ANC99LA099

NTSB accident investigation · Boeing 747-269B · Anchorage, AK · July 29, 1999

Accident · No injuriesLimited investigationFinal report
Date
July 29, 1999, 15:00 local (23:00 UTC)
Place
Anchorage, AK
Injuries
5 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N707CKBoeing 747-269B
Weather
Visual (VMC) · Day
Status
Completed · report July 10, 2001
Report
Approved by Office Director
NTSB office
Alaska Regional Office
FAA report
19990729017619A
Case key
46872

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

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Probable cause

The failure of a turbine blade, and subsequent penetration of the shroud (containment ring). A factor associated with the accident was the FAA's insufficient design standards/requirements addressed in an FAA Air Worthiness Directive, which called for a strengthened containment ring. The failed containment ring was in compliance with the Air Worthiness Directive.

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.

Loss of engine power(total) - mech failure/malfClimb - to cruise
Turbine assembly,turbine blade - failureCause
Turbine assembly,shroud - penetratedCause
Insufficient standards/requirements,aircraftFaa(organization)Factor

Analysis

During climbout, the Boeing 747 crew noted a loud 'thump,' followed by a change in the number three engine instrument indications. One crewmember noted there was a fist-sized hole in the side of the engine cowling. The captain shut down the number three engine, returned to the departure airport, and landed without further incident. A postlanding inspection revealed that the inboard aileron sustained substantial damage. Disassembly of the engine revealed that there were eleven 2nd stage turbine blades that were fractured in the midspan area, and one other 2nd stage turbine blade that was elongated and necked down in the midspan area with most of the shroud tip rubbed off. The turbine exhaust case had a 16 1/2-inch long hole between the case front flange and the front mount rail. Engine service records revealed that when the turbine exhaust case was overhauled, Airworthiness Directive (AD) 96-25-10 was complied with by incorporating Chromalloy Anniston Division's, Supplemental Type Certificate (STC) SE00047AT-D. The intent of STC SE00047AT-D is to comply with FAA Airworthiness Directive (AD) 96-25-10 by increasing the wall thickness of the turbine exhaust case, thus providing enhanced containment capabilities in the event of an internal engine failure. A portion of the turbine exhaust case was sent to the NTSB Materials Laboratory for examination. A Safety Board metallurgist confirmed that both the hardness and microstructure were consistent with design specifications stipulated in Chromally Anniston Division's STC.

Factual narrative

On July 29, 1999, about 1500 Alaska daylight time, a Boeing 747-269B airplane, N707CK, had an uncontained engine failure during climb-out from the Anchorage International Airport, Anchorage, Alaska. The flight was being conducted under Title 14, CFR Part 121, as a nonscheduled international cargo flight, operated by Kitty Hawk International, Inc., as Flight 11281. There were no injuries to the five crewmembers aboard. Visual meteorological conditions prevailed at the time of departure from Anchorage, and an instrument flight plan had been filed for the flight to Bangkok, Thailand.

During an interview with the National Transportation Safety Board (NTSB) investigator-in-charge on July 30, a company quality assurance official stated that about 20 minutes after departure, the crew noted a loud "thump," followed by a change in the number three engine instrument indications. He said that one of the crewmembers went to the back of the airplane to visually check the status of the engine, and noted there was a "fist-sized hole in the side of the engine cowling." The quality assurance official stated that the captain shut down the number three engine, returned to Anchorage International Airport, and landed without further incident.

A postaccident inspection revealed that the inboard aileron sustained substantial damage.

On July 30, 1999, the airplane was three-engine ferried from Anchorage to the operator's maintenance base in Oscoda, Michigan, where the engine was removed. The engine was subsequently shipped to a maintenance facility in Tel Avia, Israel, for disassembly and examination.

On September 7, 1999, the engine was disassembled under the direction of an NTSB Powerplant Group Chairman, and in the presence of the parties to the investigation. The disassembly revealed that there were eleven 2nd stage turbine blades that were fractured in the midspan area, and one other 2nd stage turbine blade that was elongated and necked down in the midspan area, with most of the shroud tip rubbed off.

The turbine exhaust case had a 16 1/2-inch long hole between the case front flange and the front mount rail.

The Powerplants Group completed its examination of the engine on September 8. A copy of the Group Chairman's report is included in this report.

An examination of the engine maintenance records revealed the engine was removed from service due to a cracked diffuser case on August 1, 1998, at 43,946 hours total time, and 11,629 cycles. During this maintenance procedure, an overhauled turbine exhaust case was installed.

The engine records revealed that when the turbine exhaust case was overhauled, FAA Airworthiness Directive (AD) 96-25-10 was complied with by incorporating Chromalloy Anniston Division's, Supplemental Type Certificate (STC) SE00047AT-D. The intent of STC SE00047AT-D is to comply with FAA Airworthiness Directive (AD) 96-25-10 by increasing the wall thickness of the turbine exhaust case, thus providing enhanced containment capabilities in the event of an internal engine failure.

A portion of the turbine exhaust case was sent to the National Transportation Safety Board's Materials Laboratory for examination. A Safety Board metallurgist confirmed that both the hardness and microstructure were consistent with design specifications stipulated in Chromally Anniston Division's STC. A copy of the NTSB materials laboratory factual report is included in this report.

Aircraft

Registration
N707CK
Reported as
Boeing 747-269B
Category
Airplane
Serial number
21541
Airframe hours
59,727
Engine
P&W JT9D-7J, 48,650 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Registered owner
Kitty Hawk International, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · July 19, 1999 · 268 hours before
Departed
ANC · Anchorage, AK
Destination
VTBD · Bangkok
Flight plan
IFR

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
45
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
11,000 total

Weather

Conditions
Visual (VMC) · Day
Visibility
100 statute miles
Temperature
14 °F
Altimeter
29.00 inHg

FAA reports on this event · 1

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

Other investigations on N707CK · 1

Matched to the same aircraft by N-number and date.