BOEING 737-8SOUTHWEST AIRLINES CO
Kenner, LA, USA · 2023-12-20·N8830Q
What happened
NTSB summary, verbatimDuring initial climbout shortly after takeoff, Southwest Airlines flight 554 struck and ingested a bird into its No. 1 (left) engine, resulting in damage to the left engine fan blades and a partial loss of engine power. The airplane began to “shake violently with a distinct loss of thrust” in the left engine. The engine master caution activated, and the captain reported that he heard the fire bell sound. The captain called for the Engine Fire or Engine Severe Damage or Separation checklist on the Quick Reference Card (QRC). According to the captain, after the first officer (FO) started the checklist, the cockpit began to fill with “acrid white smoke.” The FO called out “masks,” the pilots donned their masks, and they resumed performance of the checklist. The flight crew declared an emergency to air traffic control and requested airport rescue and firefighting (ARFF) in preparation for the flight’s return to the departure airport. The flight crew notified the cabin crew and passengers about the emergency. The captain later reported that, due to the smoke, his instrument panel was difficult to see and that he thought he might need to fly the airplane by solely using the heads-up guidance system. However, the captain stated that the smoke began to rapidly dissipate after the FO pulled the engine fire switch. After flight 554 landed and came to a full stop, ARFF personnel inspected the airplane before the flight crew taxied to the assigned gate. The passengers deplaned normally, and no injuries were reported. Postaccident examination found that the smoke in the cockpit was a result of the activation of the No. 1 engine’s load reduction device (LRD) after the bird ingestion. LRD activation is designed to reduce the severity of the vibration transmitted into the airframe by disconnecting the left engine’s fan blades from the turbomachinery. When the LRD activated, tubes supplying oil to the engine sump became dislodged and the flange from the sump area opened, allowing engine oil to enter the core compressor upstream of the pneumatic bleed ports that supply bleed air to the cabin and cockpit. The oil was exposed to high temperatures and resulted in smoke and fumes that were then fed into the cockpit. About 15 seconds after the bird ingestion, the left engine’s core speed (N2) was below 62% rpm, which would have de-energized the engine’s running relay and subsequently closed the pressure regulating shutoff valve (PRSOV). Following the closure of the PRSOV, which was the point of access into the cockpit, the smoke and fumes would have quickly dissipated. Considering that both crewmembers described the airplane as shaking following the bird ingestion, the captain’s decision to begin the Engine Fire or Engine Severe Damage or Separation checklist was appropriate (one of the conditions for using the checklist was airframe vibrations). Although the crew did not report performing the Smoke, Fire or Fumes checklist, the first officer stating “masks” accomplished two of the three memory items by donning their one-piece oxygen masks. Postincident review of this checklist found that it instructed pilots to turn off various switches, including the RECIRC FAN switches at step 9. It is not until step 11 that the checklist instructs that if the smoke or fumes become the greatest threat, pilots should reference another checklist. It is likely that the incident flight crew would have performed the Smoke, Fire or Fumes checklist first if they had not experienced severe airframe vibration following the bird ingestion. Boeing released a flight crew operations manual (FCOM) bulletin on February 9, 2024, that described the results of the bird ingestion in this incident and the actions a flight crew should take if they experience a similar incident. Boeing also updated the system description in the Boeing 737-8 FCOM on November 15, 2024, and the Quick Reference Handbook (QRH) on November 30, 2024, to include engine failure with smoke or fumes in the flight deck or cabin as a condition to trigger reference to the Engine Fire or Engine Severe Damage or Separation QRC. Although the NTSB found no clear evidence of significant toxic or irritant exposure to the flight crew resulting from the LRD activation on the incident flight, such an event may pose a toxicological risk. There are insufficient data to reliably determine the nature and magnitude of such risk, especially at what is expected to be limited exposure duration. It is reasonable to consider the potential for irritant effects on the pilots among the threats to the immediate safety of the flight in an LRD-related smoke event.
Photographs
1the aircraft, and what the investigators foundProbable cause
the Board's determinationA partial loss of engine power due to bird ingestion in the No. 1 (left) engine, which resulted in the activation of the load reduction device to prevent vibration. The load reduction device activation resulted in smoke and fumes entering the cockpit.
Occurrence sequence
1 stepsNTSB coding · CICTT taxonomy- 1 · TakeoffBirdstrikedefining event
Findings
2 causal · 5 contributing- CAUSEAircraft › Aircraft power plant › Power plant — Damaged/degraded
- CAUSEEnvironmental issues › Physical environment › Object/animal/substance › Animal(s)/bird(s) — Effect on equipment
- FACTORAircraft › Aircraft systems › Air conditioning system — Design
- FACTORAircraft › Aircraft power plant › Eng oil sys (airframe furnish) — Design
- FACTOROrganizational issues › Development › Manufacture/production — Manufacturer
- FACTORAircraft › Aircraft power plant › Engine bleed air system — Design
- FACTOROrganizational issues › Management › Policy/procedure › Adequacy of policy/proc — Manufacturer
Safety recommendations
5 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Ensure operators inform flight crews of airplanes equipped with CFM International LEAP-1B engines of the circumstances described in National Transportation Safety Board Aviation Investigation Report AIR-25-03, emphasizing Boeing’s changes to the quick reference handbook and flight crew operations manual so pilots are aware of actions to take if they encounter smoke in the cockpit or cabin after load reduction device activation. (Urgent)
TO THE FEDERAL AVIATION ADMINISTRATION AND THE EUROPEAN UNION AVIATION SAFETY AGENCY: Once CFM International and Boeing complete the development and certification process for software modifications to the CFM International LEAP-1B engines, require all operators of airplanes equipped with CFM International LEAP-1B engines to incorporate the software modification developed in response to Safety Recommendations A-25-13 and A-25-14 to prevent or limit the amount of smoke released into the cockpit or cabin after load reduction device activation.
TO THE FEDERAL AVIATION ADMINISTRATION, THE EUROPEAN UNION AVIATION SAFETY AGENCY, AND THE CIVIL AVIATION ADMINISTRATION OF CHINA: Work with CFM International, Airbus, and the Commercial Aircraft Corporation of China to determine if CFM International LEAP-1A or -1C engines are at risk of smoke in the cockpit or cabin as a result of load reduction device activation and require affected operators to incorporate any modification that results.
TO BOEING COMPANY: Work with CFM International to complete the development and certification process for a software modification for CFM International LEAP-1B engines that will prevent or limit the amount of smoke released into the cockpit or cabin after load reduction device activation.
TO CFM INTERNATIONAL: Work with Boeing to complete the development and certification process for a software modification for CFM International LEAP-1B engines that will prevent or limit the amount of smoke released into the cockpit or cabin after load reduction device activation.
Sequence of events
31 timed eventsfrom the FDR factual report · claude-sonnet-5- 14:13:04 CSTTakeoff rollp.6Groundspeed began to rapidly increase from 8 knots (kts), consistent with the aircraft beginning takeoff roll. The aircraft was on runway 11 at Louis Armstrong New Orleans International Airport (KMSY).
- 14:13:39 CSTTakeoffp.6The air/ground relay switch changed from ground to air.
- 14:13:44 CSTTakeoff/Climbp.6All three gear green lights were off, consistent with the gear no longer down and locked.
- 14:14:01 CSTClimbp.6While passing through 687 feet (ft) radio altitude and 170 kts computed airspeed, engine 1 N1 began to rollback from 83.0 percent revolutions per minute (%RPM).
- 14:14:02 CSTClimbp.6While passing through 747 ft radio altitude and 167 kts computed airspeed, engine 1 channel B airborne vibration monitor (AVM) increased from 0.1406 to 0.1797.
- 14:14:04 CSTClimbp.6The aircraft passed through 810 ft radio altitude and the computed airspeed was 164 kts. Engine 1 Fail status changed from normal to fail.
- 14:14:05 CSTClimbp.6Engine 1 N1 was 16.5 %RPM and continued to reduce to a minimum value of 6.1 %RPM, 46 seconds later (14:14:51 CST).
- 14:14:09 CSTClimbp.6Engine 1 channel A and B AVM began to rapidly increase.
- 14:14:12 CSTClimbp.7Engine 1 channel B AVM reached a maximum recorded value of 5. One second later, engine 1 channel A reached a maximum recorded value of 5. Note, Engine 1 channel A and B AVM operational range is limited at a maximum scalar value of 5.
- 14:14:14 CSTClimbp.7The aircraft passed through 900 ft radio altitude and the computed airspeed was 167 kts. The master caution activated and remained active for the next 11 seconds. Engine 1 N2 was 57.9 %RPM and continued to reduce to a minimum value of 0.0 %RPM, 76 seconds later (14:15:30 CST).
- 14:14:16 QAR CSTClimbp.7The left pressure regulating and shutoff valve (PRSOV) command changed from commanded open to commanded close. The left PRSOV remained closed the remainder of the flight.
- 14:14:17 QAR CSTClimbp.7The left environmental control system (ECS) pack changed from on to off. The left ECS pack remained off for the remainder of the flight. The right ECS pack remained on.
- 14:14:31 CSTClimbp.7The master caution activated and remained active for the next 2 minutes and 41 seconds.
- 14:16:07 CSTClimb/Emergency responsep.7The autothrottle (AT) disconnect switch was pressed. Subsequently, the AT was disengaged.
- 14:16:14 CSTEmergency responsep.7Engine 1 throttle resolver angle (TRA) began to reduce from 66.45 degrees. Four seconds later, it reached 36.04 degrees.
- 14:16:25 CSTEmergency responsep.7Engine 1 start lever was changed from run to cutoff.
- 14:16:56 QAR CSTEmergency responsep.7Engine 1 fire handle was pulled.
- 14:19:00 CSTEmergency responsep.7The auxiliary power unit (APU) changed from off to on. The APU remained on for the remainder of the flight.
- 14:19:59 CSTEmergency responsep.7The master caution activated and remained active for the next 5 seconds.
- 14:20:08 QAR CSTEmergency responsep.7The ECS isolation valve changed from closed to open. The ECS isolation valve was open the remainder of the flight.
- 14:23:32 CSTApproach preparationp.7The master caution activated and remained active for the next 9 seconds.
- 14:24:12 CSTApproach preparationp.7The speedbrake was armed.
- 14:24:16 CSTApproach preparationp.7Gear Lever Up transitioned from UP to NOT UP and Gear Lever Down transitioned from NOT DN to DOWN.
- 14:24:28 CSTApproachp.7All three gear green lights were on, consistent with the main and nose gears down and locked.
- 14:24:42 CSTApproachp.7The flap handle began to increase. One second later, the flap handle was at 15 degrees.
- 14:26:05 CSTLandingp.8The air/ground relay switch changed from air to ground, consistent with the aircraft landing. The aircraft landed on runway 11 at KMSY.
- 14:26:06 CSTLandingp.8The master caution activated and remained active for the next 2 seconds.
- 14:26:10 CSTLanding rolloutp.8Engine 2 thrust reverser was deployed. Engine 1 thrust reverser was not deployed and remained stowed.
- 14:26:57 CSTPost-landingp.8The groundspeed recorded was 1 kt. The aircraft position remained constant on runway 11, slightly past taxiway delta.
- 14:33:00 CSTPost-landingp.8End of valid recorded FDR data.
- 14:33:45 QAR CSTPost-landingp.8End of valid recorded QAR data. The aircraft position was in spot bravo 8 at the terminal at KMSY.
NTSB analysis
from the final reportDuring initial climbout shortly after takeoff, Southwest Airlines flight 554 struck and ingested a bird into its No. 1 (left) engine, resulting in damage to the left engine fan blades and a partial loss of engine power. The airplane began to “shake violently with a distinct loss of thrust” in the left engine. The engine master caution activated, and the captain reported that he heard the fire bell sound. The captain called for the Engine Fire or Engine Severe Damage or Separation checklist on the Quick Reference Card (QRC). According to the captain, after the first officer (FO) started the checklist, the cockpit began to fill with “acrid white smoke.” The FO called out “masks,” the pilots donned their masks, and they resumed performance of the checklist. The flight crew declared an emergency to air traffic control and requested airport rescue and firefighting (ARFF) in preparation for the flight’s return to the departure airport. The flight crew notified the cabin crew and passengers about the emergency. The captain later reported that, due to the smoke, his instrument panel was difficult to see and that he thought he might need to fly the airplane by solely using the heads-up guidance system. However, the captain stated that the smoke began to rapidly dissipate after the FO pulled the engine fire switch. After flight 554 landed and came to a full stop, ARFF personnel inspected the airplane before the flight crew taxied to the assigned gate. The passengers deplaned normally, and no injuries were reported. Postaccident examination found that the smoke in the cockpit was a result of the activation of the No. 1 engine’s load reduction device (LRD) after the bird ingestion. LRD activation is designed to reduce the severity of the vibration transmitted into the airframe by disconnecting the left engine’s fan blades from the turbomachinery. When the LRD activated, tubes supplying oil to the engine sump became dislodged and the flange from the sump area opened, allowing engine oil to enter the core compressor upstream of the pneumatic bleed ports that supply bleed air to the cabin and cockpit. The oil was exposed to high temperatures and resulted in smoke and fumes that were then fed into the cockpit. About 15 seconds after the bird ingestion, the left engine’s core speed (N2) was below 62% rpm, which would have de-energized the engine’s running relay and subsequently closed the pressure regulating shutoff valve (PRSOV). Following the closure of the PRSOV, which was the point of access into the cockpit, the smoke and fumes would have quickly dissipated. Considering that both crewmembers described the airplane as shaking following the bird ingestion, the captain’s decision to begin the Engine Fire or Engine Severe Damage or Separation checklist was appropriate (one of the conditions for using the checklist was airframe vibrations). Although the crew did not report performing the Smoke, Fire or Fumes checklist, the first officer stating “masks” accomplished two of the three memory items by donning their one-piece oxygen masks. Postincident review of this checklist found that it instructed pilots to turn off various switches, including the RECIRC FAN switches at step 9. It is not until step 11 that the checklist instructs that if the smoke or fumes become the greatest threat, pilots should reference another checklist. It is likely that the incident flight crew would have performed the Smoke, Fire or Fumes checklist first if they had not experienced severe airframe vibration following the bird ingestion. Boeing released a flight crew operations manual (FCOM) bulletin on February 9, 2024, that described the results of the bird ingestion in this incident and the actions a flight crew should take if they experience a similar incident. Boeing also updated the system description in the Boeing 737-8 FCOM on November 15, 2024, and the Quick Reference Handbook (QRH) on November 30, 2024, to include engine failure with smoke or fumes in the flight deck or cabin as a condition to trigger reference to the Engine Fire or Engine Severe Damage or Separation QRC. Although the NTSB found no clear evidence of significant toxic or irritant exposure to the flight crew resulting from the LRD activation on the incident flight, such an event may pose a toxicological risk. There are insufficient data to reliably determine the nature and magnitude of such risk, especially at what is expected to be limited exposure duration. It is reasonable to consider the potential for irritant effects on the pilots among the threats to the immediate safety of the flight in an LRD-related smoke event.