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Cases › WPR13IA144 › The analyst

BOMBARDIER DHC-8-402Horizon Air

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.

5
timed facts
8
precedents
12
passages to ask

Ask the docket

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

5 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
  1. 11:08:30FDRTakeoffp.2
    The aircraft begins its takeoff roll
    see the traces at this moment ↗
  2. 11:19:38FDRClimbp.2
    The first Master Warning alert is triggered which is preceded by a drop in Engine 2 Fuel Flow and Torque
    see the traces at this moment ↗
  3. 11:20:00FDRClimbp.2
    The aircraft reaches a maximum Pressure Altitude of about 20000ft
    see the traces at this moment ↗
  4. 11:20:06FDRClimbp.2
    Engine 2's Internal Turbine Temperature is at its highest value of 1118 degC
    see the traces at this moment ↗
  5. 11:29:50FDRLandingp.2
    The aircraft lands
    see the traces at this moment ↗
Flight Data Recorder 10 - Factual Report · 5 events extracted by claude-sonnet-5
How the Board coded the sequence
  1. Enroute-climb to cruise: Fire/smoke (non-impact)→
  2. Emergency descent: Off-field or emergency landing

Precedents

8 closest casesranked by what happened, in the Board's words, and by the findings and occurrences it coded
  • ENG14IA0282014-09-18no fatalitiesmatch 65
    AIRBUS A320 232 · jetBlue Airways
    Long Beach, CA
    • ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
    • ●Organizational issues › Development › Manufacture/production
    Fire/smoke (non-impact)
  • ENG11IA0352011-06-21no fatalitiesmatch 63
    BOEING 757-232 · DELTA AIR LINES INC
    Atlanta, GA
    • ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
    Fire/smoke (non-impact)
  • DCA17FA0212016-10-28substantialmatch 57
    BOEING 767 · AMERICAN AIRLINES INC
    Chicago, IL
    • ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
    • ●Organizational issues › Development › Manufacture/production
    Fire/smoke (non-impact)
  • ENG17IA0172017-03-19no fatalitiesmatch 57
    DOUGLAS DC 9 83 · Allegiant Air
    Dayton, OH
    • ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
    Fire/smoke (non-impact)
  • ENG10IA0102010-01-12no fatalitiesmatch 57
    ATR ATR72 · American Airlines
    St. Croix, USA
    • ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
    Fire/smoke (non-impact)
  • DCA18LA1632018-04-18substantialmatch 56
    AIRBUS A330 323 · Delta Air Lines
    Atlanta, GA
    • ●Organizational issues › Development › Manufacture/production
    Fire/smoke (non-impact)
  • ENG11IA0432011-08-06no fatalitiesmatch 55
    MCDONNELL DOUGLAS DC-9-51 · Delta Air Lines
    Atlanta, GA
    • ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)
  • ENG12IA0032011-10-23no fatalitiesmatch 55
    BOEING 747-451 · DELTA AIR LINES INC
    Detroit, MI
    • ●Aircraft › Aircraft power plant › Engine (turbine/turboprop)

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
  • 6 of 8Fire/smoke (non-impact)
  • 3 of 8Uncontained engine failure
  • 2 of 8Engine shutdown
  • 2 of 8Loss of engine power (partial)
  • 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 power plant › Engine (turbine/turboprop)
  • Development › Manufacture/production
Cited here, not seen in the precedents
  • —
Common in the precedents, not cited here
  • Aircraft power plant › Engine fuel and control
  • Development › Design

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
  • ENG14IA0282014-09-18 · AIRBUS A320 232 · jetBlue Airways
    The probable cause of the engine failure and subsequent undercowl engine fire was due to the fatigue fracture of a high pressure turbine stage 2 disk blade retaining lug that released two blades which impacted the low pressure turbine case causing a fuel line to fracture spraying fuel on the hot engine cases where it ignited. During a machining operation of the disk lug, a tool mark was introduced that set up the area for fatigue cracks to initiate.
  • 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…
  • 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…
  • ENG17IA0172017-03-19 · DOUGLAS DC 9 83 · Allegiant Air
    The probable cause of the No. 2 (right) engine fire was an uncontained generator failure. Deformed rotating generator components and/or metal fragments radially released by the generator severed the constant speed drive-to-oil cooler return line located adjacent to the generator and caused oil to spray onto hot generator and engine case surfaces that subsequently ignited.
  • ENG10IA0102010-01-12 · ATR ATR72 · American Airlines
    The sealing failure between the fuel nozzle adapter assembly and fuel transfer tubes that allowed fuel to leak into the nacelle fire zone where it was subsequently ignited by the hot combustor case. Contributing to the failure was a combination of manufacturing defects of the fuel nozzle adapter assembly by the manufacturer and incorrectly overhauled fuel transfer tubes by the engine manufacturer. Contributing to the incident was a second defect of the fuel nozzle adapter assembly by the manufacturer which prevente…
What it recommended after them
  • 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
  • A-18-010TO 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. · DCA17FA021Closed - Acceptable Action

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).