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Cases › DCA16FA013 › The analyst

BOEING 767Dynamic International

What the docket says, assembled. No language model is involved, so nothing on this page can be invented — every line traces to a recorder, a report page or the Board's own record.

0
timed facts
8
precedents
17
passages to ask

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passages, not paraphrases
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Every answer is a passage of the docket with the page it came from, or the words “not in the docket”. Nothing is summarised or reasoned for you — read the source.

One timeline

0 timed factsthe recorder events from the FDR report, with the transcript's warnings, callouts, the words nearest each event and the final seconds — on one clock, as printed in each report

No timed facts: this docket has no extracted recorder sequence and no transcript.

Recorder events without a clock time
  • 1233:14Master caution recorded
  • 1233:15Short gap in recording due to left engine shutdown causing power transfer interruption
  • 1233:16Engine 1 recorded a dip to sub-idle power
  • 1233:19Master warning recorded (5 seconds after master caution), aircraft stopped
  • 1233:20Wheel well fire detector recorded a fire alarm
  • 1233:21Fuel cutoff switch recorded in the cutoff position and fuel valve transitioned from open to not open
  • 1233:29Forward equipment bay smoke detector recorded a smoke alarm
Flight Data Recorder - Specialist's Factual Report · 7 events extracted by claude-sonnet-5
How the Board coded the sequence
  1. Taxi-to runway: Fire/smoke (non-impact)

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • ENG12IA0102012-02-08no fatalitiesmatch 56
    BOEING 767 · American Airlines
    Jamaica, NY
    Fire/smoke (non-impact)
  • DCA17FA0212016-10-28substantialmatch 55
    BOEING 767 · AMERICAN AIRLINES INC
    Chicago, IL
    • ●Aircraft › Aircraft systems › Fuel system
    Fire/smoke (non-impact)
  • ENG11IA0162011-02-09no fatalitiesmatch 55
    BOEING 757-2Q8 · DELTA AIR LINES INC
    Minneapolis, MN
    Fire/smoke (non-impact)
  • ENG11IA0352011-06-21no fatalitiesmatch 54
    BOEING 757-232 · DELTA AIR LINES INC
    Atlanta, GA
    Fire/smoke (non-impact)
  • ENG08IA0222008-04-20no fatalitiesmatch 52
    BOEING 747 · KALITTA AIR LLC
    Newark, NJ
    • ●Aircraft › Aircraft systems › Fuel system
    Fire/smoke (non-impact)
  • ENG10IA0102010-01-12no fatalitiesmatch 51
    ATR ATR72 · American Airlines
    St. Croix, USA
    Fire/smoke (non-impact)
  • ANC11CA1012011-09-10no fatalitiesmatch 50
    DOUGLAS DC-8-62F · Air Transport International LLC
    Yakota, JP
    • ●Personnel issues › Action/decision › Info processing/decision
  • CEN12FA1002011-12-094 fatalmatch 48
    CESSNA 421C · Quest Aviation Inc.
    Sioux Falls, SD
    • ●Personnel issues › Action/decision › Info processing/decision
    Fire/smoke (non-impact)

What the record says

a pattern, not a findingacross the 8 closest cases · 8 carry coded findings · 8 have a probable cause
Findings the Board cited in those cases
Occurrences it coded
  • 7 of 8Fire/smoke (non-impact)
  • 2 of 8Powerplant sys/comp malf/fail
Set against the Board’s own findings for this case
Cited here, and common in the precedents
  • Aircraft systems › Fuel system
  • Action/decision › Info processing/decision
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Aircraft power plant › Engine (turbine/turboprop)
  • Aircraft power plant › Engine fuel and control
  • Development › Design
  • Management › Resources
  • Task performance › Use of equip/info

A teaching device, not a verdict: what the record would have looked at, next to what the Board found.

In the Board’s words — the closest cases
  • ENG12IA0102012-02-08 · BOEING 767 · American Airlines
    The failure of the American Airlines aviation maintenance technicians to properly reassemble the two-piece bracket and spray shield on the integrated drive generator fuel-oil heat exchanger that caused a fuel leak that sprayed out and ignited on hot engine cases. Contributing to the cause of the fire was the 767 Aircraft Maintenance Manual’s lack of any graphical or pictorial displays of the correct assembly of the two-piece bracket and spray shield.
  • DCA17FA0212016-10-28 · BOEING 767 · AMERICAN AIRLINES INC
    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. Contribu…
  • ENG11IA0162011-02-09 · BOEING 757-2Q8 · DELTA AIR LINES INC
    the failure of the right engine's fuel control unit to operate correctly when the fuel metering valve became frozen in the full open position because of corrosion on the fuel metering valve slide and sleeve, which caused the engine to be overfueled during engine start and resulted in a tailpipe fire.
  • ENG11IA0352011-06-21 · BOEING 757-232 · DELTA AIR LINES INC
    Fuel leaking from the fuel flow transmitter that ignited on contact with the engine’s hot cases which resulted in an engine undercowl fire. The fuel leak resulted from the fuel flow transmitter end housing backing off from the main housing, creating a gap that allowed high pressure fuel to escape. Under certain assembly variances and operational load and temperature variations, the end housing joint may not be able to maintain the preload without eventually yielding, which results in the loosening of the joint and…
  • ENG08IA0222008-04-20 · BOEING 747 · KALITTA AIR LLC
    An engine fire in the No. 3 engine due to the failure of, and subsequent flammable fluid leak from, one of three fuel or hydraulic lines located in the engine's accessory raceway that ignited when the fluid came in contact with the hot engine cases. Contributing to the incident were the lack of adequate inspection and test requirements and appropriate life limit or inspection interval requirements by the manufacturer.
What it recommended after them
  • A-12-047TO THE FEDERAL AVIATION ADMINISTRATION: Issue an airworthiness directive to require the incorporation of General Electric Aircraft Engines Service Bulletin 73-0242, “Fuel and Control – (73-00-00) – Spray Shields and Support Bracket – Improv… · ENG12IA010Closed - Acceptable Action
  • A-18-003TO THE FEDERAL AVIATION ADMINISTRATION: Establish and lead an industry group that evaluates current and enhanced inspection technologies regarding their appropriateness and effectiveness for applications using nickel alloys, and use the res… · DCA17FA021Open - Acceptable Response
  • A-18-004TO THE FEDERAL AVIATION ADMINISTRATION: Require subsurface in-service inspection techniques, such as ultrasonic inspections, for critical high-energy, life-limited rotating parts for all engines. · DCA17FA021Open - Acceptable Response
  • A-18-005TO THE FEDERAL AVIATION ADMINISTRATION: Revise Advisory Circular (AC) 20-128A, “Design Considerations for Minimizing Hazards Caused by Uncontained Turbine Engine and Auxiliary Power Unit Rotor Failure,” based on an analysis of uncontained e… · DCA17FA021Open - Acceptable Response
  • A-18-006TO THE FEDERAL AVIATION ADMINISTRATION: When approving the operating procedures of a 14 Code of Federal Regulations Part 121 air carrier, require operators to develop and/or revise emergency checklist procedures for an engine fire on the gr… · DCA17FA021Closed - Unacceptable Action
  • A-18-007TO THE FEDERAL AVIATION ADMINISTRATION: Develop and issue guidance to all air carriers that conduct passenger-carrying operations under 14 Code of Federal Regulations Part 121 regarding (1) discussing this accident during recurrent flight a… · DCA17FA021Closed - Unacceptable Action
  • A-18-008TO THE FEDERAL AVIATION ADMINISTRATION: Review the training programs of all 14 Code of Federal Regulations Part 121 operators and make changes as necessary to ensure that the programs provide flight attendants and flight crews with training… · DCA17FA021Closed - Unacceptable Action
  • A-18-009TO THE FEDERAL AVIATION ADMINISTRATION: Conduct research to (1) measure and evaluate the effects of carry-on baggage on passenger deplaning times and safety during an emergency evacuation and (2) identify effective countermeasures to reduce… · DCA17FA021Open - Acceptable Response

This is the pattern in the NTSB’s own record across similar accidents — which findings it cited, what it coded, what it recommended. It is drawn from the record, not written about this case, and it never assigns blame: investigations exist to prevent the next accident (ICAO Annex 13).