Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms
http://registry.faa.gov/N345AN
Location: Chicago, IL
Accident Number: DCA17FA021
Date & Time: 10/28/2016,
Registration: N345AN
Aircraft: BOEING 767
Aircraft Damage: Substantial
Defining Event: Uncontained engine failure
Injuries: 1 Serious, 20 Minor, 149 None
Flight Conducted Under: Part 121: Air Carrier - Scheduled
Analysis
NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.
The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/01.
On October 28, 2016, about 1432 central daylight time, American Airlines flight 383, a Boeing 767-323, N345AN, had started its takeoff ground roll at Chicago O'Hare International Airport, Chicago, Illinois, when an uncontained engine failure in the right engine and subsequent fire occurred. The flight crew aborted the takeoff and stopped the airplane on the runway, and the flight attendants initiated an emergency evacuation. Of the 2 flight crewmembers, 7 flight attendants, and 161 passengers on board, 1 passenger received a serious injury and 1 flight attendant and 19 passengers received minor injuries during the evacuation. The airplane was substantially damaged from the fire. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed at the time of the accident.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The failure of the high-pressure turbine (HPT) stage 2 disk, which severed the main engine fuel feed line and breached the right main wing fuel tank, releasing fuel that resulted in a fire on the right side of the airplane during the takeoff roll. The HPT stage 2 disk failed because of low-cycle fatigue cracks that initiated from an internal subsurface manufacturing anomaly that was most likely not detectable during production inspections and subsequent in service inspections using the procedures in place. Contributing to the serious passenger injury was (1) the delay in shutting down the left engine and (2) a flight attendant's deviation from company procedures, which resulted in passengers evacuating from the left overwing exit while the left engine was still operating. Contributing to the delay in shutting down the left engine was (1) the lack of a separate checklist procedure for Boeing 767 airplanes that specifically addressed engine fires on the ground and (2) the lack of communication between the flight and cabin crews after the airplane came to a stop.
Findings
Aircraft
Turbine section - Failure (Cause)
Fuel system - Damaged/degraded
Personnel issues
Use of policy/procedure - Cabin crew (Factor)
Delayed action - Flight crew (Factor)
Lack of communication - Flight crew (Factor)
Lack of communication - Cabin crew (Factor)
Organizational issues
Equipment manufacture - Manufacturer (Cause)
Task design - Manufacturer (Factor)
Factual Information
The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/01.
On October 28, 2016, about 1432 central daylight time, American Airlines flight 383, a Boeing 767-323, N345AN, had started its takeoff ground roll at Chicago O'Hare International Airport, Chicago, Illinois, when an uncontained engine failure in the right engine and subsequent fire occurred. The flight crew aborted the takeoff and stopped the airplane on the runway, and the flight attendants initiated an emergency evacuation. Of the 2 flight crewmembers, 7 flight attendants, and 161 passengers on board, 1 passenger received a serious injury and 1 flight attendant and 19 passengers received minor injuries during the evacuation. The airplane was substantially damaged from the fire. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed at the time of the accident.
History of Flight
Takeoff-rejected takeoff
Uncontained engine failure (Defining event)
Other
Fire/smoke (non-impact)
Evacuation
Pilot Information
Certificate: Airline Transport; Flight Engineer
Age: 61, Male
Airplane Rating(s): Multi-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Glider
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed:
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 05/04/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 03/22/2016
Flight Time: 17400 hours (Total, all aircraft), 4000 hours (Total, this make and model)
Co-Pilot Information
Certificate: Airline Transport; Flight Engineer
Age: 57, Male
Airplane Rating(s): Multi-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): Glider
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed:
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 05/03/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 09/07/2016
Flight Time: 22000 hours (Total, all aircraft), 1846 hours (Total, this make and model)
Aircraft and Owner/Operator Information
Aircraft Manufacturer: BOEING
Registration: N345AN
Model/Series: 767 323
Aircraft Category: Airplane
Year of Manufacture: 2003
Amateur Built: No
Airworthiness Certificate: Transport
Serial Number: N345AN
Landing Gear Type: Retractable - Tricycle
Seats: 220
Date/Type of Last Inspection: 01/15/2011, Continuous Airworthiness
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 2 Turbo Fan
Airframe Total Time:
Engine Manufacturer: General Electric
ELT: Installed, not activated
Engine Model/Series: CF6-80C2 B6
Registered Owner: American Airlines Group, Inc.
Rated Power: lbs
Operator: AMERICAN AIRLINES INC
Operating Certificate(s) Held: Flag carrier (121)
Operator Does Business As:
Operator Designator Code: AALA
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KORD
Observation Time: 1951 UTC
Distance from Accident Site:
Direction from Accident Site:
Lowest Cloud Condition: Scattered / 2000 ft agl
Temperature/Dew Point: 16°C / 11°C
Lowest Ceiling: Overcast / 25000 ft agl
Visibility: 10 Miles
Wind Speed/Gusts, Direction: 11 knots, 180°
Visibility (RVR):
Altimeter Setting: 30.04 inches Hg
Visibility (RVV):
Precipitation and Obscuration:
Departure Point: Chicago, IL (KORD)
Type of Flight Plan Filed: IFR
Destination: Miami, FL (KMIA)
Type of Clearance: IFR
Departure Time: 1432 CDT
Type of Airspace:
Airport Information
Airport: Chicago O'Hare International A (KORD)
Runway Surface Type: Asphalt; Concrete
Airport Elevation: 668 ft
Runway Surface Condition: Dry
Runway Used: 28R
IFR Approach: None
Runway Length/Width: 13000 ft / 150 ft
VFR Approach/Landing: None
Wreckage and Impact Information
Crew Injuries: 1 Minor, 8 None
Aircraft Damage: Substantial
Passenger Injuries: 1 Serious, 19 Minor, 141 None
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Serious, 20 Minor, 149 None
Latitude, Longitude: 41.968889, -87.917778
U.S. air-accident investigators have called for upgraded engine-inspection practices and better-coordinated procedures for passenger evacuations, in their final report about a fire that badly damaged an American Airlines Group Inc. jet on a Chicago runway two years ago.
The findings and recommendations released by the National Transportation Safety Board on Tuesday stem from an October 2016 accident in which a rare manufacturing defect caused part of the right engine on a Boeing Co. 767 bound for Miami to rupture violently late in the takeoff roll. Metal parts flew as far as 3,000 feet, a fuel leak caused a massive fire under the right wing and all 161 passengers used emergency slides to leave the jet.
There were no fatalities, but the National Transportation Safety Board issued industrywide recommendations for modernized engine inspections and stepped-up airline crew training to ensure safer emergency evacuations.
According to the National Transportation Safety Board, United States regulators haven’t updated guidance on conducting emergency evacuations for three decades, despite several high-profile examples of problems getting passengers off airliners in just the past few years.
Investigators concluded that a rare manufacturing flaw dating back to the late 1990s—and likely undetectable through recent years—created microscopic cracks in the high-energy internal disc that eventually led to the accident at O’Hare International Airport. General Electric Co. manufactured the engines.
Even with significant safety advances in engines and overall airline performance over the last few decades, “there’s still improvements that can be made,” said Robert Sumwalt, the safety board’s chairman. Inspection methods “that can fail to uncover a defect in a safety critical component of an airliner,” he said, “need a closer look.:
Regarding the crew’s response, the National Transportation Safety Board concluded that the pilots, after hearing a loud bang, acted appropriately to halt the takeoff and shut down the damaged engine. But the report was critical of the level of cooperation between the cockpit crew and flight attendants.
Investigators, among other things, found that flight attendants hadn’t received adequate training on systems to communicate with the cockpit or passengers. Two attendants told the safety board they couldn’t operate the intercoms to contact the pilots, as smoke billowed inside the cabin and passengers disregarded instructions by climbing over seats and insisting on grabbing carry-on bags.
With one of the wide-body jet’s engines still running as the evacuation began, a passenger suffered a serious injury as he was hit by jet blast. The pilots told investigators the only emergency engine shut-off checklist they had didn’t call for immediately turning off the remaining engine.
Modern jet turbines are designed to prevent broken parts from being spewed outside the engine cover. But violent disintegration of some internal parts has dogged certain models of GE’s CF6-80 model engines since 2000, prompting a series of stepped-up safety actions by the manufacturer and the Federal Aviation Administration.
An Federal Aviation Administration spokeswoman didn’t have any immediate comment on the nonbinding safety recommendations.
American, which has revamped flight attendant training, told investigators the cabin crew took appropriate steps to initiate the evacuation despite communication difficulties.
Original article can be found here ➤ https://www.wsj.com The National Transportation Safety Board traveled to the scene of this accident.
Aviation Accident Preliminary Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
American Airlines Inc: http://registry.faa.gov/N345AN
Accident Number: DCA17FA021
Date & Time: 10/28/2016,
Registration: N345AN
Aircraft: BOEING 767
Injuries: 1 Serious, 19 Minor, 150 None
Flight Conducted Under: Part 121: Air Carrier - Scheduled
On October 28, 2016, at about 2:32 CDT, American Airlines flight number 383, a Boeing B767-300, N345AN, powered by two General Electric CF6-80C2B6 turbofan engines, experienced a right engine uncontained failure and subsequent fire during the takeoff ground roll on runway 28R at the Chicago O'Hare International Airport (ORD), Chicago, Illinois. The flightcrew aborted the takeoff and stopped the aircraft on runway 28R and an emergency evacuation was conducted. Of the 161 passengers and 9 crew members onboard, one passenger received serious injuries during the evacuation and the airplane was substantially damaged as a result of the fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 as a domestic scheduled passenger flight to Miami International Airport (MIA), Miami, Florida.
Aircraft and Owner/Operator Information
Aircraft Manufacturer: BOEING
Registration: N345AN
Model/Series: 767 323
Aircraft Category: Airplane
Amateur Built: No
Operator:
Operating Certificate(s) Held: Flag carrier (121)
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KORD
Observation Time: 1951 UTC
Distance from Accident Site:
Temperature/Dew Point: 16°C / 11°C
Lowest Cloud Condition: Scattered / 2000 ft agl
Wind Speed/Gusts, Direction: 11 knots, 180°
Lowest Ceiling: Overcast / 25000 ft agl
Visibility: 10 Miles
Altimeter Setting: 30.04 inches Hg
Type of Flight Plan Filed: IFR
Departure Point: Chicago, IL (KORD)
Destination: Miami, FL (KMIA)
Wreckage and Impact Information
Crew Injuries: 9 None
Aircraft Damage: Substantial
Passenger Injuries: 1 Serious, 19 Minor, 141 None
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Serious, 19 Minor, 150 None
Latitude, Longitude:
Now, 18 passengers — including three from South Florida — are suing the airline, Boeing and GE, the engine’s manufacturer, for the injuries caused by the allegedly “defective and unreasonably dangerous” aircraft, the suit says. The lawsuit was filed in Illinois circuit court, where the incident took place.
On the afternoon of Oct. 28, 170 crew and passengers on Flight 383 from Chicago’s O’Hare International Airport to Miami International Airport were forced to evacuate when the engine on the right side of the plane burst into flames on the tarmac. Footage from the scene shows passengers quickly evacuating on slides on the front and rear left side of the plane and running into a grassy area while smoke and fire rise in the background. The plane’s right wing can be seen melting and drooping.
About 20 people suffered minor injuries, officials said.
According to the lawsuit, the plaintiffs suffered “personal and bodily injuries, both physical and psychological in nature” and either have or will sustain “future medical bills, lost earnings, disability, disfigurement, and pain and suffering and emotional distress,” as a result of the accident.
The suit claims GE sold the defective engine to Boeing, which was negligent in “designing, manufacturing, assembling, and selling the accident aircraft as as not to cause injury to plaintiffs.” It also alleges that American Airlines failed to maintain, service, inspect and repair the aircraft appropriately enough to avoid the accident.
American Airlines declined to comment, citing pending litigation.
The plaintiffs are represented by Chicago-based Wisner Law Firm, which focuses solely on representing people injured or killed in aviation accidents. The firm recently resolved a similar case for an undisclosed amount involving more than 100 passengers and crew on a September 2015 British Airways. Like the Chicago to Miami flight, the British Airways flight involved a faulty GE engine on a Boeing plane that failed and caught fire at Las Vegas’ McCarran International Airport.
“GE and Boeing and American, as well, need to take a harder look at this problem because I’m concerned it’s a recurring problem,” said Floyd Wisner, principal at the law firm. “It’s not just a rare occurrence.”
The law firm expects to add other passengers as plaintiffs, as well as other parties, such as material suppliers or component manufactures, as defendants if certain parts of the engine are found as contributing to the fire.
Read more here: http://www.newsobserver.com
District Chief of EMS for O'Hare Juan Hernandez said 20 people had been transported to local hospitals with minor injuries including bruising, scrapes and ankle injuries sustained in the evacuation of the plane.
American Airlines flight 383 bound for Miami was forced to abort takeoff at about 2:35 p.m. The pilot heard a thump and thought a tire had blown. The air traffic control tower alerted the pilot to flames. A large fire quickly consumed the plane's right-side engine and wing. Flight crew immediately stopped the plane and evacuated it using the inflatable slides on the left hand side of the aircraft.
Federal officials said the cause of the fire was "uncontained" engine failure, meaning pieces were blown out of the engine.
All 170 passengers, including flight crew, and a dog were evacuated, Chicago Deputy Fire Commissioner Timothy Sampey said.
Sampey said the fire was mostly extinguished quickly, but crews are still working to put out hot spots on the plane. The plane was carrying 43,000 lbs. of fuel at the time.
"This could have been absolutely devastating if it happened later, if it happened farther. There's about a thousand variables but again, they brought the aircraft to a halt, the air tower did a great job communicating to the pilot what fire they saw and they got everybody off the plane immediately," Sampey said.
Patients were taken to hospitals including Lutheran General Hospital and Presence Resurrection.
Passenger Hector Cardenas said the plane was seconds away from taking off when he heard an explosion. Large flames and a plume of black smoke could be seen rising from the aircraft.
"Within 10 or 15 seconds we would have been in the air," Cardenas said.
Sarah Ahmed was also on the flight and described the chaos in the moments after the fire broke out.
"We were almost up in the air. We were full throttle, full speed ahead and then we heard this huge bang and there's fire at the window, and so everyone on the right side of the plane got up, jumped up and they'er now on the left side of the plane. So there's a stampede at the left side. The plane comes to a screeching stop. People are yelling 'open the door, open the door!' everyone's screaming and jumping on top of each other to open the door. Within that time, I think it was seven seconds, there was now smoke in the plane and the fire is right up against the windows and it's melting the windows," Ahmed said.
Conversation between the cockpit and air traffic control revealed how quickly the situation unfolded.
"American 383 heavy stopping on the runway."
"Roger, roger. Fire."
"Do you see any smoke or fire?"
"Yeah fire off the right wing."
"Ok, send out the truck."
"Sending them."
"American 383 can you give us any information right now?"
"Uh, standby. Chicago American 383, we're evacuating."
"American 383 roger, trucks are on the way."
In a statement, the airline said, "American Airlines is fully cooperating with the National Transportation Safety Board in its investigation of flight 383. We are operating a special flight tonight to take our customers to Miami. Twenty passengers and one flight attendant reported non-critical injuries. Several were transported to Chicago-area hospitals to be evaluated. Members of American's specially trained employee volunteer CARE Team have been mobilized and dispatched to those hospitals, and Chicago O'Hare International Airport to provide assistance for our customers, crew members and their families."
The National Transportation Safety Board have taken over the investigation. The plane will remain on the runway until the NTSB is finished with their on-site investigation.
Sampey said in his estimation it's been about eight years since an incident equivalent to this occurred at O'Hare.
One runway remains closed at O'Hare. Operations at the airport are normal. Investigators from the National Transportation Safety Board are on their way to O'Hare Airport s of 4 p.m.
ABC7 Doppler 7 MAX picked up the smoke plume from the plane fire on radar.
Story and video: http://abc7chicago.com
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