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 metal was inspected twice during its production using ultrasonic equipment that would have shown any subsurface cracks or voids in the metal. None were found."
ReplyDeleteSounds like rollerstamping by GE inspectors missed this "as close as you can get to catastrophic" defect.
This proves Kevin McAllister from GE was the right choice by corrupt Boeing management for BCA President/CEO in order to continue Boeing's own longstanding QA rollerstamping fraud that makes Boeing hundreds of millions of dollars a year (minimum) by selling largely uninspected airplanes for the price of fully inspected and conforming airplanes.
https://www.thelastboeinginspector.com/boeings-vast-network-of-fraud.html
With long haul (over oceans) using TWO engines, this is IMPERATIVE!!
ReplyDelete... long live the 747!
American has yet to recover from Robert Crandall's supposed great leadership.
ReplyDeleteI love how aviation is indisputably the safest it has been in the history of mankind, period, and yet it's all doom and gloom. Boeing is killing it's customers to make a profit, American is broken beyond repair, etc. 30 years ago the plane fills with acrid smoke and people die. Today, it was one passenger with bad jet wash luck.
ReplyDeleteLoad factors are at an all-time high on so by all means please drive instead of flying - it will be more convenience for me. Besides, cars are far safer than transport aircraft and car manufacturers never, ever cut corners.