ANC05IA020

NTSB incident investigation · Boeing 747-123 · Anchorage, AK · December 29, 2004

Incident · No injuriesIncident investigationFinal report
Date
December 29, 2004, 17:41 local (21:41 UTC)
Place
Anchorage, AK
Injuries
3 uninjured
Damage
Minor damage
Phase of flight
Initial climb
Aircraft
N858FTBoeing 747-123
Weather
Visual (VMC) · Day
Status
Completed · report December 20, 2005
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
Anchorage, FSDO-03
FAA report
20041229034139I
Case key
60803

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The failure of a high-pressure fuel line fitting, which resulted in an engine fire during takeoff/initial climb.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

FireTakeoff - initial climb
Fuel system,line fitting - failure,totalCause
Fire warning system,powerplant - activated
Loss of engine power(partial) - mech failure/malfTakeoff - initial climb
1 engine - failure,total
Emergency procedure - activatedPilot in command
Fire extinguishing equipment - activatedPilot in command
Forced landingEmergency landing after takeoff

Analysis

The 14 CFR Part 121 international cargo flight had an under-cowl fire in the number four engine during takeoff. The crew shut down the engine, activated the fire extinguishing system, and returned to the airport. An inspection of the engine disclosed that the entire outboard engine cowl was missing, and the engine had extensive fire damage. A fuel tube to the oil cooler was observed to have separated from the coupler attaching it to the oil cooler, leaving a gap of about one-half inch. The oil cooler uses the heat-exchange principle, exchanging heat via high quantity fuel flow. The fuel tube is about one and one-quarter inches in diameter, and has a working pressure of about 200 psi. Separation of the fuel tube assembly connection occurred at the brazed sleeve joint between the ferrule and the fuel tube. An examination and X-ray mapping revealed that the brazed joint did not meet the minimum requirement for filler material adhesion required in Aerospace Material Specification (AMS) 2664F for silver brazing.

Factual narrative

History of flight

On December 29, 2004, about 1741 Alaska standard time, a Boeing 747-123 airplane, N858FT, sustained minor damage resulting from an under-cowl fire in the number four engine during initial climb after takeoff from the Ted Stevens International Airport, Anchorage, Alaska. The airplane was being operated as Flight 8445, by Polar Air Cargo of Purchase, New York, as an instrument flight rules (IFR) non-scheduled international cargo flight under Title 14, CFR Part 121, when the incident occurred. The three flight crew members were not injured. Visual meteorological conditions prevailed, and an instrument flight plan was filed. The flight originated at the Ted Stevens International Airport, Anchorage, about 1735, and was bound for the Osan Air Base, Republic of South Korea.

During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on December 29, the FAA aviation safety inspector who examined the airplane said there was a fire in the number four engine compartment, and that the entire outboard cowl was missing. He said the crew reported a fire alarm indication in the engine during initial climb, and that they reported shutting down the engine and activating the fire extinguishing system. The airplane dumped fuel, returned to Anchorage, and landed without incident.

During an examination of the airplane by the IIC on December 30, the entire outboard cowl was missing. The inboard cowl had been removed by the maintenance crew. The inside of the inboard cowl had extensive fire damage. The engine also had extensive fire damage, with the most damage in the area of the fuel controller.

The number four engine was removed from the airplane and taken to a storage warehouse. During a visual inspection of the outboard section of the engine adjacent to the oil cooler, the IIC noticed a misaligned large diameter fuel tube (PW Part No. 772123). The fuel tube had separated from the coupler attaching it to the oil cooler, leaving a gap of about one-half inch. The oil cooler is co-mingled with the fuel flow transducer, and uses the heat-exchange principle to cool engine oil, exchanging heat with high quantity fuel flow. The fuel tube is about one and one-quarter inches in diameter, and has a working pressure of about 200 pounds per square inch. The connection at the oil cooler end of the tube assembly included a ferrule that had been brazed to the fuel tube about one inch from the end of the tube. An elastomeric seal (O-ring) was placed around the tube adjacent to the lip of the ferrule, and both were held in place by a nut that was threaded to an externally threaded fitting. Two safety wires were attached to the nut, one wire from the nut to the fitting, and the second from the nut to a metal tab welded onto the fuel pipe. The wire from the nut to the metal tab was broken at the tab. Separation of the fuel tube assembly connection occurred at the brazed sleeve joint between the ferrule and the fuel tube. The fuel tube was removed from the engine without disturbing the ferrule retaining nut, which was safety-wired to the fitting. The tube assembly was shipped to the NTSB Materials Laboratory in Washington, D. C.

Aircraft information

The accident airplane is a Boeing 747-123 (cargo configuration), serial number 20109. At the time of the incident, the number four engine had logged 75,863 service hours, with 2,183 service hours since overhaul.

Test and research

A detailed examination of the tube assembly was conducted, and revealed that the torque on the retaining nut was so low that, once the safety was removed, the nut was easily removed by hand. The safety wire, attached from the nut to the metal tab, had failed in a typical overstress mode. The ferrule had been brazed to the tube at a distance from the end of the tube significantly greater than that specified by the manufacturer. Visual inspection revealed that the brazing filler material adhered to the tube better than it did to the ferrule. X-ray mapping of both brazed surfaces confirmed that the filler mater adhered more readily to the tube than to the ferrule. Aerospace Material Specification (AMS) 2664F for silver brazing requires eighty percent of the mating surfaces of a joint be joined by filler metal. X-ray mapping suggested that an estimated fifty percent of the ferrule surface, and sixty percent of the tube surface, had been covered by filler material before separation.

Additional information

The Pratt & Whitney JT9D-7A engine is a discontinued model, and according to the manufacturer, there are about 220 of this model engine still in service worldwide. The fuel pipe in question is no longer in production, and is not used on any other engine model.

Aircraft

Registration
N858FT
Reported as
Boeing 747-123
Category
Airplane
Serial number
20109
Engine
Pratt & Whitney JT9D-7A, 44,000 lbs thrust, turbo fan
Damage
Minor damage
Fire
In-Flight
Flight
Part 121
Registered owner
Polar Air Cargo Inc
Airworthiness certificate
Standard, Utility
Departed
PANC · Anchorage, AK
Destination
RKSO · Osan Air Base
Flight plan
IFR
Airport
PANC · Ted Stevens International Airp, runway 32

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
54
Injuries
None
Certificates
Foreign, Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
October 1, 2004
Flight hours
24,000 total · 16,000 in this make and model · 11,000 as pilot in command · 161 in the last 90 days · 74 in the last 30 days
Role
Co-pilot
Age
55
Injuries
None
Certificates
Airline transport, Flight engineer, Flight instructor
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
October 1, 2004
Flight hours
13,500 total · 1,250 in this make and model · 114 in the last 90 days · 33 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
40° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 54 °F
Altimeter
30.38 inHg
Observed at
PANC

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.