# NTSB DCA04IA066: Boeing B-777, Houston, TX, August 11, 2004 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: August 11, 2004, 16:55 local (21:55 UTC) - Place: Houston, TX - Coordinates: 29.760574, -95.369628 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.7606&lon=-95.3696&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 129 uninjured - Status: Completed, report November 29, 2006 - Report: Approved by Office Director - NTSB office: Major Investigations Division - NTSB case key (mKey): 59874 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA04IA066 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/59874/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=59874 - Page: https://openairdocs.org/ntsb/DCA04IA066 ## Probable cause the failure of a high pressure turbine blade which damaged an oil seal and allowed smoke to enter the cabin. Contributing to the blade failure was the mis-labeling of the blade's part number by the manufacturer, which allowed the blade to remain in service far in excess of it's life limit. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - mech failure/malf, takeoff - 1 engine - turbine assembly,turbine blade - failure - inadequate substantiation process, manufacturer (contributing factor) - procedure inadequate, manufacturer - turbine assembly,turbine blade - fatigue (cause) - compressor assembly,oil seal - failure (cause) - Forced landing, landing - precautionary landing - performed, flightcrew ## Analysis As the throttles were advanced for takeoff, the flightcrew heard a noise and felt a vibration from the left side of the airplane. As the airplane rotated, the crew received a cockpit warning of LH Eng Vibration - Level 5. During the climb, the crew observed smoke and haze in the cockpit and the cabin crew advised that the cabin was filling with smoke. The flightcrew declared an emergency and made an immediate landing and emergency evacuation. The investigation revealed that a turbine blade in the left engine had failed due to a fatigue crack and the resulting damage caused excessive vibration in the engine. As the engine continued to vibrate, an oil seal failed allowing oil to contaminate the bleed air and create smoke in the cockpit and cabin. The failed blade had been mis-marked with the wrong part number by the manufacturer, which allowed it to remain in service far in excess of it's life limit until the fatigue crack developed. ## Factual narrative HISTORY OF FLIGHT On August 11, 2004, at approximately 1655 Central Daylight Time (PDT), a Boeing 777, G-VIID, operated by British Airways as flight 2024, experienced an engine failure upon takeoff from George Bush Houston Intercontinental Airport, Houston, Texas. The scheduled international passenger flight was being operated under the provisions of Title 14 CFR Part 129 and was en route to Gatwick International Airport, London, United Kingdom. The flightcrew declared an emergency and returned to Houston where an emergency evacuation was conducted. There were no injuries to the 3 flight crew, 12 cabin crew or 114 passengers. According to the flightcrew, as the throttles were advanced for takeoff, an unusual noise and vibration was heard on the left side of the airplane. The captain, who was the non-flying pilot, initially commented that it might be the runway surface grooving. As the groundspeed increased, all engine parameters appeared normal and the takeoff proceeded. As the airplane rotated, the crew received a cockpit warning of LH Eng Vibration - Level 5. As the airplane reached 1,500 feet AGL, the crew observed smoke and haze in the cockpit. The flight was leveled off at 4,000 AGL, and the crew donned oxygen masks. At that time, the cabin crew advised that they had heard a loud noise from the left side of the airplane and that the cabin was filling with smoke. The flightcrew reduced thrust on the left engine and decided to make an immediate overweight landing back at Houston. They declared an emergency and coordinated with ATC for an immediate landing. The airplane touched down safely and the captain ordered an emergency evacuation. All doors were used in the evacuation except the L4 door, which was not used due to the firefighting activity at the left engine. ENGINE INFORMATION The airplane was powered by two GE90-85B engines. The GE90-85B is an ultra-high bypass (8.4:1), variable stator, dual rotor axial-flow turbofan engine that features a 10-stage high pressure compressor and is rated for 88,870 pounds takeoff thrust. The left engine, S/N 900262, had accumulated 23,120 hours and 3,369 cycles since new. The engine had previously been removed from another airplane on September 24, 2003, with 20,586 hours and 2,999 cycles. A heavy shop visit, which included an overhaul of the High Pressure Turbine (HPT) was then performed at the GE Engine services facility in Cardiff, Wales. The engine was returned to service and installed on the accident airplane on January 26, 2004. TESTS AND RESEARCH Teardown of the left engine revealed that the stage 2 high pressure turbine (HPT) blade in position 35 had separated at its shank and damaged the trailing blades. This localized damage resulted in vibration and imbalance of the core rotor. As the engine continued to operate, asymmetric rotation caused the engine's #3 air/oil seal to fail. This seal failure allowed engine oil to enter the airpath, contaminating the bleed air being delivered to the airplane, and resulting in the smoke and fumes seen in the cockpit and cabin. The investigation revealed that the stage 2 HPT blade in Position 35 had been manufactured from on obsolete P/N 1708M21P13 casting, yet was marked as a P/N 1708M21P19 blade. Blades that were manufactured from the P/N 1708M21P13 casting were limited to a service life of 1,100 cycles because of a problem with low cycle fatigue cracking. That problem was later resolved and blades subsequently manufactured as P/N 1708M21P19 blades had no life limit. Due to the mis-marking of the P/N 1708M21P13 accident blade with P/N 1708M21P19, it was not removed from service when it accumulated 1,100 cycles. At the time of the accident, the blade had accumulated 3,333 cycles. Metallurgical examination of the blade confirmed that the crack originated at the predicted stress point and failed in fatigue after exceeding the life limit. Comprehensive review of all P/N 1708M21P19 blades produced by this manufacturer confirmed that no other blades were mis-labeled and additional review steps were added to the manufacturing process to ensure that no further mis-identified blades will be shipped. ## Aircraft - Registration: G-VIID (not matched to a registry record) - Reported make and model: Boeing B-777 - Category: Airplane - Engines: General Electric GE90-85B 88870 lbs thrust turbo fan - Damage: Minor damage - Flight: Part 129 - Operator: British Airways - Airworthiness certificate: Standard, Transport - Departed: IAH, Houston,, TX - Destination: LHR, London - Flight plan: IFR - Airport: IAH, Houston Intercontinental ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; injuries: none; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; seat: left; flight hours: 18,000 total, 2,000 in this make and model ## Weather - Conditions: Visual (VMC) - Wind: 150° at 5 knots - Visibility: 18 statute miles - Temperature: 93 °F - Altimeter: 29.88 inHg - Observed at: IAH ## Docket (16 files) The files NTSB released with the investigation on November 8, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=59874. 15.1 MB in all. - Survival Factors 6 - Factual Report of Group Chairman (item 1, .PDF, 231 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241355&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Survival Factors 6 - Attachment 1 - F/A Statements (item 2, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241311&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%201%20-%20F%2FA%20Statements-Redacted.PDF - Survival Factors 6 - Attachment 2 - ARFF Report And Firefighters' Statement (item 3, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241312&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%202%20-%20ARFF%20Report%20And%20Firefighters%27%20Statement-Redacted.PDF - Powerplants 8 - Factual Report of Group Chairman (item 4, .PDF, 10 photos, 899 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224579&FileExtension=.PDF&FileName=Powerplants%208%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Powerplants 8 - Addendum 1 Statement of Warren Hooker, Fireman (item 5, .PDF, 12 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40266173&FileExtension=.PDF&FileName=Powerplants%208%20-%20Addendum%201%20Statement%20of%20Warren%20Hooker,%20Fireman-Master.PDF - Powerplants 8 - Addendum 2 Configuration Control Investigation (item 6, .PDF, 1 photo, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40266445&FileExtension=.PDF&FileName=Powerplants%208%20-%20Addendum%202%20Configuration%20Control%20Investigation-Master.PDF - Powerplants 8 - Attachment 1: Diagram, GE90 Sump Pressurization and Vent System (item 7, .PDF, 252 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224958&FileExtension=.PDF&FileName=Powerplants%208%20-%20Attachment%201%3A%20Diagram,%20GE90%20Sump%20Pressurization%20and%20Vent%20System-Master.PDF - Powerplants 8 - Attachment 2: St 2 HPT Build List (item 8, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224959&FileExtension=.PDF&FileName=Powerplants%208%20-%20Attachment%202%3A%20%20St%202%20HPT%20Build%20List-Master.PDF - Powerplants 8 - Attachment 3: St 2 HPT blade S/N and Weights As Removed (item 9, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224961&FileExtension=.PDF&FileName=Powerplants%208%20-%20Attachment%203%3A%20St%202%20HPT%20blade%20S%2FN%20and%20Weights%20As%20Removed-Master.PDF - Powerplants 8 - Attachment 4: Engine Oil & Debris Analysis (item 10, .PDF, 879 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438550&FileExtension=.PDF&FileName=Powerplants%208%20-%20Attachment%204%3A%20Engine%20Oil%20%26%20Debris%20Analysis-Redacted.PDF - Powerplants 8 - Attachment 5: GE90 SB 78-A0006 (item 11, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224963&FileExtension=.PDF&FileName=Powerplants%208%20-%20Attachment%205%3A%20GE90%20SB%2078-A0006-Master.PDF - Powerplants 8 - Attachment 6: GE90 SB 78-13-00 (item 12, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224964&FileExtension=.PDF&FileName=Powerplants%208%20-%20Attachment%206%3A%20%20GE90%20SB%2078-13-00-Master.PDF - Powerplants 8 - Attachment 7: GE90 SB 72-400R2 (item 13, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40224965&FileExtension=.PDF&FileName=Powerplants%208%20-%20Attachment%207%3A%20%20GE90%20SB%2072-400R2-Master.PDF - General Electric Metallurgical Report FA Log No. 12714 (item 14, .PDF, 6.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40240204&FileExtension=.PDF&FileName=General%20Electric%20Metallurgical%20Report%20FA%20Log%20No.%2012714-Master.PDF - Flight Data Recorder 10 - Factual Report of Group Chairman (item 15, .PDF, 258 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241339&FileExtension=.PDF&FileName=Flight%20Data%20Recorder%2010%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Flight Data Recorder 10 - Attachment 1 DCA04IA066 FDR Tabular (item 16, .CSV, 357 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40241340&FileExtension=.csv&FileName=Flight%20Data%20Recorder%2010%20-%20Attachment%201%20DCA04IA066%20FDR%20Tabular-Master.csv From the NTSB's public API. 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