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Cases › DCA17FA021 · Part 121 airline · Class 1

BOEING 767AMERICAN AIRLINES INC

Chicago, IL, USA · 2016-10-28·N345AN

0
fatal
1
serious
Serious injury
highest injury
Substantial
damage

What happened

NTSB summary, verbatim

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/01. On October 28, 2016, about 1432 central daylight time, American Airlines flight 383, a Boeing 767-323, N345AN, had started its takeoff ground roll at Chicago O'Hare International Airport, Chicago, Illinois, when an uncontained engine failure in the right engine and subsequent fire occurred. The flight crew aborted the takeoff and stopped the airplane on the runway, and the flight attendants initiated an emergency evacuation. Of the 2 flight crewmembers, 7 flight attendants, and 161 passengers on board, 1 passenger received a serious injury and 1 flight attendant and 19 passengers received minor injuries during the evacuation. The airplane was substantially damaged from the fire. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed at the time of the accident. 

Photographs

1the aircraft, and what the investigators found
The aircraft before the accident
American Airlines B767-3Q8(ER), N345AN (5723972743)
Charles from Port Chester, New York · CC BY 2.0 · Wikimedia Commons

Probable cause

the Board's determination
The failure of the high-pressure turbine (HPT) stage 2 disk, which severed the main engine fuel feed line and breached the right main wing fuel tank, releasing fuel that resulted in a fire on the right side of the airplane during the takeoff roll. The HPT stage 2 disk failed because of low-cycle fatigue cracks that initiated from an internal subsurface manufacturing anomaly that was most likely not detectable during production inspections and subsequent in service inspections using the procedures in place. Contributing to the serious passenger injury was (1) the delay in shutting down the left engine and (2) a flight attendant's deviation from company procedures, which resulted in passengers evacuating from the left overwing exit while the left engine was still operating. Contributing to the delay in shutting down the left engine was (1) the lack of a separate checklist procedure for Boeing 767 airplanes that specifically addressed engine fires on the ground and (2) the lack of communication between the flight and cabin crews after the airplane came to a stop.

Occurrence sequence

3 stepsNTSB coding · CICTT taxonomy
  1. 1 · Takeoff-rejected takeoff
    Uncontained engine failure
    defining event
  2. 2 · Other
    Fire/smoke (non-impact)
  3. 3 · Other
    Evacuation

Findings

8 causal · 2 contributing
  • CAUSE
    Aircraft › Aircraft power plant › Engine (turbine/turboprop) › Turbine section — Failure
  • CAUSE
    Aircraft › Aircraft systems › Fuel system — Damaged/degraded
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Use of policy/procedure — Cabin crew
  • CAUSE
    Personnel issues › Action/decision › Action › Delayed action — Flight crew
  • CAUSE
    Personnel issues › Task performance › Communication (personnel) › Lack of communication — Flight crew
  • CAUSE
    Personnel issues › Task performance › Communication (personnel) › Lack of communication — Cabin crew
  • CAUSE
    Organizational issues › Development › Manufacture/production › Equipment manufacture — Manufacturer
  • CAUSE
    Organizational issues › Development › Design › Task design — Manufacturer
  • FACTOR
    Organizational issues › Management › Resources › Adequacy of documents/info — FAA/Regulator
  • FACTOR
    Organizational issues › Support/oversight/monitoring › Training › Emergency proc training — FAA/Regulator

Safety recommendations

9 issuedwhat changed because of this accident
  • A-18-003Open - Acceptable ResponseCLASS IIletter ↗

    TO 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.

  • A-18-004Open - Acceptable ResponseCLASS IIletter ↗

    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.

  • A-18-005Open - Acceptable ResponseCLASS IIletter ↗

    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.

  • A-18-006Closed - Unacceptable ActionCLASS IIletter ↗

    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.

  • A-18-007Closed - Unacceptable ActionCLASS IIletter ↗

    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.

  • A-18-008Closed - Unacceptable ActionCLASS IIletter ↗

    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.

  • A-18-009Open - Acceptable ResponseCLASS IIletter ↗

    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.

  • A-18-010Closed - Acceptable ActionCLASS IIletter ↗

    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.

  • A-18-011Closed - Acceptable ActionCLASS IIletter ↗

    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
  1. 14:22:15Pre-flight/Groundp.3
    Recording began with APU and left engine running
  2. 14:22:20Ground/Engine Startp.3
    Right engine start sequence began with N2 rotation
  3. 14:22:45Ground/Engine Startp.3
    Fuel switch moved from cutoff position
  4. 14:23:20Taxip.3
    Autobrakes selected in RTO (rejected takeoff) position
  5. 14:23:20Taxip.3
    APU was shut down (remained off for remainder of recording)
  6. 14:31:20Takeoff rollp.3
    Takeoff attempt began; throttles advanced and engines accelerated to high power
  7. 14:31:43.4Takeoff rollp.4
    Accel changes indicative of #2 engine failure
  8. 14:31:44.7Rejected takeoffp.4
    Throttles reduced to idle
  9. 14:31:45.7Rejected takeoffp.4
    RTO autobrakes activated
  10. 14:31:45.9Rejected takeoffp.4
    Peak recorded speeds
  11. 14:31:47.5Rejected takeoffp.4
    Auto speedbrakes activated
  12. 14:31:48.6Rejected takeoffp.4
    Peak deceleration achieved
  13. 14:32:00Rejected takeoffp.4
    ENG FIRE R message activated
  14. 14:32:00.5Rejected takeoffp.4
    Manual braking initiated
  15. 14:32:08Rejected takeoffp.4
    #2 engine fuel control moved to Cutoff
  16. 14:32:09.8Stopped on runwayp.4
    Aircraft came to a stop
  17. 14:32:12Stopped on runwayp.4
    #2 engine fire extinguisher activated
  18. 14:32:16Stopped on runwayp.4
    Parking brake set
  19. 14:32:20Evacuationp.4
    Left overwing exit door opened
  20. 14:32:38Evacuationp.4
    Forward left entry door opened
  21. 14:32:42Evacuationp.4
    Forward right entry door opened
  22. 14:32:48Evacuationp.4
    Aft left entry door opened
  23. 14:33:08.9Post-evacuationp.4
    End of recording, #1 engine shut down

NTSB analysis

from the final report

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/01. On October 28, 2016, about 1432 central daylight time, American Airlines flight 383, a Boeing 767-323, N345AN, had started its takeoff ground roll at Chicago O'Hare International Airport, Chicago, Illinois, when an uncontained engine failure in the right engine and subsequent fire occurred. The flight crew aborted the takeoff and stopped the airplane on the runway, and the flight attendants initiated an emergency evacuation. Of the 2 flight crewmembers, 7 flight attendants, and 161 passengers on board, 1 passenger received a serious injury and 1 flight attendant and 19 passengers received minor injuries during the evacuation. The airplane was substantially damaged from the fire. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed at the time of the accident.