Martinair Holland Flight 815 Engine Failure and Return to Calgary

Incident Overview and Initial Response On 29 September 1999, the Transportation Safety Board of Canada released its investigation into Martinair Holland Flight 815, a Boeing 767 that departed Calgary International Airport for Amsterdam with 10 crew and 272 passengers aboard. Shortly after takeoff from runway 16, the crew heard a loud bang and observed a loss of engine pressure ratio on the right engine. The right engine oil pressure fell below the minimum limit, prompting the crew to shut down the engine and return to Calgary. The aircraft landed on runway 34, where the brakes overheated, causing the aircraft to stop on a taxiway. After the wheels cooled, passengers and crew deplaned and were transported to the terminal by bus. The captain, who became the pilot-flying after the first officer initially handled the takeoff, made a PAN call to air traffic control and requested to climb to 6,000 feet. He determined that an overweight landing at approximately 172,000 kg was preferable to fuel dumping. The aircraft was vectored for a landing on runway 34, which had an operational instrument landing system, while runway 16's ILS was not serviceable. During the approach, wind conditions shifted, resulting in a slight tailwind component and high ground speed. The aircraft touched down with spoilers deployed and the left engine in full reverse, slowing to taxi speed with about 2,000 feet of runway remaining. An airport emergency response team met the aircraft, chocked the main wheels, and used fans to cool the wheels. Three tire fuse plugs melted, causing the tires to deflate. After the wheels cooled sufficiently, an air-stair was placed, and passengers and cabin crew deplaned and were bused to the terminal. Communications with the emergency response team and air traffic control were complicated by frequency congestion on the ground control frequency, which was also used for normal airport operations. The crew reported that the congestion limited their ability to communicate with both the emergency response team and the ground controller, though it did not compromise safety. A separate frequency would have allowed direct communication with the emergency response team. ## Technical Investigation and Findings Flight data recorder analysis showed that before the failure, both engines had matched parameters, with engine pressure ratio at approximately 1.61 and high-pressure compressor speed at 99 percent. When the right engine failed, its engine pressure ratio dropped to 0.95, and the high-pressure compressor speed spooled down to zero. The right engine's exhaust gas temperature rose from 600 to 680 degrees Celsius, and oil pressure dropped from 237 psi to zero. Previous flight data showed no significant deviations in engine parameters, and vibration levels on the right engine were slightly higher during the occurrence takeoff but well below maximum. The right engine, a Pratt & Whitney PW4060 with serial number 717648, was returned to the Netherlands and then to a Swissair engine overhaul facility in Zurich. It had accumulated 8,649 hours and 1,648 cycles since its last refurbishment. Disassembly revealed that one sixth-stage high-pressure compressor blade had fractured and separated at the root attachment, and another sixth-stage blade had a root attachment crack. The blades and related components were sent to Pratt & Whitney in East Hartford, Connecticut, for analysis. The cracks were determined to be due to high-cycle fatigue, with high stresses likely caused by excitation from the variable guide vanes. The source of the excitation could not be identified, and no material or manufacturing anomalies were found. The engine failed when one sixth-stage high-pressure compressor blade failed at the root due to high-cycle fatigue fractures. The cause of the fatigue cracking could not be determined. The flight data recorder analysis indicated that the failure would not have been predictable based on the recorded engine parameters. ## Safety Actions and Conclusion The Transportation Safety Board concluded that the right engine failed due to a high-cycle fatigue fracture in a sixth-stage high-pressure compressor blade, with the cause of the cracking undetermined. To improve ground communications during emergencies, Transport Canada is working through an International Civil Aviation Organization working group to establish a discrete frequency for direct communication between aircraft flight decks and senior fire officers responding to aircraft emergencies. The report was authorized for release on 29 September 1999 by the Board, consisting of Chairperson Benoît Bouchard and members Maurice Harquail, Charles Simpson, and W.A. Tadros.