................................................... ii
Glossary ............................................................................................................................................................ iii
Data summary .................................................................................................................................................. iv
1. Executive summary ...................................................................................................................................1
2. Conduct of the inquiry ...............................................................................................................................3
3. Factual information ...................................................................................................................................5
3.1. Narrative .......................................................................................................................................5
3.2. Engine damage .............................................................................................................................7
3.3. Aeroplane and engine information ........................................................................................... 10
3.4. Wildlife information ................................................................................................................... 12
4. Analysis ................................................................................................................................................... 13
4.1. Introduction................................................................................................................................ 13
4.2. Engine certification and risk management .............................................................................. 13
4.3. Departure report and inflight monitoring ................................................................................. 16
4.4. Wildlife management ................................................................................................................ 17
4.5. Crew actions .............................................................................................................................. 18
5. Findings .................................................................................................................................................. 19
6. Key lessons............................................................................................................................................. 20
7. Safety actions ......................................................................................................................................... 21
7.1. General....................................................................................................................................... 21
7.2. Safety actions addressing safety issues identified during an inquiry .................................... 21
8. Recommendations ................................................................................................................................. 22
8.1. General....................................................................................................................................... 22
9. Sources ................................................................................................................................................... 23
Appendix 1: Aircraft Maintenance Manual procedures .......................................................................... 24
Figures
Figure 1 Fractured 3rd stage blade and an example of clapper shingling ............................................. 8
Figure 2 Fractured 3rd stage blade showing soft body impact damage to the leading edge .............. 8
Figure 3 Crack Initiation x ......................................................................................................................... 9
Figure 4 Mechanical arrangement of the V2500 gas turbine engine .................................................. 10

Final report AO-2012-002 | Page i

Abbreviations
°C degree(s) Celsius

AAIB Air Accident Investigations Branch (United Kingdom)

ACARS aircraft communication addressing and reporting system
ACMS aircraft condition monitoring systems
AGL above ground level
AIRCOM aircraft communications ground server
AMM aircraft maintenance manual
ATC air traffic control

BEA Bureau d’Enquêtes et d’Analyses (France)

CAA Civil Aviation Authority (New Zealand)

DNA deoxyribonucleic acid

EASA European Aviation Safety Agency

ECM engine condition monitoring
EEC electronic engine control
EGT exhaust gas temperature

FADEC full authority digital electronic control

FOD foreign object damage

HPC high pressure compressor

HPT high pressure turbine

IAE International Aero Engines

ICA Instructions for Continued Airworthiness
ICAO International Civil Aviation Organization

LPC low pressure compressor

LPT low pressure turbine

MOC maintenance operations control

NTSB National Transportation Safety Board (United States)

RPM revolutions per minute

VHF very high frequency

VIGV variable inlet guide vanes
VSV variable stator vanes

Page ii | Final report AO-2012-002

Glossary
borescope an optical device consisting of a lens connected by a flexible fibre-
optic cable to an eyepiece or LCD screen. Used for inspecting the
internal condition of a component or engine

clapper a compressor blade mid-span support designed to prevent

aerodynamic instability and vibrations

compressor stall the disruption of normal airflow through the compressor section of
an engine resulting from a stall of the aerofoils. The event may
vary from a minor power loss that occurs too quickly to be seen on
engine instruments, to a complete breakdown of airflow through
the compressor (surge) requiring a reduction of fuel flow to the
engine

cycle one take-off and one landing

the central portion of an engine containing the compressor,

engine core
combustion and turbine sections. The outer section or bypass duct
contains the frontal fan and bypass components the speed of the
fan or low- pressure spool expressed as a percentage of the RPM.
N1 rotor speed:
the speed of the fan or low-pressure spool expressed as a
percentage of the RPM

N2 rotor speed: the speed of the high-pressure spool expressed as a percentage of

the RPM

shingling the overlapping movement of the blade clapper platform mating

edge with the adjacent blade clapper platform edge

teardown the disassembly of an item for examination or repair

Final report AO-2012-002 | Page iii

Data summary
Aircraft particulars

Aircraft registration: ZK-OJQ

Type and serial number: Airbus A320, 232

Number and type of engines: two International Aero Engines V2527-A5

Year of manufacture: 2011

Operator: Air New Zealand

Type of flight: scheduled passenger

Persons on board: 172 (including the crew)

Captain’s qualifications: airline transport pilot licence with category C and D

instructor qualifications

Captain’s flying experience: 16,464 hours total (including 2,183 hours on type)

Date and time 20 June 2012, 15151

Wellington International Airport

Location of incident
latitude: 41º 19’ 38” south
longitude: 174º 48’ 19” east

Auckland International Airport

latitude: 37º 00’ 29” south

longitude: 174º 47’ 30” east

Injuries nil

Damage significant to right engine

1Times in this report are New Zealand Standard Time (co-ordinated universal time [UTC] + 12 hours) and are
expressed in the 24-hour mode.

Page iv | Final report AO-2012-002

1. Executive summary
1.1. On 20 June 2012 an Air New Zealand Airbus A320 was landing at Wellington International
Airport when it suffered a bird strike to its right engine. The bird strike did not affect the
landing. The bird was later identified as a black-backed gull.

1.2. Maintenance engineers inspected the engine in accordance with the Airbus aircraft
maintenance manual and released it back into revenue service later the same day for a flight
to Auckland with 172 persons on board, including five crew members.

1.3. The Airbus aircraft maintenance manual required parts of the engine to be inspected using a
borescope.2 However, as the bird strike had involved only one engine and no damage had
been observed, the aeroplane was allowed to continue in service for up to 10 hours’ flying or
one more sector (one more take-off and landing), whichever came first. The engine was then
required to undergo the borescope inspection. The aeroplane was released to fly to Auckland
under this “continued operating allowance”.3

1.4. On approach to land at Auckland International Airport the same engine suffered a failure. The
captain reduced the engine thrust to idle and continued with the landing. Although damaged
internally, the engine continued to run and was used during the landing.

1.5. An inspection of the failed engine revealed damage to components caused by the bird being
ingested down the core of the engine.4 This damage had led to cracking in a compressor
blade in the third-stage compressor. The crack in this blade grew further under the stress of
continued engine operation in a damaged state. It finally fractured completely and caused
significant damage to other components as it passed through other compressor stages in the
jet engine.

1.6. This was the first reported occurrence worldwide where a V2500 engine had failed while
operating under the continued operating allowance having had a bird strike down the engine
core. The Transport Accident Investigation Commission (Commission) reviewed the operating
parameters and airworthiness requirements that underpinned the authority to continue
operating the engine. The Commission found that the resultant risk to aviation safety was
reasonable, so made no recommendations.

1.7. The aeroplane systems would normally have generated automatic reports to the operator’s
maintenance operations control during the flight, which could have alerted it that the damage
to the engine from the bird strike was worse than initially thought. However, these did not
reach the control centre as intended. The reasons that gave rise to this have now been
rectified.

1.8. The Commission also reviewed the Wellington International Airport Limited’s measures to
control bird life around the aerodrome, and found that these met industry best practice.

1.9. The Commission has made no new recommendations arising from this inquiry. However, it
notes the following key lessons:

Although the safety of the aeroplane and the persons on board was not unduly
compromised by releasing the aeroplane to service knowing that a bird had been
ingested into the core of one engine, operators will need to balance the cost of having
inspection services available at key aerodromes into which they fly with the cost of an
engine failure of this scale.

2 A borescope is an optical device consisting of a lens connected by a flexible fibre-optic cable to an eyepiece
or LCD screen. Used for inspecting the internal condition of a component or engine.
3 Also referred to as a “fly on” allowance.
4 The engine core is the central portion of an engine containing the compressor, combustion and turbine

sections. The outer section or bypass duct contains the frontal fan and bypass components.

Final report AO-2012-002 | Page 1

 Even if the minimum mandatory checks are made to an engine that has suffered a bird
strike down the core, if the aeroplane is released to service before the required full
inspection has been undertaken, the pilots and ground engineering services should
maintain increased vigilance of engine performance until the appropriate full
maintenance checks can be completed.

Page 2 | Final report AO-2012-002

2. Conduct of the inquiry
2.1. The engine failure occurred at about 1515 on Wednesday 20 June 2012. The Transport
Accident Investigation Commission (Commission) was notified by the Civil Aviation Authority
(CAA) later that evening. After making preliminary enquiries the Commission opened an
inquiry on 21 June 2012 under section 13(1) of the Transport Accident Investigation
Commission Act 1990, and appointed an investigator in charge.

2.2. On Thursday 21 June 2012 the investigator in charge, assisted by a second investigator who
had engineering experience, travelled to Auckland to inspect the aeroplane and engine.
During the next two days the investigation team interviewed the following Air New Zealand
(operator) personnel:
the captain of the flight from Wellington to Auckland
the engineers who met the aeroplane on arrival in Auckland
the engineering management and safety personnel involved.

2.3. During the following week the investigators interviewed:

the engineer who carried out the bird strike inspection at Wellington
the operator’s line maintenance manager at Wellington
Wellington air traffic control staff working in the control tower, including the controller on
duty at the time of the incident
Wellington International Airport Limited (Wellington airport) personnel concerned with
bird management on the aerodrome.

2.4. The Commission’s investigators also obtained a number of records and documents, including:
CAA bird strike and near-miss data for New Zealand aerodromes
aerodrome bird strike data and management procedures for the major aerodromes
around the country
aeroplane flight data recorder information.

2.5. On 9 July 2012 the French Bureau d’Enquêtes et d’Analyses (BEA), the United Kingdom Air
Accident Investigations Branch (AAIB) and the United States National Transportation Safety
Board (NTSB), as the states of manufacture of the aeroplane or engine, were informed of the
incident and invited to participate. BEA and AAIB appointed non-travelling Accredited
Representatives in accordance with Annex 13 to the International Civil Aviation Organization’s
Convention on International Civil Aviation. NTSB elected not to appoint an Accredited
Representative, and instead nominated a contact person to co-ordinate any requests for
support.

2.6. The Commission notified the engine manufacturer, International Aero Engines (IAE),5 of the
incident. The Commission accepted an offer of assistance from IAE, which then appointed
Rolls-Royce Air Safety Investigation as the initial point for communications. IAE later also
nominated a Pratt & Whitney representative to assist the investigation. The Commission also
notified the aeroplane manufacturer, Airbus, of the incident.

2.7. The engine was sent to the Christchurch Engine Centre for examination under the supervision
of the Commission. A full teardown6 of the engine was performed and components sent to
Rolls-Royce for further detailed inspection. Induction and teardown reports were obtained
from the engine centre. On 16 October 2012 IAE (Rolls-Royce) provided a technical services

5 A joint consortium of Pratt & Whitney, Rolls-Royce plc, Japanese Aero Engine Corporation and MTU Aero
Engines. Fiat Avio was also initially a partner but withdrew from the consortium early in the engine’s
development. It remained as a supplier.
6 A teardown is the disassembly and inspection of an engine.

Final report AO-2012-002 | Page 3

 report covering the specialist examination of the removed components and an overview of the
rotor blade fractures on the engine. The report also included engine reliability data and a bird
strike risk assessment.

2.8. On 19 June 2013 IAE provided a copy of its final technical services report on the examination
of the engine. On 21 June 2013 the Commission provided a list of questions to IAE for further
comment.7 On 15 November 2013 Pratt & Whitney provided a response to those questions.

2.9. On 15 January 2015 the Commission sought comment from BEA, on behalf of Airbus and the
European Aviation Safety Agency (EASA), the airworthiness authority for the Airbus A320. A
response was received on 27 January 2015 and as a result NTSB was asked to comment as
the representative for the state of manufacture of the engine. On 26 February 2015 a
teleconference was held involving representatives of NTSB, IAE (Pratt & Whitney) and the
Commission.

2.10. On 26 March 2015 the Commission approved a draft version of this report for circulation to
interested persons for comment. Submissions were received from the operator and crew, and
considered in preparing the final report.

2.11. On 28 May 2015 the Commission approved the publication of the report.

7 Because of a changed commercial arrangement, Rolls-Royce forwarded the questions to Pratt & Whitney for
response.

Page 4 | Final report AO-2012-002

3. Factual information
3.1. Narrative

3.1.1. On the morning of Wednesday 20 June 2012, an Airbus A320-232 aeroplane, registration
ZK-OJQ, was on a scheduled flight from Auckland to Wellington. The flight was uneventful until
the aeroplane was landing at Wellington, when a bird struck the right engine. The crew was
unaware of the bird strike and the pilot flying selected reverse thrust as normal. Shortly
afterwards a strong odour characteristic of bird ingestion was evident in the cockpit and cabin
of the aeroplane.

3.1.2. The crew reported the bird strike to the tower controller and line maintenance personnel when
they arrived at the gate.8 An engineer met the aeroplane at the gate and spoke with the pilots.
They agreed that the odour was consistent with a bird having been ingested into an engine.
The maintenance engineer made an initial inspection of the engine and confirmed that the
bird had entered the core of the right engine. The aeroplane was removed from service for a
bird strike inspection in accordance with the Airbus aircraft maintenance manual (the
maintenance manual). See Appendix 1 for a full description of the inspection procedure.

3.1.3. The three engineers who inspected the engine collected the bird remains from around the
engine and sent them to the University of Auckland for a deoxyribonucleic acid (DNA) analysis,
which confirmed that the remains were that of a male black-backed gull.

3.1.4. The lead engineer completed all the tasks outlined in the maintenance manual procedure for
when an engine has suffered a bird strike. In addition to the checklist items he inspected the
first stage rotor blades of the low-pressure compressor (LPC) stage 1.59 with a mirror and
torch. He said his experience had shown the need to check this specific area of the low-
pressure compressor for damage after a core ingestion. No damage was detected during the
inspection.

3.1.5. The engineer then performed a low-power engine ground run10 while the aeroplane was still
positioned at the gate. With the doors closed the right engine was run at idle power for eight
or nine minutes to check the engine and to try to clear the odour from inside the aeroplane.
The engineer had other people walk through the aeroplane to determine if the odour was
clearing, and after confirming it had cleared sufficiently he shut the engine down. He recalled
that the N1 and N2 rotors of the right engine had shown no signs of increased vibrations
during the engine run.11

3.1.6. The maintenance manual bird strike inspection checklist for a suspected core ingestion
directed that the engineer perform a borescope inspection of the engine’s low-pressure
compressor stages 1.5 and 2.5, and high-pressure compressor (HPC) stages 3 and 6.
Because the bird strike had affected one engine only, the maintenance manual provided a
continued operating allowance of “less than 10 flight hours or 2 flight cycles,12 which occurs
first” before the borescope inspection needed to be completed. The engineer consulted the
operator’s maintenance operations control (MOC) then released the aeroplane to service
using the continued operating allowance. He also raised a maintenance task card for the
borescope inspection to be performed when the aeroplane arrived in Auckland.

3.1.7. A replacement flight crew arrived later on the same day to fly the aeroplane to Auckland. The
engineer briefed the captain about the bird strike and the captain was agreeable to flying the
aeroplane as long as the engineer and MOC were satisfied that the requirements had been

8 The parking gate adjacent to the terminal.

9 The various stages of the engine’s compressor sections are numbered from the front of the engine starting
with the fan blades as LPC 1 followed by LPC 1.5, through to the high-pressure section.
10 Idle, or close to idle, power only.
11 Vibration detection equipment can help to identify engine damage.
12 A cycle is one take-off and one landing.

Final report AO-2012-002 | Page 5

 met and the aeroplane was cleared for the flight. The engineer told the captain that he had
performed the required maintenance tasks and that MOC had been involved with his decision
to return the aeroplane to service.

3.1.8. The engineer told the captain that even though he had run the engine to clear the smell, there
could still be a smell in the aeroplane when they left Wellington. The engineer asked the
captain if it was possible to give the engine a good run-up before take-off to check that the
engine performance parameters were normal.

3.1.9. At about 1430 the passengers boarded for the flight to Auckland. The captain told the
passengers that there could be a smell during the initial stages of the flight. When the
aeroplane reached the runway threshold the captain held it on the brakes and increased
power to check the engine parameters as the engineer had requested.13 All appeared to be
normal, so he released the brakes and commenced the take-off. As soon as the aeroplane
became airborne there was a strong smell as expected. The captain said the smell improved
slightly as the flight continued.

3.1.10. The flight from Wellington to Auckland took about 35 minutes and included a few minutes only
in the cruise. Soon after levelling at cruise altitude the first officer quickly completed the trip
number record and exhaust gas temperature (EGT) divergence monitoring form. The form was
not required to be completed on such a short flight, as normally the aeroplane needed to be in
a sustained cruise configuration to allow the engine readings to stabilise. However, he
thought he could quickly note down the information. He recorded on the paperwork the EGT
readings for both engines, which showed a 19 degrees Celsius (°C) split between the two
engines, with the right engine being hotter. The aeroplane entered the descent immediately
afterwards.

3.1.11. At about 1515 the aeroplane was between 1,500 feet and 1,000 feet on the approach to
Auckland with the runway in sight when the right engine compressor stalled,14 with loud
banging noises. The odour of burnt bird increased on the flight deck and in the cabin. The
captain moved the right engine thrust lever back to idle power and the banging noises
stopped. He elected not to spend time trying to find a thrust lever position where the stall
ceased, as the runway was clear but a heavy rain shower was approaching the far end. He
advanced the left-engine thrust lever and instructed the first officer to select the auto brakes
to medium. The landing checklist was completed and a Pan-Pan call15 made to the tower
requesting that the rescue fire service meet the aeroplane once it had landed. The first officer
spoke briefly with the inflight service manager, who advised that flames had been seen
coming from the tail pipe of the engine and that the cabin was secure for landing.

3.1.12. After the aeroplane touched down the captain moved both thrust levers into reverse, with both
engines responding as expected. As the aeroplane slowed he moved the thrust levers back to
idle and manoeuvred the aeroplane on to the taxiway to the side of the runway. The
aeroplane was brought to a halt and the right engine shut down. The rescue fire service met
the aeroplane and confirmed that there was no fire or obvious danger. The aeroplane was
taxied to the gate using the left engine. During this time the captain made several
announcements to the passengers.

3.1.13. Once on the gate the captain shut down the left engine and, after making a final
announcement, disembarked the passengers. The flight and cabin crews held a debrief a
short time later. There was no brace position instruction given to the passengers as the cabin
crew said they knew the engine stall had ceased and could hear the left engine still operating
normally, and the aeroplane appeared to be stable on the approach.

13 The power setting used was not recorded, but was probably towards 50% of take-off thrust.
14 A compressor stall is the disruption of normal airflow through the compressor section of an engine
resulting from a stall of the aerofoils. The event may vary from a minor power loss that occurs too quickly to
be seen on engine instruments, to a complete breakdown of airflow through the compressor (surge) requiring
a reduction of fuel flow to the engine.
15 A Pan-Pan call is a radio call indicating a state of urgency where assistance may be required.

Page 6 | Final report AO-2012-002

3.1.14. The aeroplane was met on the gate by a line maintenance engineer from the operator. The
engineer completed an initial inspection and said that there was a very strong smell of bird at
the rear of the engine, which seemed to confirm the likelihood of a recent bird strike.

3.1.15. The engineer walked around the outside of the engine and found no evidence of a bird strike
at the front of the engine or anywhere else on the outside of the engine, but he did find two
small pieces of bird feather on one of the fan exit guide vanes inside the engine fan case. The
pieces were sent to the University of Auckland for DNA analysis, which identified them as from
a male black-backed gull.

3.1.16. The aeroplane was taken to the operator’s engineering hangar in Auckland and a borescope
inspection was performed on the engine. The inspection revealed that one third-stage high-
pressure-compressor blade was missing. The missing blade had caused substantial damage
to the core of the engine. The engine was removed from the aeroplane and sent to an
approved overhaul and repair facility for further assessment and repair.

3.2. Engine damage

3.2.1. Four of the acoustic panels behind the fan blades were damaged, of which two were beyond
repair. A small amount of damage was evident on the fan blades and annulus fillers, which
showed that the bird had been ingested into the centre of the engine and the bulk of the bird
had gone down the core.

3.2.2. The low-pressure compressor stage 1.5 rotor blades sustained tip curl to nine of the blades.
The tip curl was caused by the stage 1.5 blades contacting the front case of the low-pressure
compressor during the bird strike or possibly during the engine stall in Auckland. Four of the
blades were damaged beyond repair and had to be replaced.

3.2.3. The high-pressure-compressor stator section had bird debris on all of the variable inlet guide
vanes and there was a significant amount of damage to the stages 4-6 rotor path segments.
All the variable inlet guide vanes, variable stator vanes and subsequent fixed stator vane
stages were damaged beyond repair and had to be replaced. The stage 8 rotor path case was
replaced due to the amount of foreign object damage.

3.2.4. One third-stage compressor blade was found fractured and the adjacent blades had soft body
impact damage typical of a bird strike. A piece of the fractured blade that was found in the 3-
8 rotor drum showed signs of soft impact damage to the leading edge. Extensive hard body
impact damage caused by the released blade was evident on all stages downstream of stage
3.

Final report AO-2012-002 | Page 7

 blade clapper

bird debris

clapper shingling

fractured blade

Figure 1
Fractured third-stage blade and an example of clapper shingling

blade leading edge

leading edge distortion

bird remains

Figure 2
Fractured third-stage blade showing soft body impact damage to the leading edge

Page 8 | Final report AO-2012-002

 Figure 3
Crack initiation x

3.2.5. All 31 of the third-stage high-pressure-compressor blades and the fractured piece of blade
were removed and sent to an approved laboratory for further analysis. The fractured blade
displayed high-cycle-fatigue crack growth (propagation) followed by aerofoil liberation. High-
cycle-fatigue crack growth is caused by stresses placed on the blade during in-service
vibrations. The crack originated from the mid chord on the suction side (convex) of the blade
about 43 millimetres above the platform and 23 millimetres from the blade leading edge.

3.2.6. The diffuser section of the engine had damage to the exit stator case vanes caused by objects
passing through the engine. The exit stator case was scrapped and 11 fuel nozzles out of the
20 were scrapped due to impact damage to the inner heat shields. All the liner segments
were scrapped in the combustion section due to the large amount of impact damage and
metal deposits found on the surface of the liners. The number 4 bearing compartment and
stage 1 nozzle guide vanes had heavy maintenance action performed due to the amount of
metal debris and metal deposits found in these areas.

3.2.7. A significant amount of metal deposits and debris found in the high-pressure turbine module.
Eleven number 1 turbine wheel blades were scrapped due to the metal deposits on the
external surfaces of the blades. The entire stage 2 nozzle guide vanes and stage 2 blades
were repaired due to the metal deposits found on the surface of the parts.

3.2.8. Metal deposits were found throughout the engine, with the exception of the exhaust, with
associated damage rearward of the third-stage high-pressure turbine.

Final report AO-2012-002 | Page 9

3.3. Aeroplane and engine information

Figure 4 Source: Aircraft maintenance manual

Mechanical arrangement of the V2500 gas turbine engine

3.3.1. The Airbus A320 aeroplane was a narrow-body aircraft of conventional design, with a
significant amount of the structure made from lightweight composite material. The aircraft
included a full digital fly-by-wire flight control system and a full glass cockpit. The flight deck
was equipped with an electronic flight instrument system (EFIS) and had an electronic
centralised aircraft monitor (ECAM) system that provided the flight crew with information
about the status of all the systems on board the aircraft.

3.3.2. The operator’s A320 fleet was fitted with IAE V2527-A516 engines, which were rated at 27,000
pounds of take-off thrust. The incident engine, serial number V15721, was an IAE V2527-A5
“select one” engine, which meant that it incorporated the latest performance improvements
supported by an aftermarket agreement. At the time of the incident it had acquired a total of
3,337 cycles and 3,164.77 hours since new.

16
The “V” in the IAE engine number was representative of the five original shareholders in IAE. In October
2011 Rolls-Royce sold its share to Pratt & Whitney’s parent company, United Technologies, but remained a
major supplier. As the manufacturer of the compressor section of the engine, Rolls-Royce was best placed to
initially assist the Commission’s inquiry.

Page 10 | Final report AO-2012-002

3.3.3. The engine operating parameters such as EGT, vibrations and fuel flow were monitored
electronically in the cockpit and fed into the Aircraft Communication Addressing and Reporting
System (ACARS) in order for regular automatic engine condition monitoring (ECM) reports to be
transmitted. The reports allowed maintenance and planning personnel to see live engine data
while the aeroplane was flying. The system was also designed to send alerts should there be
a sudden change in performance or a limit exceeded. The reports aided in condition
monitoring activities and planning for scheduled and unscheduled maintenance.

3.3.4. ACARS also allowed a direct exchange of data between aeroplane and airline ground
computers. The aeroplane-to-ground messages, commonly called the downlink, included
information relative to operations, maintenance and performance. The ground-to-aeroplane
messages, commonly referred to as the uplink, typically included operational information such
as weather and aerodrome conditions. The automatic downlink of reports was adapted to suit
individual operators’ reporting needs.

3.3.5. The operator’s A320 aeroplanes produced a take-off and cruise report for each flight as part
of the aircraft condition monitoring and reporting systems. The reports were sent to the
aircraft communications server on the ground. The aircraft communications server was
programmed to redirect the reports and messages in the form of emails to different email
addresses. The engine condition monitoring programme also received the engine reports from
the aircraft communications server while the aeroplane was flying.

3.3.6. The engine condition monitoring data for the Wellington to Auckland flight on 20 June
identified that the normal take-off report was not generated when the aeroplane departed
Wellington. The reporting programme language worked on flight phases. Because of the low-
power ground run performed at Wellington, the EGT reading did not pass a minimum figure, so
the ACMS trigger logic that controlled the generation of the take-off report was inhibited for
one flight. The aeroplane did, however, generate a cruise report that contained three alerts
indicating that there was a change in EGT, fuel flow and N2 vibrations on the right engine (the
bird strike engine).

3.3.7. The cruise report that contained the alerts was sent from the aeroplane to MOC during the
flight. However, an incorrect data character in the report resulted in it being sent to a telex-
error-holding folder, so the alerts did not appear in front of the MOC duty manager during the
flight. The alerts were only processed and seen in the evening of the same day when a
systems engineer fixed the problem by changing the data character, allowing the report to be
processed correctly.

3.3.8. A review of the aeroplane’s flight data recorder (FDR) revealed that from the beginning of the
take-off in Wellington the right engine was operating at nearly 30°C hotter than the left engine,
with an increased fuel flow of 3.7% and an increase in the N2 rotor vibrations of 0.6 units.
The temperature difference reduced to 19°C during the short cruise and about 7°C in the
descent. The aeroplane was 18 months old and trend monitoring data showed that prior to
this flight there had been no significant EGT or fuel flow split between the engines.

Final report AO-2012-002 | Page 11

3.4. Wildlife information

3.4.1. The DNA analysis of the samples taken at Wellington and Auckland identified both as being
from the black-backed gull (Larus dominicanus). Both samples were sexed as male and both
had identical DNA sequences. The two samples were indistinguishable, but because of testing
limitations the laboratory was not able to state conclusively whether the samples were from
the same bird or whether there had been two separate bird strikes, both involving male black-
backed gulls.

3.4.2. Civil Aviation Rule Part 139 (CAA, 2010) for aerodromes required aerodrome operators to
develop environmental management programmes to comply with subpart 139.71. The CAA
provided guidance material in advisory circular AC139-16 (CAA, 2011a), which helped
aerodrome operators to comply with the Rule.

3.4.3. Bird management programmes in New Zealand are mainly focused on mitigating the risk of
bird strike as it can have significant impacts for aircraft operators, including the loss of
revenue, the cost of repairing damaged aircraft and, in extreme cases, the loss of an aircraft.
The financial costs can vary depending on the extent of the damage to the aircraft; for
example, the cost of repairing damage to the engine core of a Boeing 737 or Airbus A320 can
typically be between US$2 million and US$4 million.

3.4.4. Wildlife hazard management programmes try to reduce the frequency and severity of bird
strikes and are normally developed with input from a number of parties, including aircraft
operators, air traffic control, land owners around aerodromes, local councils and government
organisations.

3.4.5. CAA Rule Part 12 (CAA, 2011b) requires the pilot in command of an aircraft to report all bird
incidents to the CAA. The pilot normally passes any information concerning a bird strike or
near strike to the nearest air traffic controller, who passes on the information to the CAA.
Operators also have internal reporting systems that pass on the information to the CAA and for
discussion with airport operators.

Page 12 | Final report AO-2012-002

4. Analysis
4.1. Introduction

4.1.1. The engine failure on the approach to land at Auckland was the result of the continued
operation of the engine damaged in the earlier bird strike as the aeroplane was landing at
Wellington. The possibility of a second bird strike on the same engine was considered highly
unlikely for several reasons. Firstly, the engine failure occurred at a height where, according
to bird strike data, a strike from a black-backed gull would not normally be expected.
Secondly, the DNA collected at Wellington and Auckland corresponded to the same bird
species and sex and, as far as testing allowed, the same bird. Finally, and perhaps most
importantly, there was clear evidence of a change in engine performance when the aeroplane
departed Wellington.

4.1.2. The engineer who carried out the inspection at Wellington followed the prescribed procedure
for a bird strike. He also performed several additional actions to identify any damage. With no
damage found, and after consulting the operator’s MOC, he released the aeroplane back into
revenue service in accordance with the fly-on allowance. The engine subsequently failed early
in the 10-hour allowance.

4.1.3. There were several opportunities after the return of the aeroplane to service in Wellington for
the performance of the engine to alert either the crew or MOC to a potential problem.
However, even if the alerts had been received and acted upon, the resulting action may have
simply been to reduce power or continue to monitor the suspect engine, which might not have
prevented the failure. Nevertheless, the failure of these established detection systems is a
concern and is examined further, along with the fly-on allowance. Bird strikes and the
management of this hazard are also examined, as well as the crew’s actions in Auckland.

4.2. Engine certification and risk management

4.2.1. The bird strike at Wellington occurred at a stage of flight when engine power and fan speed
were near their lowest, increasing the likelihood of the bird or parts of it being ingested into
the core of the engine. At higher fan speeds, for example during take-off, items are more likely
to be thrown outwards and thereby bypass the core, causing little or no damage.

4.2.2. The ingestion of the bird into the core of the engine forced the blades out of alignment,
causing blade movement during the flight to Auckland. This movement resulted in the
clappers17 shingling18 and a crack forming and growing under the stresses present.
Eventually the crack ruptured and the blade separated, causing the engine surge. It is also
possible that because of the disrupted airflow from the then excessive blade movement and
shingling, the engine surged, causing the section of blade to rupture and separate.
Regardless of the final sequence of events, the initiator was the bird strike and the resulting
soft impact damage.

4.2.3. After the initial surge at Auckland the engine continued to operate at idle power, and neither
the release of the section of compressor blade nor the use of reverse thrust after landing
caused any external damage. The containment of damage to inside the engine is a required
design feature for which the engine is certified.

17 A clapper is a compressor blade mid-span support designed to prevent aerodynamic instability and
vibrations.
18 Shingling is the overlapping movement of the blade clapper platform mating edge with the adjacent blade

clapper platform edge.

Final report AO-2012-002 | Page 13

4.2.4. The regulatory continued airworthiness threshold for a dual-engine in-flight shutdown per
aircraft flying hour for the V2500 engine was 1.0E-9 per flight hour.19 This meant that for every
flight hour there was a 0.000000001 or one-in-a-billion risk of a dual-engine shutdown.

4.2.5. The engine manufacturer performed mathematical risk assessments based on the regulator’s
requirements and developed the aircraft maintenance manual inspection schedules based on
the mathematical results. The less-than-10-hours or two-flight-cycles fly-on allowance, under
which the engine in this incident was released, was developed in this manner.

4.2.6. According to IAE, based on V2500 fleet experience at the time of the occurrence, the single-
engine bird strike event rate was 4.1E-5 per engine cycle.20 Based on V2500-A5 experience,
28% (535) of the reported bird strikes on engines resulted in core ingestion. Of the 535 core
ingestions, 41% (219) caused damage to the engines. The single-engine-event analysis
calculation of the probability of an in-flight shutdown due to bird strike was then worked out
using the following equation:

4.1 E-5 x 0.28 x 0.41 = 4.7E-6 per cycle

Bird strike Down Core Damaging Single Event

Down bypass Non-damaging

4.2.7. IAE stated that of the 41% of cases where damage resulted from known core ingestions, 75%
(164) of the aeroplanes were not able to take off on their next scheduled flights. In these
cases, typically the damage was identified either during the initial inspection or by noting a
deterioration in engine performance before the aeroplane could take off.

4.2.8. On 55 occasions21 or 25% of the damaging events, equivalent to 10.3% of the known core
ingestion events,22 the aeroplanes were able to get airborne using the fly-on allowance with
undetected damage to the engines (at that time).

4.2.9. The current dual-engine bird strike event rate for the V2500 engine was 1.0E-6 per aircraft
cycle. Using the known core ingestion and damage rates identified in the above calculation,
the possibility of a dual-engine shutdown is calculated below.

1.0E-6 x (0.28)² x (0.41)² x (0.25)² = 8.1E-10 per cycle = 4.1E-10 AFH23

Bird strike Core ingestion Bird damage In flight

4.2.10. According to IAE the data showed that the risk of a dual-engine in-flight shutdown rate of 4.1E-
10 AFH was below the regulatory continued airworthiness threshold of 1.0E-9 per aircraft
flying hour. The manufacturer said that the assessment supported the use of the aircraft
maintenance manual fly-on allowance of less than 10 hours’ flying or two flight cycles when
only one engine was subject to bird strike.

4.2.11. However, what is not known is when in the 10-hour or two-flight-cycle tolerance period the
borescope inspections were completed on any of the engines with high-pressure-compressor
damage. For example, did any of the aeroplanes released under the fly-on allowance use the
full fly-on allowance? Or were all the borescope inspections completed within one or two
hours? The average length of a flight was about two hours and the maximum was about five
hours.

19 This is the worst case scenario, as the A320 is capable of operating on a single engine for any phase of
normal flight.
20 5686 V2500 engines that have flown more than 65 million cycles in 122.3 million hours.
21 Of the 219 damage events, the damage was detected on 165 occasions, leaving 55 undetected.
22 Fifty-five out of a total 535 core ingestion events.
23 AFH – aircraft flight hour.

Page 14 | Final report AO-2012-002

4.2.12. The risk analysis calculations provided by the manufacturer were based on an aeroplane with
two good engines. When ZK-OJQ took off from Wellington with 172 persons on board, it had
already suffered a bird strike that required further inspection for damage. Because there was
clear evidence of a core ingestion of the bird, based on historical data there was theoretically
a 41% probability of some damage being present.24

4.2.13. The manufacturer advised that this occurrence was the first recorded event of a blade release
within the aircraft maintenance manual fly-on allowance. The manufacturer also reported that
until the incident on 20 June 2012 there had been no in-flight shutdowns on any of the 55
preceding flights operating under the fly-on allowance. While this may give confidence in the
robustness of the engine to withstand the core ingestion of a medium-sized bird, the engine
surge on approach to Auckland occurred within 45 minutes of the aeroplane departing
Wellington – well inside the 10-hour limit. The engine run at Wellington was a low-power run
of short duration only and was not considered part of the fly-on allowance.

4.2.14. The IAE technical services report on the incident contained the following recommendation:

EFI/0945/002: It is recommended that IAE review the fly-on time limit in

the AMM [aircraft maintenance manual] inspection (task 72-00-00-200-
010A), to determine whether or not it remains an appropriate timescale that
will mitigate future in-service blade release occurrences resulting from
similar core ingestion events.

4.2.15. The manufacturer later advised that after reviewing the information available, no change to
the fly-on allowance was proposed “as the IFSD [in-flight shutdown] risk across the fleet has
sufficient margin to the prescribed, Regulatory threshold for Continued Airworthiness”.25 The
manufacturer had surveyed three major operators of the V2500 engine26 to gauge their
actions following bird strike. The three operators advised that they followed the
manufacturer’s maintenance manual and would use the allowance if required.

4.2.16. The Commission, through BEA, sought comment from Airbus and EASA as the airworthiness
authority for the Airbus A320. BEA advised that Airbus was in agreement with IAE’s risk
analysis. The fly-on allowance remained valid, with the risk of either a dual engine failure or a
single engine failure following the satisfactory completion of the bird strike inspection
procedure sufficiently low as not to require amending.

4.2.17. EASA advised that an aircraft maintenance manual formed part of “the Instructions for
Continued Airworthiness” that a manufacturer must provide to operators. Only its
airworthiness limitations section had to be approved by EASA and fly-on allowances were
usually not part of this. The fly-on allowance contained in the aircraft maintenance manual
was therefore the responsibility of Airbus.

4.2.18. EASA’s certification specifications for engines specified no single turbine engine shutdown
rate, which was defined as a “Minor Engine Effect” (EASA, 2010).27 EASA contended that the
fleet-wide safety objective for the V2500 engine had been achieved, and both BEA and EASA
were only concerned if both engines had been subjected to bird strike and core ingestion.

4.2.19. An IAE Pratt & Whitney technical services representative confirmed that after being
questioned by the Commission and again reviewing engine reliability data, no changes to the
fly-on allowance were planned. The representative explained that while there was a 41%
possibility of damage following a core ingestion, a core ingestion was most likely to occur at
low engine speed on approach to land. These ingestions typically resulted in minor tip curl of
the blades, which did not pose an immediate danger to the aircraft. The aeroplane involved in

24 The 41% probability was determined as a result of the review undertaken by the engine manufacturer post
this occurrence.
25 Email dated 15 November 2013.
26 United Airlines – 302 engines, US Airways – 256 engines and British Airways – 174 engines.
27 EASA Certification Specifications for Engines, Subpart D – Turbine Engines; Design and Construction, CS-E

510 Safety Analysis.

Final report AO-2012-002 | Page 15

 this incident was the only example of severe damage and blade failure when operating under
the fly-on allowance.

4.2.20. However, IAE did acknowledge that the wording in the maintenance manual relating to the fly-
on allowance could be confusing. The intention was to limit the allowance to less than 10
hours’ flying and fewer than two cycles; in other words a maximum of 9.9 hours’ flying and one
cycle only. IAE is going to put out information to all operators clarifying what the fly-on
allowance is.

4.2.21. This analysis of the risk following a single-engine bird strike event involving the IAE engine
included a review of that risk assessment by the various regulators and aeroplane and engine
manufacturers. The argument supported the hypothesis that a single-engine bird strike on
this type of aeroplane fitted with this type of engine was highly unlikely to result in an
unacceptable risk to flight safety. Accordingly the Commission has no recommendation to
make on that matter.

Findings

1. It is highly likely that this contained engine failure was the result of a single bird strike
event on the previous flight when the aeroplane was landing at Wellington Aerodrome,
when a black-backed gull was ingested into the engine core.

2. The maintenance actions taken by the operator following the bird strike exceeded the
engine manufacturer’s requirements.

3. Releasing the aeroplane to service under the “fly-on allowance” would have been
highly unlikely to result in an unacceptable risk to flight safety.

4.3. Departure report and inflight monitoring

Safety issue: The non-transmission, non-receipt or mismanagement of engine condition

reports, especially those containing significant deviations from normal, can deprive flight crew
and maintenance personnel of the opportunity to identify a potential problem early.

4.3.1. The departure report was not sent because of an unusual combination of programming logic
and the low-power ground run. The cruise report was sent to a holding tray because of an
incorrect character in the text. Conceivably, if one or both reports had been correctly sent,
maintenance operations control (MOC) may have recognised the sudden split in EGT readings
for the two engines and attributed it to the earlier bird strike. The operator has since
remedied this programming logic error.

4.3.2. In this case the most likely action would have been for MOC to contact the crew, alerting them
to the EGT split and instructing them to continue to monitor the engine. However, in other
circumstances the consequence of MOC not receiving the departure report could have been
more significant. Recorded aeroplane data showed that there was little change in the EGT
split during the climb, so the crew would have had no warning of an impending failure.

4.3.3. The EGT divergence monitoring form was not required to be completed on such a short flight
because the aeroplane was not in the cruise long enough for the engine temperatures to
stabilise. In this case the aeroplane was in the cruise for about two minutes only. There was
no reason to shut down the engine at this time. No alerts had been generated and no limits
exceeded. The engine still performed satisfactorily, albeit in a reduced capacity, for the
remainder of the flight. The crew’s priority was the descent and landing.

4.3.4. The request by the engineer for the flight crew to check engine performance before take-off
was a positive action that focused the crew’s attention on detecting any obvious abnormality,
at least for the take-off phase of flight. The departure and cruise reports, and monitoring
form, may have singularly or collectively alerted the crew to a potential problem during the
flight.

Page 16 | Final report AO-2012-002

4.3.5. The aeroplane was flying under a special fly-on allowance with the consequential added risk of
a single-engine issue developing during the flight to Auckland. The operator might want to
consider a more proactive approach in future by actively monitoring aeroplanes (either directly
by MOC or through increased monitoring by the pilots) during flight rather than relying on
automated reports.

4.3.6. Borescope equipment was not available at Wellington. Had the inspecting engineer found
damage when following the checklist, a team and equipment would have needed to be flown
in from either Auckland or Christchurch. The operator advised that it would be its continued
preference to follow this procedure and not have to locate equipment at Wellington and
provide initial and ongoing training for a number of staff there. Wellington was one of many
airports into which it operated that did not have such equipment.

4.3.7. Given the low risk of an engine actually failing in flight in the manner it did on this occasion,
and the even lower risk of having a double engine failure following a single-engine bird strike
event, the operator’s preference is unlikely to create an unacceptable risk to flight safety.

Findings

4. Indications that the right-hand engine was not performing well were not detected by
the Maintenance Operation Control due to programming logic errors in the automated
engine condition report system. However, even if they had been it is unlikely that any
subsequent action would have prevented the engine compressor stall event on
landing at Auckland.

4.4. Wildlife management

4.4.1. The regular analysis of bird strike data by the CAA, aircraft operators and aerodrome operators
is critical in determining whether a hazard management programme is working. The regular
monitoring of the data allows the interested parties to look closely at bird strike trends and
determine if they are increasing, declining or static. It provides a benchmark for airport
operators to ensure that their wildlife hazard management programmes are effective and
allows them to make changes accordingly.

4.4.2. A review of bird strike data held by the CAA showed that at the time of this incident Wellington
was considered a “low risk” at 2.5 bird strikes per 10,000 aircraft movements.28 “Low risk”
was considered to be fewer than five strikes per 10,000 movements, “medium” five to fewer
than 10, and “high” 10 or more. Of the seven main international aerodromes in New Zealand,
Wellington ranked second behind Hamilton (2.1) and ahead of Palmerston North (2.8),
Auckland (3.1), Christchurch (3.6), Queenstown (3.6) and Dunedin (5.3).

4.4.3. The data also showed that the rate of bird strikes in Wellington had been trending upward.29
Similar trends had been observed at Auckland, Christchurch and Dunedin. The Queenstown
rate was constant, while Hamilton and Palmerston North were trending downwards. The
combination of risk category and trend determined any CAA action to ensure that an
aerodrome was actively minimising the risk. At the time of releasing this report the risk was
still assessed as low.

4.4.4. An examination of the bird hazard management plan for Wellington showed that a wide range
of activities were being undertaken to mitigate the risk of bird strikes. The activities included
building modifications (the addition of wires and spikes), grass height variations, bird scarers
(shotguns, noise makers, horns and sirens) and culling both on and off the aerodrome.
Wellington airport was also about to trial a new type of grass called AvanexTM. The grass
contains a fungus that affects birds but does not harm them. The grass is currently in use at

28 A movement is a take-off or a landing.

29 The trend analysis allowed for seasonal variations that were common.

Final report AO-2012-002 | Page 17

 Auckland, Christchurch and Hamilton aerodromes, and has proven successful in reducing bird
numbers by 87%.

4.4.5. Wellington airport undertook annual monitoring of the black-backed gull breeding population
near the aerodrome. The most recent report, dated 20 January 2012, showed a steady
increase in the number of nests since about 2006.

4.4.6. In November 2011 Wellington airport commissioned an ecological survey of the aerodrome
and surrounds out to 13 kilometres. The study’s report, dated 31 January 2012, noted that a
wet winter had created boggy areas on the aerodrome that were attractive to plovers and
gulls, and that an increase in recreational fishing activity around the nearby shoreline had
resulted in bait and bycatch attracting gulls. Feeding of birds was also a problem. Wellington
airport in conjunction with Wellington City Council was running an education problem to try to
dissuade the public from feeding the birds or leaving food behind.

Findings

5. Wellington International Airport is providing an effective bird management programme

that is keeping the risk of bird strikes as low as reasonably practicable.

4.5. Crew actions

4.5.1. Regardless of how well a crew manages a situation, there will often be useful lessons for other
pilots and operators to consider.

4.5.2. The crew’s initial actions on becoming aware of a problem with the right engine on approach
to Auckland were in accordance with the quick reference handbook checklist. The captain
promptly retarded the right thrust lever to idle, which stopped the engine surging. The runway
was clear but a rain shower was approaching the far end of the aerodrome. The captain’s
decision to prioritise landing the aeroplane rather than trying to analyse the problem was
appropriate in the circumstances, where he had one fully functional engine (the left engine)
and was still able to use the second engine (the right engine) if necessary. In the short time
available the captain briefed the use of medium braking after landing and made an urgency
call to alert air traffic control and rescue services.

4.5.3. The use of reverse thrust on both engines after landing was an instinctive response, done
many hundreds of times before. While understandable, a quick reminder by either pilot before
or after landing may have helped to prompt the captain not to use reverse thrust on the right
engine. There was ample runway available to avoid hard braking or reverse thrust.

4.5.4. The cabin was prepared for landing when the engine surge occurred. The cabin crew’s
decision to not contact the flight crew at this critical time allowed them to concentrate on
flying the aeroplane. The safest course of action might have been for the cabin crew to
instruct passengers to adopt a brace position, even though they were confident that at least
one engine was working and the aeroplane was under control. This could, however, have
resulted in an unco-ordinated warning to passengers that may have generated confusion and
possibly panic.

Page 18 | Final report AO-2012-002

5. Findings
5.1. It is highly likely that this contained engine failure was the result of a single bird strike event
on the previous flight when the aeroplane was landing at Wellington Aerodrome, when a black-
backed gull was ingested into the engine core.

5.2. The maintenance actions taken by the operator following the bird strike exceeded the engine
manufacturer’s requirements.

5.3. Releasing the aeroplane to service under the “fly-on allowance” would have been highly
unlikely to result in an unacceptable risk to flight safety.

5.4. Indications that the right-hand engine was not performing well were not detected by the
Maintenance Operation Control due to programming logic errors in the automated engine
condition report system. However, even if they had been it is unlikely that any subsequent
action would have prevented the engine compressor stall event on landing at Auckland.

5.5. Wellington International Airport is providing an effective bird management programme that is
keeping the risk of bird strikes as low as reasonably practicable.

Final report AO-2012-002 | Page 19

6. Key lessons
6.1. Although the safety of the aeroplane and the persons on board was not unduly compromised
by releasing the aeroplane to service knowing that a bird had been ingested into the core of
one engine, operators will need to balance the cost of having inspection services available at
key aerodromes into which they fly with the cost of an engine failure of this scale.

6.2. Even if the minimum mandatory checks are made to an engine that has suffered a bird strike
down the core, if the aeroplane is released to service before the required full inspection has
been undertaken, the pilots and ground engineering services should maintain increased
vigilance of engine performance until the appropriate full maintenance checks can be
completed.

Page 20 | Final report AO-2012-002

7. Safety actions
7.1. General

7.1.1. These are listed below.

7.1.2. The Commission classifies safety actions by two types:

(a) safety actions taken by the regulator or an operator to address safety issues identified
by the Commission during an inquiry that would otherwise result in the Commission
issuing a recommendation
(b) safety actions taken by the regulator or an operator to address other safety issues that
would not normally result in the Commission issuing a recommendation.

7.2. Safety actions addressing safety issues identified during an inquiry

7.2.1. IAE, the engine manufacturer, reviewed the bird strike and engine reliability data for the
V2500 engine and was satisfied with the airworthiness status of the engine and that no
changes to the manuals or procedures were required. Nevertheless, operators were to be
reminded of the intention of the fly-on allowance of less than 10 hours’ flying or fewer than
two cycles.

7.2.2. The operator amended its maintenance manual to further limit the fly-on allowance by
changing the maximum number of cycles permitted from two to one before a borescope
inspection was required. The 10-hour limit was retained.

7.2.3. The operator reviewed the programming logic and informed MOC staff to ensure that a
departure report is generated after the completion of any low-power ground run. Similarly the
content of the cruise report has been reviewed to help ensure that the messages are sent to
the right addresses. Further, the handling procedures for any holding tray messages have
been reviewed.

7.2.4. The operator incorporated the lessons learnt from the actions of the crew in its ongoing crew
training cycle.

Final report AO-2012-002 | Page 21

8. Recommendations
8.1. General

8.1.1. The Commission may issue, or give notice of, recommendations to any person or organisation
that it considers the most appropriate to address the identified safety issues, depending on
whether these safety issues are applicable to a single operator only or to the wider transport
sector.

8.1.2. In this case, the Commission makes no recommendations, as the actions taken by the
operator and manufacturer have addressed any potential safety issue.

Page 22 | Final report AO-2012-002

9. Sources
CAA, 2010. Civil Aviation Rule Part 139, Aerodromes – Certification, Operation and Use, effective
25 March 2010.

CAA, 2011a. Civil Aviation Advisory Circular AC139-16, Wildlife Hazard Management at Aerodrome,
effective 7 October 2011.

CAA, 2011b. Civil Aviation Rule Part 12, Accidents, Incidents, and Statistics, effective 10 November
2011.

EASA 2010. Certification Specifications for Engines CS-E, Amendment 3, effective 23 December
2010.

Final report AO-2012-002 | Page 23

Appendix 1: Aircraft maintenance manual procedures

Page 24 | Final report AO-2012-002

Final report AO-2012-002 | Page 25
Page 26 | Final report AO-2012-002
Final report AO-2012-002 | Page 27
Page 28 | Final report AO-2012-002
 Recent Aviation Occurrence Reports published by
the Transport Accident Investigation Commission
(most recent at top of list)

AO-2013-005 In-flight loss of control, Robinson R22, ZK-HIE, near New Plymouth, 30 March 2013

AO-2013-007 Boeing 737-838, ZK-ZQG, stabiliser trim mechanism damage, 7 June 2013

AO-2013-009 RNZAF Boeing 757, NZ7571, landing below published minima,Pegasus Field,
Antarctica, 7 October 2013

AO-2013-002 Robinson R44, ZK-HAD, engine power loss and ditching, Lake Rotorua,
24 February 2013

11-007 Descent below instrument approach minima, Christchurch International Airport, 29

October 2011

11-006 Britten-Norman BN.2A Mk.III-2, ZK-LGF, runway excursion, Pauanui Beach

Aerodrome, 22 October 2011

11-003 In-flight break-up ZK-HMU, Robinson R22, near Mount Aspiring, 27 April 2011

12-001 Hot-air balloon collision with power lines, and in-flight fire, near Carterton,
7 January 2012

11-004 Piper PA31-350 Navajo Chieftain, ZK-MYS, landing without nose landing gear
extended, Nelson Aerodrome, 11 May 2011

11-005 Engine compressor surges, 18 September 2011

11-001 Bell Helicopter Textron 206L-3, ZK-ISF, Ditching after engine power decrease, Bream
Bay, Northland, 20 January 2011

11-002 Bombardier DHC-8-311, ZK-NEQ, Landing without nose landing gear extended
Woodbourne (Blenheim) Aerodrome, 9 February 2011

10-010 Bombardier DHC-8-311, ZK-NEB, landing without nose landing gear extended,
Woodbourne (Blenheim) Aerodrome, 30 September 2010

12-001 Interim Factual: Cameron Balloons A210 registration ZK-XXF, collision with power
line and in-flight fire, 7 January 2012

10-009 Walter Fletcher FU24, ZK-EUF, loss of control on take-off and impact with terrain, Fox
Glacier aerodrome, South Westland, 4 September 2010
Price $16.00 ISSN 1179-9080 (Print)
ISSN 1179-9099 (Online)