BOEING 767AMERICAN AIRLINES INC
Chicago, IL, USA · 2016-10-28·N345AN
What happened
NTSB summary, verbatimNTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/01. On October 28, 2016, about 1432 central daylight time, American Airlines flight 383, a Boeing 767-323, N345AN, had started its takeoff ground roll at Chicago O'Hare International Airport, Chicago, Illinois, when an uncontained engine failure in the right engine and subsequent fire occurred. The flight crew aborted the takeoff and stopped the airplane on the runway, and the flight attendants initiated an emergency evacuation. Of the 2 flight crewmembers, 7 flight attendants, and 161 passengers on board, 1 passenger received a serious injury and 1 flight attendant and 19 passengers received minor injuries during the evacuation. The airplane was substantially damaged from the fire. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed at the time of the accident.
Photographs
1the aircraft, and what the investigators foundProbable cause
the Board's determinationThe failure of the high-pressure turbine (HPT) stage 2 disk, which severed the main engine fuel feed line and breached the right main wing fuel tank, releasing fuel that resulted in a fire on the right side of the airplane during the takeoff roll. The HPT stage 2 disk failed because of low-cycle fatigue cracks that initiated from an internal subsurface manufacturing anomaly that was most likely not detectable during production inspections and subsequent in service inspections using the procedures in place. Contributing to the serious passenger injury was (1) the delay in shutting down the left engine and (2) a flight attendant's deviation from company procedures, which resulted in passengers evacuating from the left overwing exit while the left engine was still operating. Contributing to the delay in shutting down the left engine was (1) the lack of a separate checklist procedure for Boeing 767 airplanes that specifically addressed engine fires on the ground and (2) the lack of communication between the flight and cabin crews after the airplane came to a stop.
Occurrence sequence
3 stepsNTSB coding · CICTT taxonomy- 1 · Takeoff-rejected takeoffUncontained engine failuredefining event
- 2 · OtherFire/smoke (non-impact)
- 3 · OtherEvacuation
Findings
8 causal · 2 contributing- CAUSEAircraft › Aircraft power plant › Engine (turbine/turboprop) › Turbine section — Failure
- CAUSEAircraft › Aircraft systems › Fuel system — Damaged/degraded
- CAUSEPersonnel issues › Task performance › Use of equip/info › Use of policy/procedure — Cabin crew
- CAUSEPersonnel issues › Action/decision › Action › Delayed action — Flight crew
- CAUSEPersonnel issues › Task performance › Communication (personnel) › Lack of communication — Flight crew
- CAUSEPersonnel issues › Task performance › Communication (personnel) › Lack of communication — Cabin crew
- CAUSEOrganizational issues › Development › Manufacture/production › Equipment manufacture — Manufacturer
- CAUSEOrganizational issues › Development › Design › Task design — Manufacturer
- FACTOROrganizational issues › Management › Resources › Adequacy of documents/info — FAA/Regulator
- FACTOROrganizational issues › Support/oversight/monitoring › Training › Emergency proc training — FAA/Regulator
Safety recommendations
9 issuedwhat changed because of this accidentTO 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 results of this evaluation to issue guidance pertaining to the inspection process for nickel alloy rotating engine components.
TO 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.
TO 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 engine failure data since the time that the AC was issued, to minimize hazards to an airplane and its occupants if an uncontained engine failure were to occur. The revised AC should include modifications to the accepted design precautions for fuel tanks given the fires that have occurred after uncontained engine failures.
TO 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 ground to expeditiously address the fire hazard without unnecessarily delaying an evacuation.
TO 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 attendant training to emphasize the importance of effectively assessing door and overwing exits during an unusual or emergency situation and (2) providing techniques for identifying conditions that would preclude opening exits, including an operating engine.
TO 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 aids and hands-on emergency scenarios that account for the different interphone systems that air carriers operate.
TO 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 any determined risks, and implement the countermeasures.
TO THE BOEING COMPANY: Work with operators as required to develop and/or revise emergency checklist procedures for an engine fire on the ground to expeditiously address the fire hazard without unnecessarily delaying an evacuation.
TO AMERICAN AIRLINES: For all airplanes that you operate, review existing engine fire checklists and make changes as necessary to ensure that the procedures would expeditiously address engine fires occurring on the ground without unnecessarily delaying an evacuation.
Sequence of events
23 timed eventsfrom the FDR factual report · claude-sonnet-5- 14:22:15Pre-flight/Groundp.3Recording began with APU and left engine running
- 14:22:20Ground/Engine Startp.3Right engine start sequence began with N2 rotation
- 14:22:45Ground/Engine Startp.3Fuel switch moved from cutoff position
- 14:23:20Taxip.3Autobrakes selected in RTO (rejected takeoff) position
- 14:23:20Taxip.3APU was shut down (remained off for remainder of recording)
- 14:31:20Takeoff rollp.3Takeoff attempt began; throttles advanced and engines accelerated to high power
- 14:31:43.4Takeoff rollp.4Accel changes indicative of #2 engine failure
- 14:31:44.7Rejected takeoffp.4Throttles reduced to idle
- 14:31:45.7Rejected takeoffp.4RTO autobrakes activated
- 14:31:45.9Rejected takeoffp.4Peak recorded speeds
- 14:31:47.5Rejected takeoffp.4Auto speedbrakes activated
- 14:31:48.6Rejected takeoffp.4Peak deceleration achieved
- 14:32:00Rejected takeoffp.4ENG FIRE R message activated
- 14:32:00.5Rejected takeoffp.4Manual braking initiated
- 14:32:08Rejected takeoffp.4#2 engine fuel control moved to Cutoff
- 14:32:09.8Stopped on runwayp.4Aircraft came to a stop
- 14:32:12Stopped on runwayp.4#2 engine fire extinguisher activated
- 14:32:16Stopped on runwayp.4Parking brake set
- 14:32:20Evacuationp.4Left overwing exit door opened
- 14:32:38Evacuationp.4Forward left entry door opened
- 14:32:42Evacuationp.4Forward right entry door opened
- 14:32:48Evacuationp.4Aft left entry door opened
- 14:33:08.9Post-evacuationp.4End of recording, #1 engine shut down
NTSB analysis
from the final reportNTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/01. On October 28, 2016, about 1432 central daylight time, American Airlines flight 383, a Boeing 767-323, N345AN, had started its takeoff ground roll at Chicago O'Hare International Airport, Chicago, Illinois, when an uncontained engine failure in the right engine and subsequent fire occurred. The flight crew aborted the takeoff and stopped the airplane on the runway, and the flight attendants initiated an emergency evacuation. Of the 2 flight crewmembers, 7 flight attendants, and 161 passengers on board, 1 passenger received a serious injury and 1 flight attendant and 19 passengers received minor injuries during the evacuation. The airplane was substantially damaged from the fire. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed at the time of the accident.