Resulting Safety Initiatives

As part of the process for cataloging findings and issuing safety recommendations, the ATSB identified a number of safety issues. Safety issues, for which resolution activity undertaken by the engine or airplane manufacturer were considered to be satisfactory, were closed by the ATSB and subsequent safety recommendations were not developed. Among the actions taken by Roll-Royce, Airbus, and EASA are:

Actions taken by Rolls-Royce:

  • Rolls-Royce incorporated a software change in the Engine Electronic Controller (EEC) to introduce an IP turbine overspeed protection system.
  • Rolls-Royce, after discovery in the A380 fleet of a number of oil feed stub pipes that were non-conforming, undertook a detailed analysis of those stub pipes, removing 40 engines from service and revising the minimum stub pipe wall thickness from .5 mm to .7 mm.
  • Rolls-Royce introduced new processes that required closer coordination between manufacturing engineers and design engineers to reduce manufacturing errors and maintain criteria for acceptance/rejection of non-conforming stub pipes.
  • Rolls-Royce reclassified the HP/IP bearing support structure to identify it as being "reliability sensitive," which invoked a higher level of process control during manufacture and installation.

Actions Taken by Airbus:

  • In response to Rolls-Royce's action to incorporate an EEC software revision which introduced an IP turbine overspeed protection system, Airbus issued a service bulletin to incorporate the software revision on all Trent-equipped A380 airplanes.

Actions taken by EASA:

  • EASA released an airworthiness directive 2010-0262 to require, within ten flights, an EEC software revision to incorporate an IP turbine overspeed protection per a Rolls-Royce service bulletin.

A complete list of safety actions undertaken after the accident is included in the following document, which is extracted from the official accident report: (Follow-on Safety Actions)

This document provides more detail, and a complete list of safety actions taken following the accident.

Additionally, Section 7 of the ATSB report "Safety Action" details all safety activity related to this accident, and details the relationships between ATSB safety issues and resolution activity. This section of the report is provided in its entirety at the following link: (Section 7 Safety Actions)

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