CHI95IA142

NTSB incident investigation · Mcdonnell Douglas DC10-10 · Chicago, IL · May 1, 1995

Incident · No injuriesIncident investigationFinal report
Date
May 1, 1995, 11:20 local (16:20 UTC)
Place
Chicago, IL
Injuries
192 uninjured
Damage
Minor damage
Phase of flight
Takeoff
Aircraft
N1811UMcdonnell Douglas DC10-10
Weather
Visual (VMC) · Day
Status
Completed · report April 18, 1996
Report
Approved by Office Director
Safety recommendations
Yes
FAA report
19950501047989I
Case key
9763

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

failure of the safety wire and/or safety wire lug arm on one of the stage one to two disk flange bolts due to an inadequate safetying method.

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(partial) - mech failure/malfTakeoff - aborted
1 engine
Turbine assembly,air seal - disconnectedCause
Procedure inadequateManufacturerCause

Analysis

The flightcrew reported that during the application of takeoff power, when the throttles were in approximately the vertical position, the numbers 1 and 3 engines were indicating approximately 70% N1. The number 2 engine was indicating about 48% N1 and not accelerating. They heard a 'crack' and aborted the takeoff. Examination of the engine revealed that the low pressure turbine (LPT) stage one disk had separated from the LPT rotor at the stage one to two flange joint. Seven intact toroid bolts and sets of associated hardware were recovered. No evidence of fatigue cracking or corrosion (pitting) was noted on any of the bolt pieces recovered from the engine. The shank of one of the toroid bolts exhibited significant damage. The lug arm, used for safetying the bolt, exhibited relatively minor damage. Examination of several of the lug arms revealed 'noticeable wear patterns' and 'crack arrest positions indicative of fatigue cracking.' Statements by UAL maintenance personnel indicate failures of the toroid bolt safeties are occasionally discovered when the engines are disassembled for major overhaul.

Factual narrative

On May 1, 1995, about 1120 central standard time, a McDonnell Douglas DC10-10, N1811U, operated by United Airlines (UAL) as United Airlines Flight 492, sustained minor damage following the uncontained failure of the number two engine during takeoff roll.

The flight crew aborted the takeoff, returned to the gate, and deplaned the passengers without further incident. There were no injuries to the crew of 12, or the 180 passengers aboard the airplane. The scheduled domestic passenger flight, operated under 14 CFR Part 121, originated at the Chicago O'Hare International Airport with a planned destination of the Washington Dulles International Airport, Washington, D. C. An IFR flight plan was filed, and visual meteorological conditions prevailed in Chicago.

The flight crew reported that during the application of takeoff power, when the throttles were in approximately the vertical position, the number one and three engines were indicating approximately 70 percent N1. The number two engine was indicating about 48 percent N1 and not accelerating. They heard a "crack". They aborted the takeoff, pulled the number two engine fire handle and discharged the fire bottle.

The airplane was transported to the UAL maintenance hanger at O'Hare International airport where it was subsequently examined. Fragments of the turbine blades, shroud material, bolts, and the engine case were recovered from the runway, and from within the engine cowl and the engine. A gap was located in the thrust reverser latch seam which spanned approximately three inches at the trailing edge and .25 inches at the leading edge. The left cowling had a six inch by 21 inch puncture at the ten o'clock position and the right side cowling had a four inch by eighteen inch puncture at the four o'clock position.

The engine was removed from the airframe revealing a circumferential penetration of the engine case, about one inch wide, extending around about 270 degrees of the circumference from the three o'clock position to the twelve o'clock position, in the vicinity of the first low pressure turbine. One oil line on the left side of the engine was fractured and the upper surface of the left stabilizer was oil covered.

The engine was transported to the UAL engine overhaul facility, San Francisco, California, where it was examined in the presence of the Powerplants Group Chairman. In his factual report of the examination, he reported "the LPT stage one disk was separated from the LPT rotor at the stage one to two flange joint. The bore, web and rim portion of the disk were intact...Several stage one to two disk flange bolts were recovered in the debris. The fracture surfaces on the majority of the recovered bolt fragments were smoothed and rounded. Six stage one to stage two flange bolts were fractured in the shank, adjacent to the threads, in which two bolts had coarse looking fracture surfaces with varying degrees of discoloration."

The LPT components were examined by a National Resource Specialist at the NTSB laboratory, Washington, D. C. In his factual report he stated that "the internal surfaces of the engine hardware in the low pressure turbine section contained multiple small-object impact marks". Seven intact toroid bolts and sets of associated hardware were recovered. X-ray energy dispersive spectroscopy (EDS) examination of the discolored areas of the bolts revealed substantial peaks for oxygen, aluminum, sulfur, and silver. "No evidence of fatigue cracking or corrosion (pitting) was noted on any of the bolt pieces recovered from the engine." A portion of the missing bolt, identified as an unthreaded portion of the shank, designated as bolt number six, was located with the fragments recovered from within the engine. The shank of the bolt exhibited significant damage. The lug arm, used for safetying the number six bolt, exhibited relatively minor damage. Examination of several of the lug arms revealed "noticeable wear patterns" and "crack arrest positions indicative of fatigue cracking."

Statements by UAL maintenance personnel indicate failures of the toroid bolt safeties are occasionally discovered when the engines are disassembled for major overhaul.

Aircraft

Registration
N1811U
Reported as
Mcdonnell Douglas DC10-10
Category
Airplane
Serial number
46610
Airframe hours
63,749
Engine
CFM CF6-6, 39,000 lbs thrust, turbo jet
Damage
Minor damage
Flight
Part 121
Registered owner
United Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · July 23, 1994 · 1,903 hours before
Departed
ORD · IL
Destination
IAD · Washington, DC
Flight plan
IFR
Airport
ORD · O'Hare International, runway 9L, 7,967 × 150 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
56
Certificates
Flight engineer, Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
19,011 total · 2,909 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
70° at 15 knots, gusting 24
Visibility
15 statute miles
Lowest ceiling
None
Temperature
52 °F, dew point 37 °F
Altimeter
30.00 inHg
Observed at
ORD

FAA reports on this event · 1

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