Uncontained Engine Failure and Subsequent Fire, American Airlines Flight 383, Boeing 767-323, N345AN, Chicago, Illinois, October 28, 2016

Uncontained Engine Failure and Subsequent Fire

American Airlines Flight 383

Boeing 767-323, N345AN

Chicago, Illinois

October 28, 2016

Accident Report

NTSB/AAR-18/01

PB2018-100344

National

Transportation

Safety Board

NTSB/AAR-18/01

PB2018-100344

Notation 57292

Adopted January 30, 2018

Aircraft Accident Report

Uncontained Engine Failure and Subsequent Fire

American Airlines Flight 383

Boeing 767-323, N345AN

Chicago, Illinois

October 28, 2016

National

Transportation

Safety Board

490 L’Enfant Plaza, SW

Washington, DC 20594

National Transportation Safety Board. 2018. Uncontained Engine Failure and Subsequent Fire,

American Airlines Flight 383, Boeing 767-323, N345AN, Chicago, Illinois, October 28, 2016.

NTSB/AAR-18/01. Washington, DC.

Abstract: This report discusses the October 28, 2016, accident involving American Airlines flight 383, a

Boeing 767-323, which experienced an uncontained failure of the right engine and subsequent fire during

its takeoff ground roll at Chicago O’Hare International Airport, Chicago, Illinois. 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 emergency evacuation. The airplane

was substantially damaged from the fire. Safety issues identified in this report include the lack of recent

guidance comparing production inspection processes for nickel alloy engine components, the need for

improved in-service inspection techniques for critical rotating parts of all engines, the lack of recent

guidance about design precautions to minimize hazards resulting from uncontained engine failures, the need

for separate engine fire checklist procedures for ground operations and in-flight operations, the need for

improved flight attendant training regarding assessing exits for evacuations and using interphone systems

during emergencies, the need for research on the effects of evacuating with carry-on baggage, and the need

for improved communication between flight and cabin crews during emergency situations, including

evacuations. As a result of this investigation, the National Transportation Safety Board makes seven safety

recommendations to the Federal Aviation Administration and one recommendation each to Boeing and

American Airlines.

The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting aviation,

railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress through the

Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the

accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of

government agencies involved in transportation. The NTSB makes public its actions and decisions through accident

reports, safety studies, special investigation reports, safety recommendations, and statistical reviews.

The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation,

“accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and are

not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4. Assignment

of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by

investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits

the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages

resulting from a matter mentioned in the report. 49 U.S.C. § 1154(b).

For more detailed background information on this report, visit http://www.ntsb.gov/investigations/dms.html and

search for NTSB accident ID DCA17FA021 Recent publications are available in their entirety on the Internet at

http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by

contacting:

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Records Management Division, CIO-40

490 L’Enfant Plaza, SW

Washington, DC 20594

(800) 877-6799 or (202) 314-6551

NTSB publications may be purchased from the National Technical Information Service. To purchase this publication,

order product number PB2018-100344 from:

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http://www.ntis.gov/

NTSB Aircraft Accident Report

Contents

Figures ........................................................................................................................................... iii

Tables ............................................................................................................................................ iv

Abbreviations .................................................................................................................................v

Executive Summary .................................................................................................................... vii

1. Factual Information ...................................................................................................................1

1.1 History of Flight .........................................................................................................................1

1.2 Personnel Information ................................................................................................................4

1.2.1 The Captain ......................................................................................................................4

1.2.2 The First Officer ..............................................................................................................6

1.2.3 The Flight Attendants ......................................................................................................7

1.3 Airplane and Engine Information ..............................................................................................7

1.3.1 High-Pressure Turbine Stage 2 Disk Manufacturing Process .........................................8

1.3.1.1 Triple-Melt Process ............................................................................................9

1.3.1.2 Ultrasonic Inspection Process ..........................................................................11

1.3.1.3 Manufacture History of Accident HPT Stage 2 Disk ......................................13

1.3.2 Accident Engine Maintenance Events ...........................................................................14

1.3.3 Postaccident Engine Observations .................................................................................15

1.3.4 Metallurgical Examinations ...........................................................................................18

1.4 Tests and Research ...................................................................................................................22

1.4.1 Number of Flight Cycles in Low-Cycle Fatigue Regions .............................................22

1.4.2 Ultrasonic Response Characteristics of Discrete Dirty White Spots .............................23

1.5 Survival Aspects ......................................................................................................................24

1.5.1 Interphone Communication System ..............................................................................24

1.5.2 Evacuation .....................................................................................................................27

1.6 Organizational Information ......................................................................................................30

1.6.1 American Airlines Flight Crew Manuals .......................................................................30

1.6.1.1 Engine Fire Checklist .......................................................................................30

1.6.1.2 Evacuation Guidance .......................................................................................31

1.6.1.3 Evacuation Checklist .......................................................................................33

1.6.1.4 Evacuation Duties ............................................................................................34

1.6.2 American Airlines Flight Attendant Manual .................................................................35

1.6.3 American Airlines Training ...........................................................................................36

1.6.3.1 Flight Crew Training........................................................................................36

1.6.3.2 Flight Attendant Training ................................................................................37

1.6.4 American Airlines Operating Manual—Engine Fire Warning System .........................37

1.6.5 Boeing ............................................................................................................................38

1.6.6 Federal Aviation Administration ...................................................................................39

1.6.6.1 Advisory Circular 20-128 ................................................................................39

1.6.6.2 Inspection Techniques for Nickel Billets .........................................................41

NTSB Aircraft Accident Report

1.6.6.3 Definition of Stealth Anomalies ......................................................................41

1.6.6.4 Notice of Proposed Rulemaking ......................................................................42

1.7 Additional Information ............................................................................................................43

1.7.1 Discrete White Spot Formation .....................................................................................43

1.7.2 Master Heat FA94 ..........................................................................................................43

1.7.3 Previous Related Safety Recommendations ..................................................................44

1.7.3.1 Recommendations From United Airlines Flight 232 Accident .......................44

1.7.3.2 Communication and Coordination Among Flight and Cabin Crews ...............46

1.7.3.3 Retrieval of Carry-On Baggage .......................................................................48

2. Analysis .....................................................................................................................................50

2.1 Accident Sequence ...................................................................................................................50

2.2 Checklist Issues ........................................................................................................................52

2.2.1 Decision to Perform Engine Fire Checklist ...................................................................52

2.2.2 Engine Fire Checklist Design ........................................................................................53

2.3 Evacuation Issues .....................................................................................................................55

2.3.1 Evacuation Sequence .....................................................................................................55

2.3.2 Flight and Cabin Crew Communication ........................................................................57

2.3.2.1 Interphone Issues .............................................................................................59

2.3.2.2 Recurring Evacuation-Related Issues ..............................................................61

2.3.3 Flight and Cabin Crew Evacuation Duties ....................................................................64

2.3.4 Carry-On Baggage Issue ................................................................................................65

2.4 High-Pressure Turbine Stage 2 Disk Failure ...........................................................................66

2.4.1 Discrete Dirty White Spot Detection During Manufacturing ........................................67

2.4.2 American Airlines Inspection of High-Pressure Turbine Stage 2 Disk .........................69

2.4.3 Guidance on Design Precautions to Minimize Rotor Burst Hazards ............................71

3. Conclusions ...............................................................................................................................75

3.1 Findings....................................................................................................................................75

3.2 Probable Cause.........................................................................................................................76

4. Recommendations ....................................................................................................................77

4.1 New Recommendations ...........................................................................................................77

4.2 Previously Issued Recommendations Reiterated in This Report .............................................78

4.3 Previously Issued Recommendation Classified in This Report ...............................................78

5. Appendixes................................................................................................................................80

Appendix A: Investigation .............................................................................................................80

Appendix B: Cockpit Voice Recorder Transcript ..........................................................................81

References .....................................................................................................................................90

NTSB Aircraft Accident Report

iii

Figures

Figure 1. Right side of airplane after uncontained engine failure and subsequent fire. ................ 4

Figure 2. HPT rotor. ...................................................................................................................... 8

Figure 3. Vacuum arc remelting process. ................................................................................... 11

Figure 4. Longitudinal wave scan used during ultrasonic inspections. ...................................... 12

Figure 5. Main fragments of the HPT stage 2 disk (forward side). ............................................ 16

Figure 6. Disk fragment locations. .............................................................................................. 17

Figure 7. Holes located forward and aft of the right wing front spar. ........................................ 17

Figure 8. Engine cross-section and fracture origin location. ...................................................... 19

Figure 9. Fracture surface from disk fragment A........................................................................ 19

Figure 10. Discrete dirty white spot in fracture surface. ............................................................. 21

Figure 11. Stringer in material microstructure. ........................................................................... 21

Figure 12. Fatigue cracks that initiated from discrete dirty white spot. ...................................... 22

Figure 13. N345AN configuration. ............................................................................................. 24

Figure 14a. Classic model interphone......................................................................................... 25

Figure 14b. New model interphone. ........................................................................................... 26

Figure 15. Engine fire handles. ................................................................................................... 31

NTSB Aircraft Accident Report

Tables

Table 1. Flight attendant position, initial new hire date, and last recurrent training date. ............ 7

Table 2. Evacuation events shown on videos of left side of airplane. ........................................ 27

Table 3. Summaries of flight attendant evacuation actions. ....................................................... 28

NTSB Aircraft Accident Report

Abbreviations

AAIB Air Accidents Investigation Branch

AC advisory circular

AD airworthiness directive

AIA Aerospace Industries Association

APU auxiliary power unit

ARAC aviation rulemaking advisory committee

ARFF aircraft rescue and firefighting

ATC air traffic control

ATI SM ATI Specialty Materials

ATSB Australian Transportation Safety Board

BOS General Edward Lawrence Logan International Airport

CFR

Code of Federal Regulations

CLT Charlotte/Douglas International Airport

CRM crew resource management

CVR cockpit voice recorder

ECI eddy current inspection

EDT eastern daylight time

EICAS engine indicating and crew alerting system

ESN engine serial number

FAA Federal Aviation Administration

FDR flight data recorder

FPI fluorescent penetrant inspection

GE General Electric

HPT high-pressure turbine

JFK John F. Kennedy International Airport

MIA Miami International Airport

MTU Motoren- und Turbinen-Union GmbH

NPRM notice of proposed rulemaking

NTSB National Transportation Safety Board

ORD Chicago O’Hare International Airport

NTSB Aircraft Accident Report

PA public address [system]

POI principal operations inspector

QRH quick reference handbook

RTO rejected takeoff

SAFO safety alert for operators

SB service bulletin

SEM scanning electron microscope

TWA Trans World Airlines

UPS United Parcel Service

takeoff decision speed

NTSB Aircraft Accident Report

vii

Executive Summary

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.

The uncontained engine failure resulted from a high-pressure turbine (HPT) stage 2 disk

rupture. The HPT stage 2 disk initially separated into two fragments. One fragment penetrated

through the inboard section of the right wing, severed the main engine fuel feed line, breached the

fuel tank, traveled up and over the fuselage, and landed about 2,935 ft away. The other fragment

exited outboard of the right engine, impacting the runway and fracturing into three pieces.

Examination of the fracture surfaces in the forward bore region of the HPT stage 2 disk

revealed the presence of dark gray subsurface material discontinuities with multiple cracks

initiating along the edges of the discontinuities. The multiple cracks exhibited characteristics that

were consistent with low-cycle fatigue. (In airplane engines, low-cycle fatigue cracks grow in

single distinct increments during each flight.) Examination of the material also revealed a discrete

region underneath the largest discontinuity that appeared white compared with the surrounding

material. Interspersed within this region were stringers (microscopic-sized oxide particles) referred

to collectively as a “discrete dirty white spot.” The National Transportation Safety Board’s

(NTSB) investigation found that the discrete dirty white spot was most likely not detectable during

production inspections and subsequent in-service inspections using the procedures in place.

The NTSB’s investigation also found that the evacuation of the airplane occurred initially

with one engine still operating. In accordance with company procedures and training, the flight

crew performed memory items on the engine fire checklist, one of which instructed the crew to

shut down the engine on the affected side (in this case, the right side). The captain did not perform

the remaining steps of the engine fire checklist (which applied only to airplanes that were in flight)

and instead called for the evacuation checklist. The left engine was shut down as part of that

checklist. However, the flight attendants had already initiated the evacuation, in accordance with

their authority to do so in a life-threatening situation, due to the severity of the fire on the right

side of the airplane.

The NTSB identified the following safety issues as a result of this accident investigation:

• Lack of recent guidance comparing production inspection processes for nickel alloy

engine components. The HPT stage 2 disk was made of a nickel-based alloy. Ultrasonic

inspections are typically performed during the manufacture of nickel alloy engine

components to detect internal defects (such as cracks and voids) in the material. However,

NTSB Aircraft Accident Report

viii

the discrete dirty white spot, which is consistent with the description of a “stealth” anomaly

in a 2008 Federal Aviation Administration (FAA) report on turbine rotor material design,

was most likely not detectable by the ultrasonic inspection methods used during production

of the HPT stage 2 disk. A 2005 FAA report that presented the results of industry’s research

about nickel billet inspections found that enhanced ultrasonic inspection techniques, such

as multizone and phased array inspections, could better detect internal defects than

conventional ultrasonic inspection techniques. The report also stated that multizone

inspection techniques were being used for titanium engine parts but that conventional

ultrasonic inspection techniques were still being used for nickel engine parts during

manufacturing. Additional FAA and industry efforts are needed to evaluate the

appropriateness of current and enhanced inspection technologies for nickel engine parts.

Updated FAA guidance describing the results of such evaluations would benefit those

involved with the inspection process for nickel alloy rotating engine components.

• Need for improved in-service inspection techniques for critical rotating parts of all

engines. In January 2011, American Airlines performed maintenance—an eddy current

inspection (ECI) and a fluorescent penetrant inspection (FPI)—of the forward bore region

of the HPT stage 2 disk with no anomalies found. (American Airlines did not have another

opportunity to inspect the disk before the accident because no engine maintenance between

January 2011 and the time of the accident involved disassembling the HPT stage 2 disk.)

These inspection techniques were not capable of detecting the cracks that emanated from

the discrete dirty white spot (a subsurface anomaly) because they could only detect cracks

and other anomalies at the surface (FPI) and near the surface (ECI) of a material.

Although ultrasonic inspections might be limited in their capability to detect anomalies

during the production stage, such a subsurface inspection technique would be appropriate

for in-service maintenance because of the propensity for cracks to propagate over time. If

a subsurface ultrasonic inspection had been required at the time of the disk’s last inspection,

the cracks that developed from the discrete dirty white spot would most likely have been

detectable because of the size of the cracks at that time and the sensitivity of ultrasonic

inspection techniques.

In September 2017, the FAA issued a notice of proposed rulemaking to mandate the

ultrasonic inspection of HPT stage 1 and 2 disks of General Electric CF6-80-series turbofan

engines (the model engine on the accident airplane). The proposed airworthiness directive

would be an appropriate step for ensuring the continued airworthiness of airplanes with

those engines, but the FAA has not addressed ultrasonic inspections on other engine models

during in-service maintenance to ensure their continued airworthiness.

• Lack of recent guidance about design precautions to minimize hazards resulting from

uncontained engine failures. In March 1997, the FAA issued Advisory Circular

(AC) 20-128A, “Design Considerations for Minimizing Hazards Caused by Uncontained

Turbine Engine and Auxiliary Power Unit Rotor Failure.” The AC provided rotor burst and

blade release fragment trajectory data so that airframe manufacturers could integrate

appropriate design precautions to minimize hazards to an airplane and its occupants. The

AC also contained specific information about accepted design precautions to reduce the

overall risk of an uncontrolled fire for airplanes with fuel tanks located in impact areas.

NTSB Aircraft Accident Report

Since the time that the AC was issued, numerous uncontained disk rupture events have

occurred, and lessons learned from these events could be incorporated into more robust

guidance, including updated trajectory analyses, for airframe manufacturers to use when

considering design mitigations for minimizing hazards resulting from uncontained engine

failures. Also, even though the flight 383 accident airplane had design mitigations for

reducing the overall risk of an uncontrolled fire that were consistent with the AC’s

guidance, the uncontained engine failure resulted in a subsequent fire.

• Need for separate engine fire checklist procedures for ground operations and in-flight

operations. American Airlines’ engine fire checklist for the Boeing 767 (which was based

on Boeing’s engine fire checklist procedure) delayed the flight crew from initiating the

evacuation checklist, shutting down the left engine, and commanding an evacuation. The

engine fire checklist did not differentiate between an engine fire in flight and an engine fire

while the airplane was on the ground and did not include a step, for an engine fire on the

ground, to shut down the unaffected engine or perform the evacuation checklist sooner.

Also, the engine fire checklist included a 30-second wait time between discharging the first

fire extinguishing bottle and determining if the second bottle would also need to be

discharged. Engine fire checklists that are specific to ground operations generally instruct

flight crews to discharge both fire extinguisher bottles about the same time, which could

be critical for containing a fire and/or commanding an evacuation.

• Need for improved flight attendant training regarding assessing exits for evacuations

and using interphone systems during emergencies. As the evacuation was unfolding,

three flight attendants stationed on the right side of the airplane blocked their assigned exits

because they recognized that the engine fire would present a danger. A flight attendant

stationed on the left side of the airplane blocked her assigned exit until the left engine was

shut down. However, another flight attendant stationed on the left side of the airplane

assessed the conditions outside the airplane yet opened the left overwing exit while the

engine was still operating. The one serious injury that resulted during the evacuation

occurred after a passenger evacuated using the left overwing exit. Once on the ground, the

passenger stood up to get away from the airplane but was knocked down by the jet blast

coming from the left engine.

American Airlines 767-300-series airplanes are equipped with one of two interphone

system models, which operate differently. After the accident airplane came to a stop, one

flight attendant tried to use the interphone to alert the flight crew that the left engine was

still operating but was unsuccessful because she operated the interphone incorrectly. Also,

another flight attendant tried to use the interphone to make an announcement to the

passengers but could not recall how to use the interphone. The NTSB could not determine,

based on the available evidence, if the flight attendants’ difficulty operating the interphone

was directly related to training deficiencies or the stress associated with the situation.

However, the interphone system model installed on the accident airplane was not installed

on American Airlines’ 767 simulators used for flight attendant training. Further, although

company flight attendants were trained on interphone systems during initial training,

airplane differences training, and recurrent training, the subject was presented during

recurrent training without providing flight attendants with hands-on experience using an

interphone during an emergency.

NTSB Aircraft Accident Report

• Need for research on the effects of evacuating with carry-on baggage. Video taken

during the evacuation and postaccident interviews with flight attendants indicated that

some passengers evacuated from all three usable exits with carry-on baggage despite

instructions to leave the bags. Although the NTSB has not identified any accident

evacuations in which delays related to carry-on baggage caused injuries, passengers

evacuating airplanes with carry-on baggage has been a recurring safety concern. The NTSB

is not aware of any study that measured the potential delays associated with passengers

retrieving and carrying baggage during an emergency evacuation. The results of such a

study could help determine appropriate countermeasures to mitigate any potential safety

risks.

• Need for improved communication between flight and cabin crews during emergency

situations, including evacuations. The flight crew did not communicate with the flight

attendants to relay its intent not to immediately evacuate. The flight attendants had both

the evacuation signaling system and the interphone system available to them to alert the

flight crew that an evacuation was underway, but none of the flight attendants activated the

signaling system, and only two of the seven flight attendants attempted (unsuccessfully) to

communicate with the flight crew using the interphone system. Even with an unfolding

emergency, there should have been better communication between the flight and cabin

crews.

The NTSB has a long history of investigating accidents (including three other accident

investigations within the last 2 years) in which communication between flight and cabin

crews during an evacuation was inadequate and issuing related safety recommendations in

response. However, the FAA has not yet acted on a 2009 safety recommendation to revise

related guidance (issued in 1988) to reflect the most recent industry knowledge on the

subject based on research and lessons learned from relevant accidents and incidents. In

addition, the FAA has not yet established a multidisciplinary working group, in response

to a 2016 recommendation, to develop best practices to resolve recurring

evacuation-related issues. It is time for the FAA to emphasize the importance of ensuring

that flight and cabin crew communications can facilitate safe and effective decision-making

and action during emergency situations.

The NTSB determines that the probable cause of this accident was the failure of the 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.

NTSB Aircraft Accident Report

As a result of this investigation, the NTSB makes safety recommendations to the FAA,

Boeing, and American Airlines.

NTSB Aircraft Accident Report

1. Factual Information

1.1 History of Flight

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 (ORD), 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. A section of the high-pressure turbine (HPT) stage 2 disk

burst and penetrated through the inboard section of the right wing and was recovered in a United

Parcel Service (UPS) warehouse about 2,935 ft from the location where the uncontained engine

failure occurred. The airplane was operating under the provisions of 14 Code of Federal

Regulations (CFR) Part 121. Visual meteorological conditions prevailed at the time of the accident.

Flight 383 was a scheduled passenger flight to Miami International Airport (MIA), Miami,

Florida.

The flight crew’s duty day began in ORD at 1320, with a scheduled departure time to

MIA 1 hour later. The captain was the pilot flying, and the first officer was the pilot monitoring.

The captain taxied the airplane to runway 28R for a takeoff from the intersection of the

runway with taxiway N5. Runway 28R was 13,000 ft long and 150 ft wide, and the available length

from the N5 intersection was 9,750 ft.

According to the cockpit voice recorder (CVR), at 1430:57, the tower controller cleared

the airplane for takeoff, and the first officer acknowledged this instruction.

At 1431:19, the CVR

recorded a sound similar to increasing engine rpm, and the flight data recorder (FDR) indicated

that the engines achieved takeoff power at 1431:24.

During a postaccident interview, the flight

(a) All times in this report are central daylight time unless otherwise noted. (b) An uncontained failure of a

turbine engine “is any failure which results in the escape of rotor fragments from the engine or APU [auxiliary power

unit] that could result in a hazard,” according to Federal Aviation Administration (FAA) Advisory Circular

(AC) 20-128A, “Design Considerations for Minimizing Hazards Caused by Uncontained Turbine Engine and

Auxiliary Power Unit Rotor Failure.”

This flight was the first of two planned sequences that day for the flight crewmembers; they were also scheduled

to fly from MIA to ORD. On the day before the accident, the flight crew flew one sequence, from MIA to ORD. The

captain reported that he and the first officer had flown together several times before that flight, most recently at the

beginning of October 2016.

The airplane was equipped with an L-3/Fairchild FA2100-1020 solid-state CVR, which records at least the last

2 hours of digital audio. The CVR records audio information from five channels—the captain’s, first officer’s, and

observer’s audio panels; a mixed crew audio panel; and the cockpit area microphone. Each of the channels contained

either excellent- or good-quality audio information, and a transcript was prepared for the final 2 minutes 42 seconds

of the recording. (See appendix B for the transcript and descriptions of excellent- and good-quality audio.) The

transcript begins at 1430:29, just before the airplane turned onto runway 28R, and ends at 1433:12.

The airplane was also equipped with an L-3/Fairchild FA2100 256 wps FDR. The recorder was in good

condition, and the data were extracted normally from the recorder using the manufacturer’s recommended procedures.

NTSB Aircraft Accident Report

crew described the engine spool-up (as thrust advanced to the predetermined reduced power setting

for takeoff) as “normal.” At 1431:32, the first officer made a routine callout indicating that the

airplane’s airspeed was 80 knots.

FDR data showed that, at 1431:43.4 and with the airplane’s airspeed indicating 128 knots,

the longitudinal acceleration decreased suddenly from 0.23 to 0.13 G, and variations in the vertical

acceleration increased in magnitude, consistent with a sudden engine imbalance causing a

vibration force on the airframe.

About the same time, the CVR recorded a “bang” sound and the

captain’s statement “whoa.” Both flight crewmembers reported hearing the sound and feeling the

airplane drift to the right. At that time, the airplane was about 3,300 ft from the N5 intersection.

The captain initiated the rejected takeoff maneuver; FDR data showed that the throttles were

moved to idle power at 1431:45.

One second later, the autobrakes, which for takeoff had been

selected in the “RTO” (rejected takeoff) position, activated.

At that time, the airplane’s airspeed

was 134 knots, which was also the calculated takeoff decision speed (V

). The auto speedbrakes

activated about 2 seconds after the autobrakes.

In a postaccident statement, the captain indicated

that he rejected the takeoff because he thought that the airplane was “unable/unsafe to fly.”

At 1431:50, the first officer contacted the air traffic control (ATC) tower and stated that

the airplane would be “stopping on the runway,” and the tower controller responded, “roger roger

fire,” which was the flight crew’s first indication that a fire had begun. The first officer asked the

controller if he saw any smoke or fire, and the controller stated, “yeah, fire off the right wing.”

At 1432:00, the CVR recorded the first officer stating, “okay, send out the [fire] trucks,” and a

About 56 hours of operational data were retained on the recording medium, including about 11 minutes of data from

the accident flight, from 1422:15 to 1433:09.

(a) G is a unit of measurement of acceleration and deceleration. One G is equivalent to the acceleration caused

by the earth’s gravity (about 32.2 ft/sec

). (b) FDR data indicated that, between 1431:21 and 1431:37, the airplane

reached a steady longitudinal acceleration of about 0.25 G. Between 1431:37 and 1431:43, the longitudinal

acceleration began to slowly decrease. When the longitudinal acceleration decreased suddenly at 1431:43, the vertical

acceleration also decreased, from 1.14 to 0.97 G. The vertical acceleration before that time had basically been steady—

between 0.98 and 1.02 G.

The CVR recorded a sound similar to throttles contacting idle stops and a sound similar to a decrease in engine

rpm.

Autobrakes are selected in the RTO position during takeoff to provide maximum braking in the event of a

rejected takeoff. During a postaccident interview, the captain described the performance of the RTO autobrake system

as an “aggressive stop.”

During that time, the FDR recorded the flight’s maximum airspeed—135 knots—which decreased by 15 knots

by 1431:49.

American Airlines 767 Operations Manual, QRH (Quick Reference Handbook) indicated that a rejected takeoff

was a “non-normal maneuver.” According to the QRH, “the captain has the sole responsibility for the decision to reject

the takeoff. The decision must be made in time to start the rejected takeoff maneuver by V

. If the decision is to reject

the takeoff, the captain must clearly announce ‘REJECT,’ immediately start the rejected takeoff maneuver, and assume

control of the airplane.” The QRH also stated that a takeoff should be rejected between 80 knots and V

if an engine

failure, fire, or fire warning occurred or if the airplane was unsafe or unable to fly and that “the crew member observing

the non-normal situation will immediately call it out as clearly as possible.”

National Transportation Safety Board (NTSB) investigators sat in the first officer’s seat in an exemplar

American Airlines 767 airplane to determine whether the right wing and right engine could be viewed from that

position. The investigators found that the right wingtip was visible only when the occupant’s head was pressed against

the closed right-side cockpit window. The right engine was not visible with the right-side cockpit window closed. The

right engine was visible with the window opened to allow the occupant to look outside the fuselage.

NTSB Aircraft Accident Report

sound similar to the engine fire warning. FDR data showed that the engine indicating and crew

alerting system (EICAS) warning message “ENG FIRE R” had annunciated at the same time and

that the airplane had decelerated to an airspeed of 35 knots.

The tower controller indicated that

he would send emergency vehicles, and the captain called for the engine fire checklist (which

included five memory items) at 1432:04.1, 20.6 seconds after the CVR recorded the “bang” sound.

FDR data showed that the airplane came to a stop at 1432:09.8, which was 26.4 seconds after the

right engine failure. The captain reported that he could smell smoke “as soon as [the airplane]

came to a stop.”

As part of the engine fire checklist, the fuel switch for the right engine was shut off. Also,

the first officer pulled the right engine fire handle, and he later rotated the handle to release the

contents of one of the fire extinguisher bottles into the right engine.

The left engine remained at

idle power. At 1432:41, the captain stated, “oh look at the smoke—check out the smoke.”

The CVR recording indicated that, at 1432:45, the captain called for the evacuation

checklist; the first officer acknowledged the instruction about 1.5 seconds later. The first officer

announced the items on the evacuation checklist, and the captain accomplished the items. The

second and third steps in the checklist depressurized the airplane, and the captain stated, during a

postaccident interview, that it took “a long time” for the airplane to depressurize.

While

performing the checklist, the captain could hear “commotion” outside the cockpit door and realized

that the flight attendants had begun an evacuation. The captain stated that, after completing the

fourth step in the checklist—to shut down the left engine—he made an announcement to the cabin

to evacuate and activated the emergency evacuation signal switch.

The captain then completed

the remaining steps of the evacuation checklist and exited the cockpit, at which time both flight

crewmembers observed “a lot of smoke” in the cabin.

After exiting the cockpit, the flight crewmembers were met by the lead flight attendant,

who informed them that all passengers and the other flight attendants were off the airplane.

(Section 1.5.2 describes the evacuation.) The first officer then evacuated the airplane, followed by

the lead flight attendant and the captain. After evacuating the airplane, the captain used his personal

cell phone to contact American Airlines dispatch to obtain the total count of occupants on board

Also at 1432:00, the master WARNING light (on the glareshield in front of each pilot) illuminated.

The left and right engine fire handles (for the left and right engines, respectively) were located on the engine

fire control panel, which was located on the center console in the cockpit (as shown in section 1.6.1.1). According to

American Airlines’ 767 Operations Manual, QRH, “Fire Protection,” the airplane was equipped with two fire

extinguisher bottles. One or both bottles, which contained halon, could be discharged into either engine. The FDR

parameter for the right engine fire extinguisher bottle activated at 1432:12. (The FDR records when the fire handle is

pulled for the first time; the FDR does not record when each fire extinguisher bottle discharges.) Postaccident

examination of the fire extinguisher bottles showed that, according to the data in their labels, each weighed about 24

pounds at the time of installation. The weight of both bottles after removal from the airplane was about 10.5 pounds.

According to the CVR, the first officer announced the checklist item to depressurize the airplane at 1432:57.

(This issue is further discussed in section 2.2.1.) The first officer announced the next evacuation checklist item—to

cut off the fuel control switches—at 1433:07.

At 1433:10, the CVR recorded the first officer prompting the captain (as part of the evacuation checklist) to

make a public address (PA) system announcement to evacuate the passenger cabin; this transmission was interrupted

by the sound of a “thunk” 1 second later. The evacuation signal switch was on the emergency evacuation command

panel, which was located on the overhead panel above the captain’s head. The signal was intended to alert the flight

attendants to evacuate the cabin.

NTSB Aircraft Accident Report

for first responders. The 20 injured passengers were transported to local hospitals to receive

treatment, and all were released within 24 hours.

The fire was extinguished by aircraft rescue and firefighting (ARFF) vehicles. According

to ARFF, aqueous film-forming foam was first applied within 2 minutes 51 seconds after

notification of the fire.

Most of the fire damage was contained to the right engine, the right wing,

portions of the right fuselage, and the right horizontal stabilizer. Figure 1 shows the accident

airplane after the fire was extinguished.

Figure 1. Right side of airplane after uncontained engine failure and subsequent fire.

The airplane’s final position on runway 28R was about 5,975 ft from the N5 intersection

(where the takeoff roll began) with about 3,775 ft of runway remaining. Braking marks from the

left and right main landing gear tires were observed on the runway surface starting about 3,961 ft

from the N5 intersection. The braking marks continued for about 2,284 ft to the airplane’s final

position on the runway.

1.2 Personnel Information

1.2.1 The Captain

The captain, age 61, held an airline transport pilot certificate with a multiengine land rating

and an FAA first-class medical certificate dated May 4, 2016, with no limitations. The captain

received a type rating for the Boeing 757 and 767 on March 31, 1995.

The captain was employed at Trans World Airlines (TWA) from January 1986 to

April 2001 and has been employed by American Airlines since May 2001 (when AMR

Corporation, the parent company of American Airlines, acquired TWA). He had been a captain on

The flight attendant who received a minor injury was not transported to the hospital but instead went to the

ORD medical office.

According to the Bureau of Operations, Chicago Fire Department, 21 vehicles (including 8 ARFF units) and

56 personnel responded to the crash/fire alert on runway 28R.

NTSB Aircraft Accident Report

the 767 for about 2.5 years before the accident.

The captain estimated that he had accumulated

about 17,400 hours of total flight time, including about 4,000 hours on the 767 and about

1,500 hours as 767 pilot-in-command. He had flown about 157, 59, 12, and 3 hours in the 90, 30,

and 7 days and 24 hours, respectively, before the accident. The captain’s last line check occurred

on October 21, 2015, and his last recurrent ground training occurred on March 20, 2016. FAA

records indicated no accident or incident history or enforcement action.

The captain stated that he had never experienced an engine fire or performed a rejected

takeoff during his career (except during simulator training). He also stated that he had never

performed the evacuation checklist or commanded an evacuation on an actual flight.

72-Hour History

According to postaccident interviews and company records, on October 25, 2016, the

captain’s duty day started at 1400 eastern daylight time (EDT).

He departed from BOS at 1502

EDT and arrived at Philadelphia International Airport, Philadelphia, Pennsylvania, at 1703 EDT

and then deadheaded to Charlotte-Douglas International Airport (CLT), Charlotte, North Carolina,

arriving at 2043 EDT. Afterward, he flew from CLT to JFK, arriving at 2338 EDT. He went to

sleep about 0100 EDT on October 26.

The captain did not recall his wakeup time on October 26, but he thought that he received

7 to 8 hours of sleep during the night. He left the hotel between 1400 and 1430 EDT and began his

duty day at 1440 EDT. He flew from JFK to MIA, arriving at 1829 EDT. He described his duty

day as “easy.” He spent the night at his residence near MIA. He did not recall the time that he went

to sleep.

On October 27, the captain awoke about 0900 EDT and began his duty day at 1550 EDT.

He and the first officer departed MIA at 1706 EDT, arriving in ORD at 1943. The captain arrived

at the hotel before 2000, got something to eat, and then used his computer until about 0000 on

October 28 before going to sleep. The captain awoke between 0800 and 0900. He departed the

hotel about 1235 for ORD, where his duty day began at 1320.

The captain reported no problems falling or staying asleep in the days before the accident.

He woke up each day feeling rested, including on the morning of the accident. His normal sleep

pattern when off duty was to go to sleep between 2300 and 0000 and wake up about 0700. He did

not take any prescription or nonprescription medicine in the 72 hours before the accident that might

have affected his performance on the day of the accident. He did not use tobacco products or illicit

drugs, and his only alcohol consumption during the time period was during dinner on October

Company records indicated that the captain upgraded to that position on the 767 on January 7, 2014. Before

that time, he was an MD-80 captain; he received a type rating for the DC-9 (a variant of which is the MD-80) on

July 13, 1998.

The captain flew a 3-day trip from October 24 to 26. On October 24, his duty day started at 1726 EDT. He flew

from MIA to John F. Kennedy International Airport (JFK), Jamaica, New York, arriving at 2021, and then he

deadheaded (traveled as a nonrevenue passenger) to General Edward Lawrence Logan International Airport (BOS),

Boston, Massachusetts, arriving at 2346 EDT. He arrived at a hotel and went to sleep between about 0100 and 0130

EDT on October 25. The captain awoke between 0900 and 1000 EDT that day and left the hotel about 1330 EDT to

begin his duty day.

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27.

He considered his health to be “pretty good” and had no changes in his health, finances, or

personal life in the 12 months before the accident that would have affected his performance on the

day of the accident.

1.2.2 The First Officer

The first officer, age 57, held an airline transport pilot certificate with a multiengine land

rating and an FAA first-class medical certificate dated May 3, 2016, with a limitation that required

him to possess glasses for near and intermediate vision. (During a postaccident interview, the first

officer stated that he was wearing his glasses during the attempted takeoff.) The first officer

received a type rating for the Boeing 757 and 767 on June 14, 2014.

The first officer was employed at TWA between December 1995 and April 2001 and then

American Airlines beginning in May 2001 (when AMR Corporation acquired TWA). He was

furloughed in July 2003, recalled from furlough in March 2008, furloughed again in February

2010, and recalled from furlough again in December 2010.

The first officer estimated that he had

accumulated about 22,000 hours of total flight time, including about 1,600 hours on the 767. He

had flown about 116, 78, 13, and 3 hours in the 90, 30, and 7 days and 24 hours, respectively,

before the accident. The first officer’s last line check occurred on February 15, 2015, and his last

recurrent ground training occurred on September 5, 2016. FAA records indicated no accident or

incident history or enforcement action.

72-Hour History

According to postaccident interviews and company records, the first officer was off duty

from October 24 to 26, 2016.

The first officer could not recall his sleep/wake times for the 3 days

before the accident flight. On October 27, he commuted from his home in Tampa, Florida, to MIA

and started his duty day at 1550 EDT. He flew from MIA to ORD with the captain, arriving at

1943. He recalled going to sleep shortly after arriving at the hotel and not having any trouble falling

or staying asleep. He reported feeling rested when he awoke on October 28. His duty day began at

1320.

The first officer stated that he usually slept about 7 hours each night and that he normally

went to sleep early and woke up early. He did not take any prescription or nonprescription

medication in the 72 hours before the accident that might have affected his performance on the

day of the accident. He did not use tobacco products or illicit drugs and did not consume alcohol

during the time period.

He considered his health to be a “10 out of 10.” He had no changes in his

health, finances, or personal life in the 12 months before the accident that would have affected his

performance the day of the accident.

The results of postaccident drug and alcohol screening for the captain were negative.

During the first officer’s first furlough from American Airlines, he worked at Atlantic Southeast Airlines as a

first officer and then a captain on the Bombardier CL-65.

The first officer was on duty from October 20 to 23.

The results of postaccident drug and alcohol screening for the first officer were negative.

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1.2.3 The Flight Attendants

The flight was operated with seven flight attendants. Table 1 shows each flight attendant’s

position, initial new hire date, and last recurrent training date before the accident. Section 1.5

provides information about the flight attendants’ seating positions within the cabin and their

actions before and during the evacuation.

Table 1. Flight attendant position, initial new hire date, and last recurrent training date.

Flight attendant (FA) position Initial new hire date Last recurrent training date

FA 1—Lead

April 1988

April 2016

FA 2

November 1998

November 2015

FA 3

November 2014

November 2015

FA 4

July 1991

March 2016

FA 5

October 1989

July 2016

FA 6

April 1984

April 2016

FA 7

November 1989

October 2016

The lead flight attendant was the primary liaison between the captain and the flight

attendants. According to American Airlines Flight Manual Part I, “Flight Attendant/Purser

Briefing,” dated October 1, 2016, the lead flight attendant is responsible for promptly informing

the captain of “all on-board cabin emergencies, irregular issues, passenger concerns, and cabin

discrepancies.”

1.3 Airplane and Engine Information

Boeing delivered the airplane involved in this accident, serial number 33084, to American

Airlines on April 30, 2003; American Airlines records showed that the airplane was registered as

N345AN on the same date. At the time of the accident, the airplane had 50,632 total flight hours

and 8,120 total flight cycles.

The airplane was equipped with two General Electric (GE)

CF6-80C2B6 turbofan engines, with one engine mounted under each wing. The No. 1 (left) engine

had accumulated 46,822 total hours and 7,299 total cycles, and the No. 2 (right) engine had

accumulated 68,785 total hours and 10,984 total cycles.

The CF6-80C2B6 is a dual-rotor, high-bypass ratio turbofan engine. The low-speed rotor

(N1) consists of a large diameter fan and four low-pressure compressor booster stages that are

interconnected to a five-stage low-pressure turbine rotor. The high-speed rotor (N2), which is

located between the fan rotor/booster and the low-pressure turbine rotor, consists of a 14-stage

high-pressure compressor and a 2-stage HPT. The HPT rotor drives the high-pressure compressor

rotor by converting the combustor exhaust gas flow into mechanical force. The HPT stage 1 disk

has 80 blades, the HPT stage 2 disk has 74 blades, and each blade has its own retaining post.

Figure 2 shows an HPT rotor for a CF6-80C2B6 engine.

A flight cycle is one complete takeoff and landing sequence.

For more information about the CF6-80C2B6 engine, see the Powerplants factual report in the docket for this

accident investigation, DCA17FA021, at the NTSB’s website

(www.ntsb.gov).

NTSB Aircraft Accident Report

Source: American Airlines.

Figure 2. HPT rotor.

1.3.1 High-Pressure Turbine Stage 2 Disk Manufacturing Process

The HPT stage 2 disk installed on the right engine was made of alloy 718 (a wrought

nickel-based alloy). The material used to manufacture the disk for GE was produced by TDY

Industries LLC doing business as ATI Specialty Materials (ATI SM) in 1997 at the company’s

Monroe, North Carolina, facility. ATI SM used a triple-melt process to produce an ingot (a mass

of metal cast into a specific size or shape) per GE specifications.

Afterward, ATI SM converted

GE first used alloy 718 in the 1970s, and the material underwent a double-melt process at that time. In the early

1980s, GE started using a triple-melt process for some part applications manufactured with alloy 718. In the

mid-1990s, GE began using the triple-melt process for all of its critical life-limited rotating parts manufactured with

alloy 718.

NTSB Aircraft Accident Report

ingots to billets (larger diameter bars) using thermal and mechanical processes and inspected the

billets for internal defects using an ultrasonic inspection procedure.

1.3.1.1 Triple-Melt Process

ATI SM’s triple-melt process consisted of vacuum induction melting, electroslag

remelting, and vacuum arc remelting, as described below. After completion of the triple-melt

process, an ingot undergoes a billet conversion process, which is also described below.

Vacuum Induction Melting

The first step of the triple-melt process, vacuum induction melting, is also referred to as

the master heat. Vacuum induction melting uses an induction furnace in a vacuum chamber to

(1) combine raw material to establish the desired chemistry and (2) refine the material by removing

impurities. Melting the raw material in a vacuum reduces the oxygen and nitrogen content, thus

inhibiting the formation of oxides and nitrides, which are detrimental to the mechanical properties

of the alloy. After the material is completely melted and agitated, in-process samples are taken

until the desired chemistry has been achieved. The molten material is then poured into a series of

vertical molds, creating a series of ingots that function individually as an electrode for the next

step in the triple-melt process.

Electroslag Remelting

The second step of the triple-melt process, electroslag remelting, establishes the cleanliness

of the material. This step involves (1) continuously melting an ingot (which functions as an

electrode) through a molten bath of electrically conductive and chemically reactive slag and

(2) collecting the purified material in a water-cooled mold. A stub, referred to as a stinger, is

welded to the ingot to provide a current path to complete the electrical circuit and structurally

support the ingot.

As the ingot melts, droplets are created that descend through the superheated slag layer,

and impurities dissolve or bind with the reactive elements within the slag layer and float toward

the top. When the droplets reach the bottom of the water-cooled mold, they solidify, creating a

new ingot that builds up from the bottom of the mold and moves the slag layer up the side of the

mold.

A slag skin layer also builds up between the new ingot and the water-cooled mold, which

helps reduce the formation of oxides. The skin layer limits the rate at which heat can be removed

from the newly formed ingot, which negatively affects the macrostructure of the material. As a

result, before the ingot undergoes the next step in the triple-melt process, the top and bottom of

the ingot are removed to reduce the possibility of contamination, and any scale on the outside of

the ingot (the slag skin layer in this case) is also removed.

Material defects are most likely to form in the top and bottom of the ingot because the temperature is the least

stable in these areas during the melting and subsequent cooling/solidification of the ingot.

NTSB Aircraft Accident Report

Vacuum Arc Remelting

Although the final step in the triple-melt process, vacuum arc remelting, further refines the

cleanliness of an ingot, the main purpose of this process is to establish the desired macrostructure

for the ingot material. Similar to electroslag remelting, vacuum arc remelting involves

continuously melting an original ingot (which functions as an electrode), collecting the molten

material in a water-cooled mold, and forming a new ingot. Unlike electroslag remelting, vacuum

arc remelting is a direct current process conducted under a vacuum and does not use a molten slag

layer.

The original ingot is lowered into the mold until an arc is struck between the electrode and

the bottom of the mold. The high-temperature arcing melts the original ingot. As molten droplets

fall through a gap, dissolved gases are removed, and unwanted contaminants are vaporized. The

molten droplets collect at the bottom of the mold, where they resolidify and form the new ingot,

as shown in figure 3.

The position of the original ingot is controlled to keep the melt rate constant

as the new ingot builds up from the bottom of the mold. Similar to electroslag remelting, after the

vacuum arc remelting process is completed, the top and bottom of the ingot are removed, and any

scale on the outside of the ingot is also removed.

Figures showing the vacuum induction melting and the electroslag remelting processes appear in the

Powerplants factual report in the docket for this accident investigation, DCA17FA021

NTSB Aircraft Accident Report

Source: ATI SM.

Figure 3. Vacuum arc remelting process.

Billet Conversion Process

The billet conversion process replaces the original non-uniform coarse grain structure of

an ingot with a new recrystallized (finer) grain structure. During this process, the ingot is subjected

to a series of heat treatments and axial, transverse, and radial forging operations until the material

has reached the desired size, shape, and microstructure. At the end of this process, the material

becomes a billet.

1.3.1.2 Ultrasonic Inspection Process

After completion of the conversion process, a billet is prepared for ultrasonic inspection,

which is a nondestructive inspection method for detecting surface and subsurface anomalies and

NTSB Aircraft Accident Report

determining the position, shape, and possibly the size of those anomalies. ATI SM uses a

longitudinal wave water immersion, pulse-echo ultrasonic inspection technique in which the billet

is submerged in a water tank and rotated while two transducers move longitudinally along the

length of the billet. The rotation of the billet ensures that its entire diameter is inspected by the

combination of the two transducers. The technique involves a pulsed sound wave from a transducer

that propagates through the material and reflects off any discontinuity, such as a void (an internal

cavity), crack, or variation in material density, providing an echo back to the transducer.

The location of a discontinuity can be determined by comparing the amount of time for the

echo to return to the transducer with the normal reflective wave from a known discontinuity.

Although the size of a discontinuity can be determined by the strength (amplitude) of the echo

return, this information must also be correlated with a known defect size. The advantage of this

technique is the ease of moving the transducer along the material while both remain acoustically

coupled.

Figure 4 shows a representation of a longitudinal wave scan.

Figure 4. Longitudinal wave scan used during ultrasonic inspections.

Before the ultrasonic inspection, the top and bottom of a billet are cut off because these

areas are where defects are most likely to have formed. Additional cuts at the top and bottom of

the billet are made for visual macroscopic inspection. The final steps before the ultrasonic

inspection are a machining operation termed “peeling” and polishing to enhance the effectiveness

of the inspection. ATI SM uses the requirements of GE specification P3TF15, titled “Ultrasonic

Inspection of Billet – Immersion,” class C and class E, for the billets.

As part of the inspection

process, any identified defects are cut out of the billet material for evaluation, and an ultrasonic

The immersion transducer uses the water to facilitate the transmission of acoustic waves from the transducer

to the material to be inspected. The transducer cables are electrically sealed and waterproof.

GE specification P3TF15 called for the surface finish for the polishing step to be 125 microinches or better,

which “will normally ensure inspectability.” A microinch (µin) is equal to one-millionth of an inch. Class C refers to

alloy 718 (fine grain), and class E refers to general applications (high sensitivity).

NTSB Aircraft Accident Report

billet map sheet is created for each billet to provide the location of any defects that were cut out of

the material.

1.3.1.3 Manufacture History of Accident HPT Stage 2 Disk

According to ATI SM production records related to the accident HPT stage 2 disk, the

triple-melt process produced five ingots, designated as FA94-1 through -5, from the master heat,

and the ingot designated as FA94-2 was the one from which the HPT stage 2 disk was

manufactured. ATI SM stated that the furnaces that were used to produce these ingots were still in

use at the company’s facility (as of November 2017). Ingot FA94-2, which became billet FA94-2,

was forged into a 10-inch-diameter round. The ultrasonic inspection technique that ATI SM used

for billet FA94-2 was the same as that in use as of November 2017, and the equipment that was

used for inspecting the billet was the same design as the equipment in use as of November 2017.

Review of the ultrasonic billet map sheet for FA94-2 showed no defects or rejections in the billet

material.

Two companies, in addition to ATI SM, were involved in manufacturing the HPT stage 2

disk that was delivered to GE: Wyman-Gordon of Houston, Texas, and Motoren- und

Turbinen-Union GmbH (MTU) of Germany. Once billet FA94-2 was deemed acceptable (that is,

it passed all required inspections), ATI SM cut the billet to the lengths specified by

Wyman-Gordon. Review of the ATI SM certification test sheet (used to certify billets) for FA94-2,

dated June 17, 1997, indicated that (1) the metallography, microstructure, and grain size were

acceptable per specifications; (2) an ultrasonic inspection was performed with no defects found;

and (3) macroscopic inspection results were acceptable.

ATI SM sent the billet to Wyman-Gordon, which further cut the billet into nine pieces,

with each piece representing the precise length of material needed to manufacture the intended

part. These pieces were press forged, heat treated, and rough machined. Wyman-Gordon certified

the forging on August 8, 1997, and sent the forged pieces to MTU for additional inspections and

final machining.

MTU performed ultrasonic inspections (with the pulse-echo technique, similar to ATI SM)

on “sonic-shape” forged pieces using its own work instructions, which GE approved.

MTU’s

work instructions met GE specification P3TF1, titled “Ultrasonic Inspection,” class A longitudinal

The transducers for the ultrasonic equipment need to be replaced periodically to prevent calibration issues

resulting from deterioration.

For FA94-1, the ultrasonic billet map showed a “macro-rejectable” defect in the bottom of the billet, so

additional material was removed. For FA94-3, the ultrasonic billet map showed a “sonic-rejectable” indication in the

top of the billet, so material containing the indication was removed, and the defect was located and identified. For

FA94-4, the ultrasonic billet map showed a sonic-rejectable indication in the top of the billet, so material containing

the indication was removed, but the indication could not be identified after the material was removed. For FA94-5,

the ultrasonic billet map showed a macro-rejectable indication in the bottom of the billet, so additional material was

removed.

MTU performed pre-machining and cleaning operations before the ultrasonic inspection; those operations

produced the forging shape configurations (referred to as sonic-shape pieces) for the inspection.

NTSB Aircraft Accident Report

and circumferential shear ultrasonic requirements.

Afterward, additional machining,

shot peening, a final visual and dimensional inspection, and a high-sensitivity fluorescent

penetrant inspection (FPI), per a GE specification, were performed. Review of the MTU final

inspection sheet for the HPT stage 2 disk, dated February 3, 1998, indicated that the completed

disk was acceptable. In March 1998, MTU sent the HPT stage 2 disk to GE, which installed the

disk in the CF6-80C2B6 turbofan engine that was eventually installed on the right side of the

accident airplane. The engine serial number (ESN) for the right engine was ESN 690-373.

1.3.2 Accident Engine Maintenance Events

On April 30, 1998, Boeing delivered a 767 airplane to American Airlines with

ESN 690-373 (including the HPT stage 2 disk involved in this event) installed; that airplane was

registered as N392AN. On March 25, 2007, American Airlines removed ESN 690-373 from

N392AN and sent it to the company’s Tulsa, Oklahoma, engine maintenance facility to, among

other things, accomplish the mandatory inspection requirements of FAA Airworthiness Directive

(AD) 2002-07-12, which were to be performed on the HPT stage 2 disk at “each piece-part

opportunity.”

To satisfy the AD’s HPT stage 2 disk inspection requirements, maintenance

personnel performed FPIs and eddy current inspections (ECI) of the HPT stage 2 rim bolt holes

and the disk bore. Initial FPI results revealed that the bolt holes needed repairs, which were made;

follow-up FPI results revealed no other disk anomalies. Maintenance personnel reinstalled the HPT

stage 2 disk into the same engine and, on September 16, 2007, installed ESN 690-373 in company

767 airplane N386AA.

On January 15, 2011, American Airlines removed ESN 690-373 from N386AA and sent it

to the company’s Tulsa maintenance facility for scheduled heavy maintenance. Among other

things, maintenance personnel removed the HPT stage 2 disk from the engine and performed all

mandatory inspections as well as visual and dimensional inspections. Among the mandatory

inspections performed were those required by AD 2009-04-10, which superseded

A 2002-07-12.

Regarding the CF6-80C2 HPT stage 2 disks, AD 2009-04-10 had the same ECI

and FPI requirements as those mandated by AD 2002-07-12, and maintenance personnel

documented no anomalies when performing those inspections. Maintenance personnel reinstalled

the HPT stage 2 disk into the same engine and, on May 12, 2011, installed ESN 690-373 in the

right engine position of the accident airplane (N345AN).

GE specification P3TF1 called for a surface finish of 90 microinches for longitudinal wave and circumferential

shear wave, which “will usually provide ultrasonic inspection with acceptable surface noise effects.” Class A refers

to immersion ultrasonic inspection.

FAA AD 2002-07-12, “General Electric Company CF6-80A, CF6-80C2, and CF6-80E1 Series Turbofan

Engines” (67 Federal Register 17279, April 10, 2002), effective May 15, 2002, stated the following: “within the next

30 days after the effective date of this AD, revise the manufacturer’s Life Limits Section of the Instructions for

Continued Airworthiness…and for air carrier operations revise the approved continuous airworthiness maintenance

program” by adding the mandatory inspections detailed in the AD for life-limited rotating engine parts. According to

the AD, “piece-part opportunity” meant that “the part has accumulated more than 100 cycles-in-service since the last

piece-part opportunity inspection, provided that the part was not damaged or related to the cause for its removal from

the engine” (FAA 2002).

FAA AD 2009-04-10, “General Electric Company CF6-80A, CF6-80C2, and CF6-80E1 Series Turbofan

Engines” (74 Federal Register 7995, February 23, 2009), effective March 30, 2009, incorporated additional inspection

requirements (FAA 2009).

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On November 11, 2013, American Airlines removed ESN 690-373 from the airplane for

reliability improvement program tasks while at the company’s Tulsa maintenance facility.

Maintenance personnel did not disassemble the HPT rotor and thus did not inspect the HPT stage 2

disk. On December 4, 2013, maintenance personnel reinstalled ESN 690-373 in the right engine

position of the accident airplane, where it remained through the time of the accident.

As previously stated, the right engine had accumulated 10,984 total cycles since new. The

HPT stage 2 disk has a life limit of 15,000 cycles when installed on the CF6-80C2B6 engine. Thus,

at the time of the accident, the HPT stage 2 disk had 4,016 cycles of in-service life remaining.

Also, since the time of the right engine’s shop visit in January 2011 (the last time before the

accident that the HPT stage 2 disk was removed from the engine and inspected), the engine had

accumulated 19,139 hours and 3,057 cycles.

1.3.3 Postaccident Engine Observations

The HPT stage 2 disk of ESN 690-373 (right engine) was recovered on scene in four

fragments, as shown in figure 5. About 96% of the disk, including the entire disk bore, was

recovered.

As mentioned in section 1.1, one disk fragment (labeled “A” in figure 5), which

weighed about 56.6 pounds, was recovered on the airport property in a UPS warehouse located

about 2,935 ft south of the airplane’s position on the runway where the uncontained engine failure

occurred.

After the accident, 71 of the 74 blade retaining posts in the HPT stage 2 disk were recovered. In addition,

smaller pieces of engine debris were recovered at or near the location on the runway where the uncontained engine

failure occurred.

The disk fragment penetrated the roof of the UPS warehouse and was found on the floor.

NTSB Aircraft Accident Report

Figure 5. Main fragments of the HPT stage 2 disk (forward side).

The other three disk fragments (labeled “B,” “C,” and “D” in figure 5) were recovered on

the airport property north of runway 28R. These three disk fragments were located 475 ft

(fragment D), 1,365 ft (fragment B), and 1,500 ft (fragment C) from the airplane’s location on the

runway where the uncontained engine failure occurred. Specifically, fragment B, which weighed

about 83.1 pounds, was recovered in the grassy area near a taxiway; fragment C, which weighed

about 6.6 pounds, was recovered on another taxiway; and fragment D, which weighed about

0.2 pound, was recovered on the overrun area at the departure end of runway 15.

Figure 6 shows

the disk fragment locations overlaid on a map of the airport.

According to GE, without blades or thermal shield attachment bolts, the HPT stage 2 disk weighs about

153 pounds. The disk fragment weights in this section reflect the weight with blade shanks and attachment bolts

removed when possible.

NTSB Aircraft Accident Report

Figure 6. Disk fragment locations.

On-scene examination of the right wing (inboard of the right engine pylon) revealed two

distinct penetration holes.

One hole (referred to as hole 1) was located forward of the front spar

in the leading-edge panel; the other hole (referred to as hole 2) was located aft of the wing front

spar. Figure 7 shows holes 1 and 2.

Figure 7. Holes located forward and aft of the right wing front spar.

All right wing impact damage from exiting HPT stage 2 disk or engine debris was observed inboard of the right

engine pylon.

NTSB Aircraft Accident Report

The on-scene examination also revealed the following:

• fragments of the ruptured HPT stage 2 disk, along with blade and vane fragments,

penetrated through the HPT case and right engine nacelle structure;

• small engine hardware fragments impacted the right side of the fuselage and the left and

right main landing gear doors;

• small engine hardware fragments penetrated the left engine nacelle, with no engine damage

observed;

• a disk fragment, along with smaller engine hardware fragments, impacted the right engine,

right wing, and portions of the right fuselage, severing the main engine fuel feed line and

breaching the right-wing fuel tank, which led to a fuel-fed fire; and

• another disk fragment, along with smaller engine hardware fragments, created multiple

impact scars on runway 28R.

1.3.4 Metallurgical Examinations

The NTSB’s Materials Laboratory in Washington, DC, examined the three largest HPT

stage 2 disk fragments (A, B, and C; see figure 5). Visual examination found a discolored

(heat-tinted) region on the fracture surfaces separating fragments A and B.

The discolored region

was at the forward end of the disk bore region, as indicated in figures 8 and 9, and this region was

identified as the location where the fracture originated.

The main impact scar was a gouge that was consistent with the impact from exiting HPT stage 2 disk fragments.

The gouge was oriented about 30° forward of the direction of airplane travel (relative to the HPT stage 2 plane of

rotation) and in the general direction where three separate fragments of the HPT stage 2 disk were located (north of

runway 28R). The gouge measured about 33 inches long, 8 inches wide, and 2 inches deep and was located about 32

ft to the right of the runway 28R centerline.

The fracture surfaces comprised right and left sides. The right sides were on disk fragment A, and the left sides

were on disk fragment B.

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Figure 8. Engine cross-section and fracture origin location.

Figure 9. Fracture surface from disk fragment A.

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Metallurgical examination of the fracture surfaces revealed multiple subsurface

microstructural discontinuities with multiple cracks initiating along the boundary of the

discontinuities. The discontinuities, which had a dark gray appearance, were elongated in the

direction of, and aligned with, the grain structure pattern produced during forging. The

discontinuities spanned a total length of about 0.78 inch, with the largest of the discontinuities

measuring about 0.43-inch-long by 0.07-inch-wide and having an inclination of about 26º from

the bore centerline.

Multiple cracks had initiated along the upper and lower edges of the discontinuities and

progressed toward the disk rim and disk bore. Scanning electron microscope (SEM) images of the

fracture surface revealed relatively coarse striations at regularly spaced intervals, consistent with

crack growth by low-cycle fatigue, followed by a transition to cyclic tensile crack growth and then

tensile overstress.

The net size of the cracked region immediately before the disk fracture (given

the size of the discolored region) ranged from about 0.47 to 0.93 inch in the radial direction and

about 0.96 inch to 1.13 inches in the axial direction and encompassed an area of about

0.82 square inch.

SEM examination of the discontinuities on the fracture surface showed that the

discontinuities were regions of discrete micron-sized oxide particles, referred to as stringers,

embedded in a material consistent with alloy 718. A polished and acid-etched metallurgical

cross-section through the largest of these features showed that these oxide stringers surrounded

and were interspersed in a discrete underlying region where the alloy 718 grain size was coarser

than the surrounding material. The coarse grain region beneath the discontinuity exhibited a white-

etched appearance compared with the surrounding fine grain material due to the acid etch. The

stringers and coarse grain region collectively formed a subsurface anomaly referred to as a

“discrete dirty white spot” that measured about 0.15 by 0.10 inch.

Figure 10 shows the discrete

dirty white spot, and figure 11 shows a close-up view of one of the stringers.

Striations are linear features on a fatigue fracture surface that indicate how far a crack advanced with each

stress cycle. The NTSB selected three of six cracks for striation density measurements to estimate the number of low-

cycle fatigue crack growth cycles before the disk ruptured. In airplane engines, low-cycle fatigue is associated with

one striation per flight cycle. For information about the NTSB’s work in this area, see section 1.4.1.

If stringers are present, a white spot is “dirty”; if stringers are absent, a white spot is “clean.” Section 1.7.1

provides information about white spot formation as it related to the manufacturing process for the HPT stage 2 disk.

NTSB Aircraft Accident Report

Figure 10. Discrete dirty white spot in fracture surface.

Figure 11. Stringer in material microstructure.

Crack

Stringers

Discrete dirty

white spot

Fracture surface/stringer

Fracture

Radially

Figure 11

NTSB Aircraft Accident Report

GE Aviation’s Materials Laboratory in Evendale, Ohio, performed additional metallurgical

examinations on the disk segments and produced a report detailing its findings (Morales 2017).

This work included additional striation density measurements (discussed in section 1.4.1),

hardness measurements, microprobe chemical analysis of the discrete dirty white spot, additional

cross-section metallography, and bulk alloy chemistry. The report stated that the hardness,

chemistry, and grain size of the material away from the discrete dirty white spot was within the

blueprint requirements for the disk and that GE’s cross-sections through the discrete dirty white

spot found stringers with no voids.

GE and ATI SM conducted a study of discrete dirty white spots “to better understand their

ultrasonic response characteristics.” The report detailing the study results is discussed in

section 1.4.2.

1.4 Tests and Research

1.4.1 Number of Flight Cycles in Low-Cycle Fatigue Regions

As previously stated, the NTSB documented the presence of multiple fatigue cracks that

initiated at a discrete dirty white spot in the forward bore region of the HPT stage 2 disk. The

NTSB and GE estimated flight cycles for a total of six cracks, numbered 1 through 6, as shown in

figure 12. The cracks exhibited striated features consistent with low-cycle fatigue.

Figure 12. Fatigue cracks that initiated from discrete dirty white spot.

The NTSB selected cracks 1, 2, and 6 for a study to estimate the number of flight cycles in

each low-cycle fatigue region. (The NTSB focused on these cracks for the study because they did

not emerge from the surface.) SEM images were taken for each of the cracks (along the path of

crack progression up to the transition to cyclic tensile crack growth), and striation densities were

measured on those images to estimate the number of cycles from crack initiation to the HPT stage 2

disk failure. The study assumed that one striation correlated with one flight cycle and that the

NTSB Aircraft Accident Report

forces during takeoff, when the stresses on the HPT stage 2 disk would be at their highest, caused

the crack to progress. The study results showed that cracks 1, 2, and 6 progressed by low-cycle

fatigue for about 5,700, 5,600, and 3,700 cycles, respectively.

GE made striation density measurements for all six cracks, which showed that the greatest

striation count, assuming one striation per mission/flight cycle, was about 7,000 cycles before the

disk ruptured in tensile overload. This striation density measurement estimate was for crack 6,

which progressed outward and did not reach the bore of the disk. GE’s estimates for cracks 1 and 2

were 6,000 and 5,900 low-cycle fatigue crack growth cycles, respectively. (The NTSB notes that

striation density measurements can be affected by subjectivity in measuring the striation densities

and interpreting the results.) GE’s striation density measurement estimates for cracks 3, 4, and 5

indicated that the cracks progressed by low-cycle fatigue for 1,400, 1,200, and 3,200 cycles,

respectively.

1.4.2 Ultrasonic Response Characteristics of Discrete Dirty White Spots

As stated in section 1.3.4, GE and ATI SM conducted a study of discrete dirty white spots

to better understand their ultrasonic response characteristics. GE provided the NTSB with a report

on the results of the study.

ATI SM selected and characterized six discrete dirty white spots found by ultrasonic

inspection of alloy 718 billets during the 2.5 years before the study was completed (in April 2017).

According to GE’s report, the sample represented “a typical range of sizes, shapes, stringer

distribution, and radial position observed historically.” GE performed further characterization of

the six discrete dirty white spots, including metallographic examination. Voids/cracks were found

in five of the six discrete dirty white spots; findings for one discrete dirty white spot were

inconclusive.

The report concluded that voids/cracks in discrete dirty white spots might provide a

reflection surface that is conducive to ultrasonic detection (GE 2017). Specifically, the report

compared one of the sample discrete dirty white spots with the discrete dirty white spot found on

the HPT stage 2 disk from the accident airplane. The sample discrete dirty white spot had multiple

voids along a stringer, which made detection via ultrasonic inspection likely. The discrete dirty

white spot on the HPT stage 2 disk from the accident airplane showed no voids, and, as previously

stated, ultrasonic detection performed during manufacturing of the billet did not detect any

anomalies.

NTSB Aircraft Accident Report

1.5 Survival Aspects

The airplane was configured with 2 flight crew seats (and a cockpit jumpseat, which was

unoccupied during the accident flight), 10 flight attendant jumpseats (3 of which were

unoccupied), and 206 passenger seats.

The airplane had four door exits and four overwing exits.

Figure 13 shows the airplane configuration and the seating positions within the cabin for the seven

flight attendants.

Figure 13. N345AN configuration.

1.5.1 Interphone Communication System

The airplane’s interphone communication system comprised a flight crew interphone and

five flight attendant interphones, which enabled voice communications to and from the flight deck

and five flight attendant locations (1L, 1RC, 2R, 4L, and 4R jumpseats). The interphones were

also used to make PA announcements and enable communication between flight attendant

locations.

American Airlines 767-300-series airplanes have two different interphone models: the

“classic” model, shown in figure 14a, which was installed on 767C-300ER airplanes delivered

before January 2003, and the “new” model, shown in figure 14b, which is installed on

767N-300ER airplanes delivered beginning in January 2003. The accident airplane, delivered in

April 2003, had the new model interphone system installed.

The three unoccupied jumpseats were at the 1LC (left center), 4LC, and 4RC (right center) positions.

NTSB Aircraft Accident Report

Figure 14a. Classic model interphone.

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Figure 14b. New model interphone.

The classic model interphone has a key pad with four keys (buttons) to call locations within

the airplane. The new model interphone has a key pad that resembles a standard telephone key

pad. On the back of the new model interphone is a list of 10 communication options for making

calls to various locations within the airplane. According to American Airlines flight attendant

interphone procedures, although the classic and new model interphones both required flight

attendants to activate the interphone buttons slowly and pause between each high/low chime to

NTSB Aircraft Accident Report

allow the chiming cycle to complete, the procedures for placing routine and emergency calls

between the cockpit and the cabin differed between the models.

Section 1.5.2 describes the experience of three flight attendants with the interphone during

the emergency. Also, section 1.6.3.2 discusses flight attendant training, including the use of

simulators. The classic model interphone was installed on one of two Boeing 767 simulators used

for flight attendant training. The other 767 simulator had a nonfunctioning mockup of the new

model interphone.

1.5.2 Evacuation

After the airplane came to a stop (1432:10), the flight attendants began evacuating the

airplane. FDR data showed that, at 1432:20 (10 seconds after the airplane came to a stop), the left

overwing exit opened. The forward left (1L) and forward right (1R) cabin doors opened 18 and

22 seconds later, respectively. At 1432:48 (38 seconds after the airplane came to a stop), the aft

left (4L) cabin door opened. The left engine was shut down at 1433:09.

American Airlines provided the NTSB with two videos of the accident airplane that were

taken by witnesses. One video was 2 minutes 28 seconds long, and the other video was 57 seconds

long. Both videos show only the left side of the airplane. Also, the videos do not show the time

that the last passenger evacuated via the left overwing exit slide. From the available information

on those videos, the NTSB determined the timeline of evacuation events shown in table 2.

Table 2. Evacuation events shown on videos of left side of airplane.

Elapsed time (min:sec) Event