FINAL REPORT OF SERIOUS INCIDENT INVOLVING AIRBUS A320 (NEO)

AIRCRAFT VT-WGLOPERATED BY M/s GO AIRLINES (INDIA) LIMITED ON

23RD - DECEMBER 2019

Jasbir Singh Larhga Amit Kumar

(Investigation-In-Charge) (Investigator)

i
 FOREWORD

In accordance with Annex 13 to the Convention on International Civil

Aviation Organization (ICAO) and Rule 3 of Aircraft (Investigation of
Accidents and Incidents), Rules 2017, the sole objective of the investigation
of an accident shall be the prevention of accidents and incidents and not to
apportion blame or liability. The investigation conducted in accordance with
the provisions of above said rules shall be separate from any judicial or
administrative proceedings to apportion blame or liability.

This document has been prepared based upon the evidences

collected during the investigation, opinion obtained from the experts and
laboratory examination of various components. Consequently, the use of
this report for any purpose other than for the prevention of future accidents
or incidents could lead to erroneous interpretations.

ii
 INDEX

Para Content Page No.

SYNOPSIS 2

1 FACTUAL INFORMATION 3

1.1 HISTORY OF THE FLIGHT 3

1.2 INJURIES TO PERSONS 4

1.3 DAMAGE TO AIRCRAFT 4

1.4 OTHER DAMAGE 4

1.5 PERSONNEL INFORMATION 5

1.6 AIRCRAFT INFORMATION 6

1.7 METEOROLOGICAL INFORMATION 10

1.8 AIDS TO NAVIGATION 10

1.9 COMMUNICATIONS 10

1.10 AERODROME INFORMATION 11

1.11 FLIGHT RECORDERS 12

1.12 WRECKAGE AND IMPACT INFORMATION 12

1.13 MEDICAL AND PATHOLOGICAL INFORMATION 12

1.14 FIRE 13

1.15 SURVIVAL ASPECTS 13

1.16 TESTS AND RESEARCH 13

ORGANISATIONAL AND MANAGEMENT

1.17 14
INFORMATION

1.18 ADDITIONAL INFORMATION 14

iii
 USEFUL OR EFFECTIVE INVESTIGATION
1.19 18
TECHNIQUES

2 ANALYSIS 18

2.1 GENERAL 18

2.2 CIRCUMSTANCES LEADING TO THE INCIDENT 19

3 CONCLUSIONS 19

3.1 FINDINGS 19

3.2 PROBABLE CAUSE OF THE INCIDENT 20

4 SAFETY RECOMMENDATIONS 20

iv
 GLOSSARY
AAIB Aircraft Accident Investigation Bureau
AOP Air Operator Permit
ARC Aircraft Review Certificate
ASDA Accelerate Stop Distance
ASR Area Surveillance Radar
ATB Air Turn Back
ATC Air Traffic Control
BECMG Becoming
CAR Civil Aviation Requirement
CEO Current Engine Option
DGCA Directorate General of Civil Aviation
EGT Exhaust Gas Temperature
ENG Engine
ESN Engine Serial Number
ETA Estimated Time of Arrival
ETD Estimated Time of Departure
GTB Ground Turn Back
HPC High Pressure Compressor
ICAO International Civil Aviation Organization
IDG Integrated Drive Generator
IFSD In-Flight Shut Down
LDA Landing Distance Available
LPT Low Pressure Turbine
LSOP Lube & Scavenge Oil Pump
MCT Maximum continuous Thrust
MGB Main Gear Box
NEO New Engine Option
NO SIG No Significant
NTSB National Transport Safety Board
OEM Original Equipment Manufacturer
PIC Pilot in Command
QRH Quick Reference handbook
RESA Runway End Safety Area
RTO Rejected Take-Off
SB Service bulletin
SCT Scattered
SSCVR Solid State Cockpit Voice Recorder
SSFDR Solid-State Flight Data Recorder
TLA Throttle liver angle
TODA Take-off Distance Available
TORA Take-off Run Available
TWR Terminal Weather Radar
UTC Coordinated Universal Time

v
 FINAL REPORT OF SERIOUS INCIDENT INVOLVING AIRBUS A320 (NEO) AIRCRAFT
VT-WGLOPERATED BY M/s GO AIRLINES (INDIA) LIMITED
ON 23RD -DECEMBER 2019.

1. Aircraft Type : Airbus A320(NEO)

Nationality : Indian

Registration : VT-WGL

2. Owner & Operator : Go Airlines (India) Limited

3. Pilot : ATPL Holder

Extent of Injuries : Nil

4. Co- Pilot : CPL Holder

Extent of Injuries : Nil

5. No. of Passengers on board : 134

6. Date & Time of Serious Incident : 23rdDecember 2019at 0550 UTC

7. Place of Serious Incident : Guwahati Airport

8. Co-ordinates of Incident Site Lat: 26°06’22” N

: Long: 91°35’09” E.

9. Last point of Departure : Guwahati Airport

10. Intended landing place : Kolkata Airport

11. Type of Operation : Scheduled Operation

12. Phase of operation : Climb

13. Type of Serious Incident : System/Component Failure or

Malfunction (Powerplant)

(All the timings in this report are in UTC unless otherwise specified)

1
 SYNOPSIS

On 23rd December 2019, Airbus A320 aircraft VT-WGL operated by M/s Go Air
carried out an air turn back due to high engine vibration while operating a scheduled flight
from Guwahati to Kolkata. Aircraft landed safely at Guwahati.

The aircraft was under the command of an ATPL holder, who was Pilot Flying (PF)
with a co-pilot, a CPL holder, who was Pilot Monitoring (PM). There were 134 passengers
on board the aircraft with 04 cabin crew members.

The aircraft took-off from Guwahati airport and while climbing passing 1500ft altitude
a loud bang sound was heard by the flight crew. Subsequently, “Engine stall” and “High
Engine Vibration” ECAM warning message triggered for engine # 1. The crew carried out
the ECAM and QRH procedures. As the engine vibration was continuous and parameters
were fluctuating, the crew decided to return to Guwahati. The aircraft landed safely at
Guwahati. On visual inspection from the rear side of the engine almost all Low-Pressure
Turbine (LPT) blades were found burnt and broken from the tip.

The occurrence was classified as a Serious Incident by AAIB and Sh. Jasbir Singh
Larhga, Deputy Director, AAIB was appointed as Investigator – In – Charge along with Sh
Amit Kumar, Safety Investigation Officer as Investigator to investigate into the probable
cause(s) of the serious incident, vide Order No. INV.12011/25/2019-AAIB dated 23rd
December 2019 under Rule 11 (1) of Aircraft (Investigation of Accidents and Incidents),
Rules 2017.

2
1 FACTUAL INFORMATION

1.1 HISTORY OF THE FLIGHT

On 23rd Dec 2019, M/s Go Air Airbus A320 (NEO) aircraft VT-WGL was scheduled to
operate flight G8-546 from Guwahati to Kolkata. There was no abnormality reported on the
aircraft during any previous flight of the day. The aircraft was scheduled to depart from
Guwahati at 05:30 UTC and arrive in Kolkata at 06:55 UTC.
There were 133 passengers on board and flight was operated by 02 cockpit crew
and 04 cabin crew. The aircraft took-off from Guwahati at around 05:46UTC. Immediately
after take-off, while climbing passing 1500ft, a loud bang was heard by the crew.
Subsequently, “Engine Stall” followed by “High Engine Vibration” warnings were triggered
on ECAM. At 05:47:12 UTC, N1 and N2 vibration for Engine # 1 was 10 units and 3.7 units
respectively with EGT at 877℃. Within a second N2 vibration also reached up to 10 units.
The crew followed ECAM actions and QRH checklist/procedures for High Engine Vibration.

Meanwhile the PIC had taken over the control. The engine#1 power was gradually
brought back to IDLE at 05:47:21 UTC. The N1 and N2 vibration was 10 units at that time
with EGT at 1011℃. Subsequently, engine # 2 power was changed from CLIMB to MCT.
engine # 1 parameters i.e., N1 and N2 vibration continued to remain at about 10 units.

All other engine#1 parameters were also fluctuating. Cabin crew informed the crew
about the tail pipe fire seen by them and some passengers. Hence, the crew decided to
return to Guwahati and informed ATC Guwahati accordingly, at 0550 UTC. ATC had also
confirmed the crew that some metal pieces were found on ground after G8-546 departure.
At 05:52:12 UTC, crew carried out precautionary shutdown of engine #1.

After obtaining necessary clearance from ATC, Guwahati, the aircraft landed safely
at Guwahati on Runway 02 at 0607 UTC. Overweight landing was not required. The
passengers were disembarked normally. There was no fire and no injury to any of the
occupants on board the aircraft.

Post landing during visual inspection of the engine exhaust area all blades of Low-
Pressure Turbine (LPT) 3rd stage were found damaged.

3
1.2 INJURIES TO PERSONS

Injuries Crew Passengers Others

Fatal NIL NIL NIL
Serious NIL NIL NIL
Minor/ None 02+04 133 __

1.3 DAMAGE TO AIRCRAFT

The aircraft damages due to the incident was limited to its left engine. The LPT 3rd
Stage blades of left engine were found broken during inspection. The images of damaged
blades is shown below:-

Figure 1: Engine LPT 3rd Stage blades were found damaged during inspection.

1.4 OTHER DAMAGE

Nil

4
1.5 PERSONNEL INFORMATION

1.5.1 PILOT – IN – COMMAND

Age 40Yrs
License ATPL
Date of Issue 11 Aug 2014
Valid up to 10 Aug 2021
Date of Class I Med. Exam. 25 Apr 2019
Class I Medical Validity 20 May 2020
Date of issue FRTOL License 04 Jun 2012
FRTO License Validity 03 Jun 2022
Endorsement on Type 13 Oct 2015
Total flying experience 12647:23Hrs
Total flying experience on Type 3019:59Hrs
Last Flown on Type A320
Total flying experience during last 1 year 791:28 Hrs
Total flying experience during last 6 Months 432:59Hrs
Total flying experience during last 30 days 70:54Hrs
Total flying experience during last 07 Days 19:06Hrs
Total flying experience during last 24 Hours 08:58Hrs
Rest period before flight 23:15Hrs

1.5.2 CO-PILOT

Age 37 Yrs
License CPL 6014
Date of Issue 14 Jan 2008
Valid up to 13 Jan 2023
Date of Class I Med. Exam. 06 Jun 2019
Class I Medical Validity 24 Jun 2020
Date of issue FRTOL License 14 Jan 2008
FRTO License Validity 13 Jan 2023
Endorsement on Type 22 Mar 2018
Total flying experience 4398:10Hrs
Total flying experience on Type 1440:15Hrs
Last Flown on Type A 320
Total flying experience during last 1 year 772:25Hrs
Total flying experience during last 6 Months 397:03Hrs
Total flying experience during last 30 days 58:36Hrs
Total flying experience during last 07 Days 21:25Hrs
Total flying experience during last 24 Hours 11:17Hrs
Rest period before flight 20:15 Hrs

5
1.6 AIRCRAFT INFORMATION

1.6.1 AIRBUS A320 (NEO) AIRCRAFT DESCRIPTION

The Airbus A320is a narrow-body (single-aisle) aircraft with a retractable
tricycle landing gear and is powered by two wing pylon-mounted turbofan engines. The
A320 family aircraft fitted with new engines were named as NEO (New Engine Option) and
the rest were named as CEO (Current Engine Option). These new engines were
manufactured with the idea that it will consume less fuel as compared to other engines,
reduced CO2 emissions and reduction in engine noise. A320NEO can be fitted with either:

- The PW1127G-JM, manufactured by Pratt & Whitney or;

- The LEAP-1A, manufactured by CFM International.

The A320 NEO aircraft made its first flight on 25th September 2014 and it was first
introduced by Lufthansa on 20th January 2016. A total of 38 operators worldwide are
operating A320 NEO family aircraft. After acceptance of Type Certification by DGCA, these
A320 NEO aircraft (fitted with PW1127G-JM engines) were inducted by two airline
operators in India i.e., M/s Indigo and M/s Go Air.

M/s Go Airlines (India) Ltd had inducted the first A320 NEO aircraft in its fleet on 31st
May 2016. The number of A320 NEO family fleet operating in India and globally (as of
November 2020) is given below:

Airlines A320 NEO A321 NEO Total

Global (Including India) All 485 249 734
India Indigo 115 161 25 25 186
Go Air 46 0

Table: A320/A321 Neo fleet Global vs India.

1.6.2 BRIEF TECHNICAL DESCRIPTION OF PW1127G-JM ENGINE

The PW1127G-JM turbofan engine is an axial-flow, twin spool turbofan engine with
an ultra-high bypass ratio, low speed gear-driven fan. Details of engine construction and
different engine Modules is shown in the following figures.

6
 Figure 2: ENGINE CROSS SECTION
The engine comprises of Modules/Build Groups as shown below: -

1. Fan Rotor Group 13. High Compressor Front Case Group

2. Fan Drive Bearing Group 14. High Compressor Rotor Group

3. Fan Drive Gear Group 15. Diffuser Case Group

4. Fan Intermediate Case Group 16. Combustor and Turbine Nozzle Group

5. No. 2 Bearing Group 17. High Turbine Stator Group

6. Fan Case Group 18. High Turbine Rotor Group

7. Low Compressor Stator Group 19. Turbine Intermediate Case Group

8. Low Compressor Rotor Group 20. Low Turbine Stator Group

9. 2.5 Bleed Group 21. Low Turbine Rotor Group

10. Compressor Intermediate Case Group 22. Turbine Exhaust Case Group

11. No. 3 Bearing Group 23. Main Gearbox Group

12. High Compressor Rear Stator Group 24. Angle Gearbox Group

7
Figure 3: Engine Modules/ Build Group

Figure 4: Engine Modules/ Build Group

8
1.6.3 AIRCRAFTGENERAL INFORMATION: VT-WGL

Aircraft Model A320-271N

Aircraft Sr. No. 07813
Year of Manufacturer 2017
Name of Owner GY Aviation Lease 1722 Co. Ltd
C of R 4851
C of A 6954
Category Passenger
C of A Validity Valid
A R C issued on 18/12/2020
ARC valid up to 18/12/2021
Aircraft Empty Weight 42441 kg
Maximum Take-off weight 73500 kg
Date of Aircraft weighment 05/09/2019
Operating Empty Weight 43401 kg
Max Usable Fuel 18622 kg
Max Payload with full fuel 11476 kg
Empty Weight C.G 42550 kg
Next Weighing due 05/09/24
Total Aircraft Hours 7310:04 hrs / 4431 Cycles
(As on 26/12/2019)
Last major inspection Not due
Engine Type PW1127GA-JM
Date of Manufacture (LH) 27/12/2017
Engine Sr. No. (LH) P770398
Last major inspection (LH) 07/02/2019
(TSN- 2613:26 Hrs / CSN- 1720 Cycles)
Total Engine Hours/Cycles (LH) 4997:18 Hrs / 3101 Cycles
(As on 26/12/2019)
Date of Manufacture RH 30/12/2019
Engine Sr. No. RH P771194
Last major inspection (RH) Not due
Total Engine Hours/Cycles (RH) 1335:15 Hrs / 724 Cycles
(As on 26/12/2019)
Aeromobile License 31/12/2022

All concerned Airworthiness Directives, mandatory Service Bulletins, and DGCA

Mandatory Modifications on this aircraft and its engines were complied with as on date of
event.

9
1.7 METEOROLOGICAL INFORMATION

MET Report Guwahati Airport from 0500 UTC to 0700 UTC

Time Wind Visibility Clouds Temp Dew QFE QNH TREND

(UTC) (m) (°C) Point hPa hPa
(°C)
0500 030°/06 kt 1300 SCT 1000 17 17 1012 1018 NOSIG
FT
0530 060°/05 kt 1500 SCT 1000 18 17 1012 1017 NOSIG
FT
0600 020°/05 kt 1700 FEW 18 17 1011 1017 BECMG
1000 FT 3000 BR
0630 050°/04 kt 1800 FEW 1000 19 17 1010 1016 NOSIG
FT
0700 070°/03 kt 1800 FEW 1000 19 17 1010 1016 NOSIG
FT

1.8 AIDS TO NAVIGATION

All Navigational Aids available at Guwahati airport were serviceable. The aircraft was
equipped with standard navigational aids and there was no recorded defect with any of the
navigational aids during the flight

1.9 COMMUNICATIONS
The aircraft was given take-off clearance by Guwahati TWR (118.75Mhz) at 0545:24
UTC. At the time of incident, the aircraft was in contact with Guwahati ASR on frequency
123.9 MHz. The transcript of relevant communication is placed below:-

Transcript of communication with ASR (123.9 MHz)

TIME FROM TO TRANSMISSION
RADAR NAMASKAR GOAIR546 PASSING
0547:04 GOW546 ASR
1600 0471
0547:04 ASR GOW546 GOAIR546 GUWAHATI RADAR IDENTIFIED
CLIMB TO FLIGHT LEVEL 260
0547:54 GOW546 ASR …546 DUE TECHNICAL LEVELLING OFF AT
2000 FEET MA’M GOAIR 546. CAN WE CLIMB
TO 3000?
0548:02 ASR GOW546 AFFIRM SIR CLIMB TO 3500 FEET
0548:06 GOW546 ASR CLIMB 3500 GOAIR546
0548:24 ASR GOW546 GOAIR546 CONTACT CONFIRM YOU WILL
CONTINUE ON SID
0548:29 NEGATIVE SIR WE ARE MAINTAINING
GOW546 ASR HEADING AS OF NOW AND SIR WE ... I
THINK THERE IS OSME PROBLEM IN THE

10
 ENGINE WE WILL LET YOU KNOW IN
ANOTHER MINUTE AND HALF
0550:42 G0W546 ASR GUWAHATI G0AIR546 SIR WE HAVE HIGH
ENGINE VIBRATIONS I THINK PROBABLY WE
HAVE REVERTED TO SOMETHING WE
MIGHT HAVE TO COME BACK AND LAND IN
TO GUWAHATI
0551:03 ASR G0W546 AND CONFIRM YOU DO NOT NEED ANY
KIND OF JETTISONING OR YOU WILL.. CAN
DIRECTLY COME FOR LANDING?
0551:09 G0W546 ASR WE CAN DIRECTLY COME FOR LANDING SIR
WE ARE WITHIN MINIMA EVERYTHING AND
... WE DON'T REQUIRE ANY ASSISTANCE
ALSO, IF YOU
WANT YOU CAN JUST KEEP THE FIRE
TRUCKS
0552:57 ASR G0W546 GOAIR546 CONFIRM REASON IS DUE TO
HIGH VIBRATION IN THE ENGINE
0553:01 G0W546 ASR AFFIRM SIR HIGH VIBRATION IN ENGINE
PROBABLY WE MIGHT HAVE REVERTED SIR
WE DON'T KNOW WE HAVE TO CHECK
AFTER LANDING
0600:26 ASR G0W546 JUST FOR INFORMATION OUR CISF
PERSONNEL WHICH IS … WHICH ARE
DEPLOYED AT THE END OF THE RUNWAY
02 THEY SAW SOME THAT PARTS TO BE
FALLEN DOWN WHILE TAKING OFF FOR
THE LAST DEPARTURE I ASSUME THAT
YOU THAT YOU ARE PROBABLY THE LAST
DEPARTURE FROM RUNWAY 02
0600:45 G0W546 ASR SIR WE WILL HAVE TO DIAGNOSE ON THE
GROUND
ONLY SIR WE CANNOT (UNREADABLE)
RIGHT NOW

Two-way communication between the aircraft and the ATC was maintained
throughout the flight.
1.10 AERODROME INFORMATION
Lokpriya Gopinath Bordoloi Airport, also known as Guwahati Airport and formerly as
'Borjhar Airport', is the primary airport for the North-Eastern states of India. It is being
operated &managed by Airport Authority of India.

11
 The IATA Location Identifier Code is GAU and ICAO Location Indicator Code is
VEGT. The airport co-ordinates are 26°06’22”N,91°35’09” E. Airport Elevation is 162 ft
(49.37m). The details of runway distances are given below:

Runway TORA(m) TODA (m) ASDA (m) LDA (m) RESA

02 3103 3103 3103 3103 240mX 140m
20 3103 3103 3103 3103 90m X90m

Category 7 Rescue and Fire Fighting Services is available at Guwahati Airport.

1.11 FLIGHT RECORDERS

Both Solid State Cockpit Voice Recorder (SSCVR) and Solid-State Flight Data
Recorder (SSFDR) were downloaded, and readout was carried out. Relevant data was
used for analysis. Sequence of some relevant events recorded in the DFDR is given below:-
a) At 05:46:30 UTC, aircraft took off from Guwahati airport.
b) At 05:47:12UTC, engine #1 N1 vibration was at 10 units, N2 vibration was at 3.7
units and EGT was at 877℃.
c) At 05:47:13 UTC, engine # 1 N1 vibration was at 10 units, N2 vibration was at 10
units and EGT was at 892℃.
d) At 05:47:21UTC, crew brought the TLA of engine # 1 gradually to IDLE position,
engine # 1 N1 vibration was at 10 units, N2 vibration was at 10 units and EGT was at
1011℃.
e) At 05:52:12 UTC, Crew put the engine # 1 Master Switch OFF, N1 vibration was at
10 units, N2 vibration was at 7.9 units and EGT was at 581℃.
f) At 06:06:53 UTC, aircraft touched down at Guwahati airport.

1.12 WRECKAGE AND IMPACT INFORMATION

The damages were confined to engine # 1 only.

1.13 MEDICAL AND PATHOLOGICAL INFORMATION

The crew had undergone pre-flight medical (Breath Analyzer Test) at Guwahati
before departure as per requirement of CAR Section 5, Series F, Part III. The test result
was satisfactory.

12
1.14 FIRE
There was no fire.

1.15 SURVIVAL ASPECTS

The Incident was survivable.

1.16 TESTS AND RESEARCH

1.16.1 TEAR DOWN INSPECTION OF ENGINE

The damaged LH engine was replaced with a serviceable engine. The damaged
engine was sent to OEM after the incident. The engine was inducted in OEM’s facility and,
Engine Disassembly and Inspection was carried out. As there were several similar
occurrences involving the failure of LPT 3rd stage blades preceding this incident, no
Technical Investigation was carried out by the OEM on the engine ESN P770398. The LPT
3rd stage blade failure was considered to be a known issue, which had a developed
corrective action in place.

Engine ESN 770398 was inducted into the shop for stall and high vibration issues.
The LPT Stage 3 was found with several broken blades. The discs and blades of LPT Stage
1 and 2, along with the 2nd stage support and 3rd stage vanes were replaced due to wear /
damage. The Low Turbine module had the LPT 3 blades, shrouds, and disc replaced as per
SB 72- 00-0111 in accordance with the work scope requirements. HPC IBRs were replaced
to combat vibration issues and all HPC seals were repaired to address stalling problems.
The Diffuser Case Group had the combustion chamber and additional parts replaced /
modified to a block D configuration. The High Turbine Case Module was upgraded to a
block D configuration and had the T1 and T2 blades replaced. All unserviceable parts were
repaired or replaced as per EM specifications. The engine was tested as per IAW Test # 9
and passed successfully.

13
1.17 ORGANISATIONAL AND MANAGEMENT INFORMATION
The aircraft was operated by a scheduled operator holding AOP No. S-18 in
Passenger and Cargo Category which is valid till 27.10.2022 M/s Go airlines (India) Ltd.
currently have seven A320-214 and fifty A320-271N (NEO), with a total of 51aircraft.
The operator carries out its own maintenance as a CAR 145 approved organization.
The year wise induction of NEO fleet (Graphical Representation) by M/s Go Airlines (India)
is shown below: -

Aircraft (NEO)
18 17
16
14 13
12
10 9
8 Aircraft (NEO)
6 5
4
4 3
2
0
2016 2017 2018 2019 2020 2021

Figure 5: Yearwise induction of NEO fleet

1.18 ADDITIONAL INFORMATION

1.18.1 SIMILAR OCCURRENCES INVOLVING PW1127G-JM ENGINES

Since the induction of PW1100G-JM engines in India in the year 2016, there have
been several snags reported on aircraft fitted with these engines. Most of the snags were
repetitive in nature. In order to prevent reoccurrence of such failures, Pratt & Whitney came
up with some rectification actions/modifications for each snag.

S. Typical Snag Rectification Action Action Taken by M/s GoAir

No. Reported proposed by P&W (As of Dec 2020)
1. Number 3 bearing Issued SB 72-00-087 All the Serviceable engines in GOW
seal failure fleet are complied with SB 72-00-
0087
2. Combustor failure IssuedSB72-00-0136 All the Serviceable engines in GOW
fleet are complied with SB 72-00-
0136
3. Low Pressure Issued SB 72-00-0111 All the Serviceable engines in GOW
Turbine failure fleet are complied with SB 72-00-
0111

14
 4. N2 Vibration SB72-00138 was 42 engines in GOW fleet are
released to replace HPC complied with SB 72-00-0138
stage 6 ring seal with
modified one.
5. MGB IDG/LSOP Issued SB 72-00-0129 All the Serviceable engines in GOW
gear failure. fleet are complied with SB 72-00-
0129
Table: Typical Engine Failures and Rectification Action by Pratt & Whitney.

The typical engine failures discussed in above para led to significant occurrences like
In-Flight Shut Down (IFSD), Air Turn Back (ATB), Ground Turn Back (GTB), Rejected Take-
Off (RTO), etc. The type and number of occurrences (Involving Indigo & Go Air aircraft)
corresponding to each of the typical engine failures are listed below: -

Type of Failure
Number 3 MGB
Combustor LPT N2
bearing seal IDG/LSOP
failure failure Vibration
Type of Event failure gear failure.

RTO (Rejected Take-

Nil 1 Nil 2 Nil
off)
Engine Stall Nil Nil 1 Nil Nil
ATB (Air Turn Back) Nil 1 18 5 3
GTB (Ground Turn
Nil Nil Nil 1 Nil
Back)
Diversion Nil Nil 6 1 1
Diversion/ATB Nil Nil Nil Nil Nil
Emergency Landing 1 Nil Nil Nil Nil
Table: Type of Occurrences corresponding to each engine failure.

Out of the significant occurrences mentioned in the table above, 18 occurrences

were classified as serious incidents by AAIB and Annex 13 investigation were instituted to
investigate these serious incidents. Further distribution of these 18 serious incidents
corresponding to type of failure is as below: -

Type of Failure Number of Serious Incidents

Number 3 bearing seal failure 01
LPT failure 15
N2 Vibration 01
MGB IDG/LSOP gear failure. 01
Table: Number of serious incidents corresponding to type of failures.

As per the above table, it can be seen that majority of these serious incidents
corresponds to LPT failure wherein the blades of 3rd Stage of LPT failed in flight. All engines

15
involved in the 18 serious incidents discussed above were quarantined after the occurrence
and sent to OEM (Pratt & Whitney) facility in USA and Germany for repair. Pratt and
Whitney did not subject any of these engines to any technical investigation as the events
were similar to various prior occurrences and considered to be a known issue. The Shop
Visit report of Engine was shared with AAIB through Accredited Representative of NTSB.

Fractured blades from three engines from three random aircraft involved in 15
incidents where LPT 3rd stage blade failures occurred were sent to National Aerospace
Laboratories (NAL), Bengaluru to carry out Failure Analysis on these blades. NAL carried
out failure analysis of these blades and submitted its report to AAIB.

VT-WGL was fitted with ESN P770398at the time of incident. Given the similar
nature of failure and findings of shop inspection, it is presumed that failure on ESN
P770398was similar to failure on three engines involved in other LPT 3rd stage turbine
failure incidents for which failure analysis was carried out at NAL, Bengaluru.

Following are the salient observations made in the failure analysis report provided by
NAL, Bengaluru: -

• Examination revealed that all 78 LPT 3rd stage blades had fractured in the
airfoil at varying heights from the blade root platform.

• Impact damages were found present predominantly along trailing edge (TE) of
the available part of the airfoil.

• Fracture surfaces of the blades showed a flat appearance with vaguely

delineated chevron marks emanating from the crack origins in many occasions.

• Fractography study confirmed that LPT 3rd stage blades had fractured
instantaneously in a brittle manner. None of the blades showed presence of any signatures
of progressive failure such as fatigue.

• Scanning electron fractography study confirmed that the crack propagation in

the blades was by mixed mode of cleavage and interlamellar separation. In the fractured
blades, the fracture process in gamma-phase was by cleavage while it was by interlamellar
separation in lamellar colonies.

• Metallurgical evaluation of the Material of Construction (MoC) showed that

stage 3 LPT blades were made of a Gamma base Titanium Aluminide (Ti-Al), an
intermetallic material. The MoC of the blades has the nominal composition of 52% Titanium

16
(Ti), 43% Aluminium (Al), 4% Niobium (Nb) and 1% Molybdenum (Mo). The material did not
have any metallurgical abnormalities that could be responsible for failure of the LPT blades.

• Ti-Albase intermetallic materials are, in general, brittle in nature having low

fracture toughness. Although, the alloy used for stage III LPT blades is an improved version
of Ti-Al alloys with engineered microstructure, the material still lacks adequate damage
tolerance properties compared to the conventional Nickel (Ni)base super alloy that is
generally used in this section of gas turbine engines.

• The MoC possessed a duplex microstructure consisting of mostly colonies of

lamellae and isolated single phase gamma grains.

• Fatigue test conducted in this laboratory on the MoC of LPT 3rd stage blades
showed that the material does not have enough crack growth resistance and after initiation,
the crack propagates instantaneously leading to fracture.

1.18.2 SERVICE BULLETIN 72-00-0111

Service Bulletin (SB) on “Engine - Disk, LPT 3rd Stage and Blade, LPT 3rd Stage
and Shroud-Segment, Ring, 3rd Stage - Introduction of a New LPT 3rd Stage Blade which
is more resistant to Impact Damage”. The SB was initially issued on 14th May 2019,
thereafter, Issue 2 was issued on 18th October 2019 and finally, Issue 3 was issued on 28th
May 2020.

The reason for issue of this SB was given as “LPT 3rd stage blades fractured in
service due to impact damage”. The cause of failure was given as “The LPT 3rd stage
blade material is sensitive to impact damage.” The solution to this failure was given as
“Introduction of a new LPT 3rd stage blade made of a different material which is more
resistant to impact damage.”

The SB required that the LPT 3rd stage disk, blades, locking plates, and shroud
segments be replaced by the new set made of different material.

1.18.3 GUIDELINES/DEADLINE ISSUED & ACTION TAKEN BY DGCA.

Taking cognizance of repeated failures of PW1127G-JM engines, DGCA issued a

deadline to operators stating that, each A320 NEO aircraft with PW1127G-JM engine
(where both engines of which has done more than 2900 FH) must have at least one LPT
modified engine installed forthwith. Further, it stated that, all the A320 NEO aircraft fitted

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with Pratt and Whitney engines must have LPT modified for both its engines by 31st
January 2020.

On 25th November 2019, DGCA issued an order stating that the new aircraft which
has been inducted will slip into the role of one existing aircraft with unmodified (LPT)
engines. It was also stated that no leased engines without modified LPT 3rd stage shall be
imported. Thereafter, DGCA on 19th December 2019 issued an order stating that the order
dated 25th November 2019 and 16th December 2019 will be kept in abeyance to the extent
of grounding an existing aircraft with both unmodified engines upon induction of new aircraft
in the fleet. However, it said all other advisories issued by DGCA regarding the same will
continue to remain in force.

DGCA issued order dated 13th January 2020 in which they extended the deadline of
replacement of un-modified engines with modified engines to 31st May 2020. Later on, 27th
May 2020, DGCA issued yet another order wherein the deadline was further extended to
31st August 2020 keeping in view of the COVID19 pandemic.

M/s Go Airlines (India) Ltd complied with SB 72-00-0111 i.e., all its NEO fleet were
installed with LPT modified engines by 31st Aug 2020.

1.19 USEFUL OR EFFECTIVE INVESTIGATION TECHNIQUES

Nil

2. ANALYSIS

2.1 GENERAL

a) Both pilots were appropriately licensed and qualified to operate the flight.

b) The aircraft had a valid Certificate of Airworthiness at the time of incident. The
Aircraft held a valid Certificate of Release to Service which was issued at the airport of
departure. Airworthiness Directives & Service Bulletins were complied with. Transit
Inspections were carried out as per the approved Transit Inspection Schedules and all
higher Inspection Schedules including checks/inspection as per the manufacturer’s
guidelines and specified in Maintenance Programme.

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2.2 CIRCUMSTANCES LEADING TO THE INCIDENT

VT-WGL was equipped with PW1127G-JM ESN P770398. This engine was fitted
with pre-modified LPT 3rd stage blades which had less crack growth resistance and impact
tolerance. The aircraft suffered LPT 3rd stage blade failure immediately after take-off, while
climbing passing 1500ft, a loud bang was heard by the crew. Subsequently, “Engine Stall”
followed by “High Engine Vibration” warnings were triggered on ECAM. The crew followed
ECAM actions and QRH checklist/procedures for High Engine Vibration.
Cabin crew informed the crew about the tail pipe fire seen by them and some
passengers. Precautionary engine # 1 shutdown was carried out by the Crew and ATC was
informed about the Air Turn Back at 0550 UTC. After obtaining necessary clearance from
ATC, Guwahati, the aircraft landed safely with single engine at Guwahati at 0607 UTC.
During post flight inspection while carrying out visual inspection of the involved engine, LPT
3rd stage blades were found damaged.
Incident was one amongst series of similar events and hence Pratt and Whitney did
not carry out Technical Investigation into this case.

3. CONCLUSION

3.1 FINDINGS

1. The aircraft had valid Certificate of Airworthiness, Certificate of Registration and the
Certificate of Flight Release before operating the incident flight.

2. Both pilots were appropriately qualified to operate the flight.

3. There was no fire and no injury to any occupant on board the aircraft.

4. During post flight inspection, while carrying out visual inspection of the involved
engine, i.e. inlet area and exhaust area of engine # 1, Low Pressure Turbine 3rd stage
blades were found damaged.

5. The incident was similar to series of other events where LPT 3rd stage blades failed
during operation. The failure was considered to be a known issue by the OEM andno
Technical Investigation was carried out by the OEM.

6. Pratt & Whitney has issued SB 72-00-0111 to Introduce of a new LPT 3rd stage
blade made of a different material which is more resistant to impact damage. The airline
has subsequently incorporated the said SB in all its affected aircraft.

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3.2 PROBABLE CAUSE OF THE INCIDENT

The incident was caused by failure of LPT 3rd stage blades in flight as the blade
material lacked crack growth resistance and damage tolerance to withstand any impact
from material that may have liberated upstream.

4. SAFETY RECOMMENDATIONS

In view of corrective action initiated by the OEM to introduce new blades with better
impact resistance and subsequent compliance by the Airline no recommendation is made.

Dated: 30.12.2021

Sd/-
Jasbir Singh Larhga Sd/-
Investigator-In-Charge Amit Kumar
Investigator

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