ATL02LA075

NTSB accident investigation · Boeing 767-332ER · Atlanta, GA · April 5, 2002

Accident · No injuriesLimited investigationFinal report
Date
April 5, 2002, 17:15 local (22:15 UTC)
Place
Atlanta, GA
Injuries
199 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N1608Boeing 767-332ER
Weather
Visual (VMC) · Day
Status
Completed · report April 15, 2003
Report
Approved by Office Director
Parties
Atlanta FSDO
FAA report
20020405011069A
Case key
54503

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

Company maintenance personnel inadequate maintenance inspection that resulted in the in-flight separation of the APU inspection doors.

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.

Airframe/component/system failure/malfunctionClimb - to cruise
Maintenance,inspection - inadequateCompany maintenance personnelCause
Door,inspection - not securedCause

Analysis

The Boeing 767-332ER, experienced an in-flight separation of the auxiliary power unit doors while climbing to the assigned cruise altitude. According to the Captain, as the airplane climbed through 15, 000 feet, and accelerated through 320 knots, he heard a loud bang. He elected to reduce the airspeed to 270 knots and return to Atlanta. The flight landed in Atlanta without further incident. A review of maintenance records showed that the auxiliary power unit (APU) had been serviced by ground maintenance personnel about one hour before the airplane departed. The examination of the airframe revealed that both APU doors were missing from their normally installed positions. Examination of the APU door assembly failed to disclose a mechanical problem with the door latching assemblies.

Factual narrative

On April 5, 2002,at 1715 eastern standard time, a Boeing 767-332ER, N1608, registered to Delta Airlines Inc, operating as flight DAL74, experienced an in-flight separation of the auxiliary power unit door while climbing to cruise altitude near Atlanta, Georgia. The international passenger flight operated under the provisions of Title 14 CFR Part 121 with an instrument flight plan filed. Visual weather conditions prevailed at the time of the separation. The airplane sustained substantial damage. The air transport pilot (Captain), the flight crew, and 187 passengers were not injured. The passenger flight departed Atlanta, Georgia, enroute to Milan, Italy, at 1700.

According to the Captain, as the airplane climbed through 15, 000 feet, and accelerated through 320 knots, he heard a loud bang. Shortly after that the pilot felt a severe vibration that shook the entire airplane. The pilot took immediate action and leveled off, he then called for an altitude hold and a reduction in airspeed to 270 knots. There were no warnings, cautions or other abnormal indications in the cockpit. The hydraulic pressure was normal and engine indications were steady with no fluctuations. The Captain directed the First Officer to tell air traffic controller that they had a problem and needed to return to the airport. The flight was issued an instrument clearance to Atlanta. The flight landed in Atlanta without further incident.

A review of maintenance records showed that the auxiliary power unit (APU) had been serviced by ground maintenance personnel about one hour before the airplane departed. The examination of the airframe revealed that both APU doors were missing from their normally installed positions. Examination also discovered a 19 inches wide by 26 inches long hole in the left inboard elevator. On the right inboard elevator there was also a hole that measured 14 inches wide by 29 inches long. Damage was also noted on the fuselage structure that enclosed the APU. Prior to the flight the ground personnel had conducted a pre-departure check that included the servicing of the APU. This check was performed one hour before the flight. No other mechanical malfunctions were reported prior to the flight.

According to the operators engineering division, there were two possible reasons for the loss of the APU doors: (1). The lack of latch engagement, (2). The failure of the receiving pins. The right door was recovered in three pieces. Only one hinge was recovered for the left door. The forward three latch hooks were intact. The latch for the aft position was fractured. The left door in which the receiving pins were attached was not recovered. Failure examination of the right door structure indicated that a load was applied to the forward lower corner of the door and it failed in a tearing motion. The APU door aft latch hook had been severed. The fracture surface of the aft latch hook indicated a ductile tension failure. The other portions of the recovered door shoe rivet failures and structural failures also suggestive of an overload condition. The other three remaining latches appeared to be functional and were not damaged.

Aircraft

Registration
N1608
Reported as
Boeing 767-332ER
Category
Airplane
Serial number
30573
Airframe hours
9,219
Engines
General Electric 706106, 60,800 lbs thrust, turbo fanGeneral Electric 706110, 60,800 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Registered owner
Delta Air Lines Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · March 18, 2002 · 263 hours before
Departed
ATL · Atlanta, GA
Destination
MXP · Milan
Flight plan
IFR
Airport
ATL · The William B Hartsfield Atlan, runway 27R, 11,889 × 150 ft, asphalt

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
54
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
April 14, 2001
Seat
Left
Flight hours
6,984 total · 3,300 in this make and model · 179 in the last 90 days · 1 in the last 24 hours
Role
Co-pilot
Age
43
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
January 30, 2002
Seat
Right
Flight hours
8,311 total · 3,027 in this make and model · 179 in the last 90 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 13 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 21 °F
Altimeter
30.14 inHg
Observed at
ATL, 17 nm away

Docket · 9

The files NTSB released with the investigation on January 17, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.2 MB in all.

FAA reports on this event · 1

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