ATL95MA106

NTSB accident investigation · Douglas DC-9-32 · Atlanta, GA · June 8, 1995

Accident · Serious injuriesClass 1 · MajorFinal report
Date
June 8, 1995, 19:08 local (23:08 UTC)
Place
Atlanta, GA
Injuries
1 serious, 6 minor, 55 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N908VJDouglas DC-9-32
Weather
Visual (VMC) · Dusk
Status
Completed · report January 17, 1997
Report
Board-adopted at Board Meeting
Investigation class
Class 1
Safety recommendations
Yes
FAA report
19950608017449A
Case key
3631

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

failure of Turk Hava Yollari maintenance and inspection personnel to perform a proper inspection of a 7th stage high compressor disc, thus allowing the detectable crack to grow to a length at which the disc ruptured, under normal operating conditions, propelling engine fragments into the fuselage; the fragments severed the right engine main fuel line, which resulted in a fire that rapidly engulfed the cabin area. The lack of an adequate recordkeeping system and the failure to use 'process sheets' to document the step-by-step overhaul/inspection procedures contributed to the failure to detect the crack and, thus, to the accident.

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/malfunctionTakeoff - roll/run
Compressor assembly,rotor disc - fatigueCause
Maintenance,inspection - improperOther maintenance personnelCause
Maintenance,recordkeeping - inadequateOther maintenance personnelFactor
Procedure inadequateOther maintenance personnelFactor
Compressor assembly,rotor disc - failureCause
Loss of engine power(total) - mech failure/malfTakeoff - roll/run
Aborted takeoff - performed
FireTakeoff - aborted
Fuselage - fire

Analysis

As ValuJet Flight 597 began its takeoff roll, a 'loud Bang' was heard by the occupants, the right engine fire warning light illuminated, the crew of a following airplane reported to the ValuJet crew that the right engine was on fire, and the takeoff was rejected. Shrapnel from the right engine penetrated the fuselage and the right engine main fuel line, and a cabin fire erupted. The airplane was stopped on the runway, and the captain ordered evacuation of the airplane. A flight attendant (F/A) received serious puncture wounds from shrapnel and thermal injuries; another F/A and 5 passengers received minor injuries. Investigation revealed that an uncontained failure of the right engine had occurred due to fatigue failure of its 7th stage high compressor disc. The fatigue originated at a stress redistribution hole in the disc. Analysis of fatigue striation measurements indicated that the fatigue crack had originated before the disc was last overhauled at a repair station (Turk Hava Yollari) in 1991, but was not detected. Also, investigation of the repair station revealed evidence concerning a lack of adequate recordkeeping and a failure to use 'process sheets' to document the step-by-step overhaul/inspection procedures. (See NTSB/AAR-96/03 for additional information)

Factual narrative

Group Chairmen narrative reports are available in the docket.

Aircraft

Registration
N908VJ
Reported as
Douglas DC-9-32
Category
Airplane
Serial number
47321
Airframe hours
630
Engine
P&W JT8D-9A, 14,500 lbs thrust, turbo jet
Damage
Substantial damage
Fire
On-Ground
Flight
Part 121
Registered owner
Valujet Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · June 2, 1995 · 45 hours before
Departed
ATL
Destination
MIA · Miami, FL
Flight plan
IFR
Airport
ATL · Hartsfield International, runway 27R, 11,889 × 150 ft, concrete

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
Certificates
Flight instructor, Airline transport, Flight engineer
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
9,500 total · 3,500 in this make and model · 4,500 as pilot in command · 221 in the last 90 days · 91 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dusk
Wind
290° at 8 knots
Visibility
12 statute miles
Lowest ceiling
5,500 ft broken
Temperature
93 °F, dew point 72 °F
Altimeter
29.00 inHg
Observed at
ATL, 1 nm away

FAA reports on this event · 1

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