DCA25LA114

United Airlines flight 1382, an Airbus A319, experienced a contained failure of the right engine during its takeoff roll at George Bush Intercontinental Airport (IAH), Houston, Texas. The flight crew rejected the takeoff and stopped the airplane on the runway, and the aft flight attendants initiated an emergency evacuation. Although no injuries were reported among 107 passengers and 5 crew members, the event prompted an emergency response, partial evacuation, and subsequent investigation into passenger behavior and slide deployment issues. Figure 1. Photo of evacuation door slide 2L after aborted takeoff. (Source: United Airlines) The flight crew reported no operational or air traffic control (ATC) pressures during taxi and confirmed all checklists were completed. Takeoff commenced using reduced thrust and prior to reaching V1 (138 knots), a loud bang was recorded on the cockpit voice recorder (CVR), followed by an “ENG 2 FAIL” indication, and a momentary yaw to the right. After initiating a rejected takeoff, the flight crew made a passenger announcement (PA) instructing passengers to remain seated, and they brought the airplane to a complete stop on runway 15R. The flight crew initiated the rejected takeoff checklist. Shortly thereafter, the procedure was interrupted by a call from a flight attendant (FA), who relayed that several passengers had reported observing a fire in the right engine. In response, the flight crew transitioned to the Engine Fire Checklist. Subsequent coordination with cabin crew confirmed that no smoke was present within the passenger cabin. The flight crew contacted ATC to report the situation and requested airport rescue and firefighting (ARFF) assistance. Evacuation There were three FAs assigned to the flight: the forward FA (FM1), acting as the purser, and two aft FAs—FA2 positioned at Door 2R and FA1 positioned at Door 2L. Following the flight crew’s PA announcement instructing passengers to remain seated, both the purser and FA2 repeatedly issued verbal commands reinforcing this directive. Despite these efforts, multiple individuals began shouting, “fire on the engine, let me get out!”—specifically referring to the right engine. This triggered widespread panic among the aft cabin passengers, many of whom stood up and began retrieving personal belongings. FA2 and the purser attempted to calm the cabin, instructing passengers to stay seated and return items to the overhead bins. Airbus’s Cabin Crew Operating Manual (CCOM) 14 030, Evacuation Guidelines – Assessing the Outside Conditions, requires crew members to evaluate exterior conditions, ensuring the slide deployment area is free of smoke, fire, a running engine, or obstacles. According to United Airlines, in a situation where FAs must take immediate action in the interest of safety, FAs should attempt to contact the pilots prior to initiating an evacuation. However, if conditions exist where danger is obvious and imminent, or contact is not possible, flightattendants should evacuate as quickly as possible by using the appropriate commands. They must also assess conditions (look for fire or other hazards inside and outside the aircraft) and shout: “STAND BACK!” while assessing exits. If the route is usable, proceed with evacuation and then continue to assess conditions throughout the evacuation. For a FA to detect a running engine, an FA would need to utilize auditory cues or establish contact with the flight deck. According to statements from the cabin crew, FA1 conducted an external assessment using the 2L and 2R door viewing windows and observed no smoke, fire, obstructions, or other abnormalities. The statements did not indicate whether FA1 attempted to assess whether the left engine was still operating. FA1 next attempted to assess the interior cabin; however, passenger behavior impeded this effort. Passengers began shouting “fire,” climbing over seats, and obstructing the aisle with carry on baggage as they moved toward the aft galley. This congestion physically prevented FA1 from accessing the economy cabin area to conduct a more complete evaluation. Additionally, three tall and large male passengers moved toward Door 2L insisting that an evacuation occur. FA1 was forced to step back until positioned against the aft lavatory adjacent to 2L. One passenger was described as aggressive and vocal, repeatedly stating, “Open this door now!” and “We need to get out—there is a fire!” FA1 continued issuing instructions: “Please stand back and stay clear of the galley and door area. The flight attendants and pilots are assessing conditions. I need to assess conditions and can only do that if everyone remains seated.” Despite this, the passengers were described as panicked, fearful, and acting irrationally. FA1 attempted to contact the captain via interphone but received no response. FA1 then attempted to reach the purser, also without success. With passengers escalating their attempts to reach the doors, FA1 informed FA2 that a flight attendant initiated evacuation was necessary, and FA2 agreed. FA2 asked which side to use, and FA1 indicated the left side. FA2 moved to block door 2R while FA1 proceeded to open door 2L. The aft FAs did not activate the evacuation alarm before or after opening the door because the passengers in the aft were already moving towards an emergency exit. The evacuation alarm serves as an auditory signal not only to passengers, but it also alerts crew that an emergency evacuation is required. Because the evacuation alarm was not activated, there was a delay in the flight crew’s awareness of the cabin evacuation which contributed to the left engine running during slide deployment. FA1 continued issuing “stand back” commands and attempted to verify full slide deployment. However, as soon as the door opened, the three male passengers pushed past FA1 and went down the 2L slide before it had fully deployed. Immediately following their descent, the slide began to deflate. Recognizingthat the slide was no longer functional, FA1 blocked the 2L exit using “exit block—stand back” commands and instructed passengers to wait, as the exit was no longer usable. This highlights the challenges faced by cabin crews when attempting to manage passenger behavior during emergencies or perceived emergency situations, particularly when passenger fear and urgency result in disregard for crewmember authority and standard evacuation procedures. Cabin crew training emphasizes assertive command presence and passenger control during evacuations; however, this event demonstrates how rapidly escalating passenger behavior can affect evacuation dynamics even in the absence of confirmed fire or smoke conditions. Since passengers were now visible outside the airplane on the left side and firefighters were present near their vehicles, the captain instructed the FO to initiate the evacuation checklist. Five seconds later, the purser queried the flight crew regarding deployment of the forward left door (1L) evacuation slide, and the crew confirmed the deployment. The captain indicated that when the FA communicated with him about the evacuation at 1L, they immediately started to shut down the left engine. The captain also indicated that when the 2L and 2R doors opened, without his command, the left engine was still running. Post-incident review of airport surveillance footage confirmed the sequence of door openings, passenger egress and the erratic behavior of the 2L slide while the left engine was still running. Critical coordination challenges can exist between flight and cabin crew during emergency scenarios, particularly regarding communication, evacuation command authority, and procedural adherence. In this incident, the failure to activate the evacuation alarm and the premature opening of doors while an engine was running, contributed to evacuation complications and potential safety risks. Evacuation Slides Examination All evacuation slides were removed and initially inspected by United Airlines and subsequently examined in detail by Safran Aerosystems Evacuation, the slide manufacturer. The root cause for the deflation of the evacuation slide at door 2L was the partial separation of the communication patch assembly between a side support tube and the main body of the slide assembly. This separation allowed the pressurized gas inside the slide assembly to escape, causing the slide assembly to deflate. Examination of the separated area on the communication patch indicated that the patch separated due to a mechanical separation of the coating layers of the slide fabric, and not due to a loss of adhesion at the bond lines that linked the communication patch to the fabric on the side support tube and to the sill tube of the slide assembly. The adhesive bond between fabrics remained intact; it was the coating layer that peeled off the fabric when the communication patch separated. This evidence indicated that the communication patch assembly separated dueto a structural overload, and not due to cement degradation. A review of airport video footage revealed that at about 1.5 minutes after the airplane came to a stop, the evacuation slide at door 2L deployed and rapidly inflated. Immediately upon deployment, the slide was blown aft and began to twist violently. The slide remained attached to the doorway, and flapped up and down, which resulted in the end of the slide repeatedly bouncing off the ground and then rising so that it was horizontal and aft of the 2L door. During this time, three passengers were observed to have utilized the slide. This erratic motion continued for approximately 100 seconds. The flight data recorder (FDR) information showed that the left engine, located on the left wing forward of the 2L evacuation door/slide, was still operating at the time. As a result, the motion of the slide caused by the running engine led to the communication patch assembly separation. Safran indicated that slide inflation into the exhaust airstream of an operating aircraft engine is outside the design parameters for an evacuation system. When evacuation slides are tested with wind speeds up to 25 knots (per 14 Code of Federal Regulations 25.810 requirements), they generally experience less movement, compared to the subject event. The deployed forward left door (1L) and aft right door (2R) evacuation slides were briefly inspected, with no unusual findings. These slides were deployed successfully and were used during the evacuation. The forward right door (1R) slide was not inspected because it was still in its packed condition. Right Engine Examination Post-incident borescope inspection of the right engine revealed significant damage to the high-pressure compressor (HPC) 3rd stage rotor blades, including one blade that had fractured and separated below the platform. The engine was subsequently removed and transported to United Airlines’ maintenance facility in San Francisco, California for a detailed teardown examination. This examination confirmed the blade separation and identified additional downstream impact damage, consistent with liberated blade fragments entering the gas path. Metallurgical analysis determined that the primary fracture originated on the concave side root pressure face, approximately 0.12 inch from the leading edge, and was caused by high cycle fatigue (HCF). A secondary HCF fracture was also observed near the balance hole, with evidence of shot peening. Wear on the mid-span shrouds of adjacent blades was noted, a condition known to reduce blade engagement and increase operational stresses, contributing to crack initiation and eventual failure. The incident blade had accumulated over 40,000 hours and 19,536 cycles since installation and although the engine was equipped with redesigned HPC 3rd stage blades per International Aero Engines (IAE), Service Bulletin (SB) 72-0487 Revision 2, intended to mitigate such failures, the incident blade still fractured and seperated. Thefindings indicate that despite compliance with the SB and use of improved blade design, HCF-related failure mechanisms remain a persistent risk within the V2500 engine fleet. Passengers Noncompliance during Emergency Evacuation After the rejected takeoff, evacuation efforts were complicated by passenger panic in the aft cabin following reports of a right engine fire. Despite FAs’ repeated instructions to remain seated, several passengers moved toward the rear exits with carry-on items. The presence of carry-on baggage significantly impeded the evacuation flow, requiring crew intervention. This issue reflects a longstanding safety concern identified in the NTSB’s June 2000 safety study which found that passenger insistence on retrieving carry-on items was the most frequently cited obstruction during emergency evacuations. Although no injuries have been directly attributed to such delays, the potential risk remains unquantified due to the absence of formal studies measuring evacuation delays or evaluating countermeasures. In response, the NTSB issued Safety Recommendation A-00-88, prompting Federal Aviation Administration (FAA) revisions to crew training guidance and briefing materials, now incorporated into FAA Orders 8400.10 and 8900.1, and Advisory Circulars 121-24C and 121-29B. More recently, Safety Recommendation A-18-009, stemming from the 2016 American Airlines flight 383 accident, urged the FAA to conduct research on the impact of carry-on baggage being retrieved by passengers during evacuations and identify effective mitigation strategies. On September 16, 2025, the FAA issued a Safety Alert for Operators (SAFO) 25003 addressing safety risks associated with passenger noncompliance during emergency evacuations, specifically the retrieval or retention of carry-on baggage and personal items. According to operational data and post-event analyses cited in the SAFO, attempts by passengers to retrieve belongings during evacuations have been shown to delay egress, increasing the likelihood of injury and reducing survivability in time-critical events, including those involving fire or structural damage. SAFO 25003 recommends that operators review and, as necessary, enhance evacuation procedures, passenger safety briefings, and educational materials to reinforce the importance of leaving all personal items behind during an evacuation. The SAFO further recommends the use of operators’ Safety Management Systems to identify and mitigate evacuation-related hazards, the adoption of standardized messaging in safety briefings, and the implementation of passenger outreach strategies, including visual aids and universally recognizable symbols, to promote compliance during emergency evacuations.

Flight 1382 was a scheduled passenger flight, from IAH to LaGuardia (LGA) airport, New York, New York, with a planned departure time of 0805 CST. The flight crew reported that this was day three of a four-day trip. The captain was the pilot flying, and the first officer (FO) was pilot monitoring. According to the flight crew, there were no operational or ATC pressures while taxiing to runway 15R. All checklists were completed in advance, and the correct runway was verified prior to takeoff. Takeoff was conducted using reduced thrust, with a 10-knot tailwind, as per the runway 15R takeoff data message. V1, the takeoff decision speed, was calculated at 138 knots. According to the CVR, the flight was cleared for takeoff by the IAH local control (LC) controller at 0814:08. Flight data recorder (FDR) data showed that the airplane aligned with the runway heading at about 0814:33. At 0814:43, the CVR captured sounds consistent with an increase in engine rpm and the FDR showed that engine N1 (low-pressure compressor), the longitudinal acceleration, and the ground speed increased, consistent with the start of the takeoff roll. At 0815:00, the pilot monitoring made the standard 100-knot callout. At 0815:05, prior to reaching V1, a loud bang was recorded on the CVR, after which the flight crew declared a rejected takeoff. The flight crew reported that this event was followed by electronic centralized aircraft monitor (ECAM) indications of “ENG 2 FAIL,” accompanied by a momentary yaw of the aircraft to the right. At 0815:17, the flight crew then made a PA announcement instructing passengers to remain seated. According to United, during a rejected takeoff, pilots will make the “remain seated, remain seated” announcement. This announcement is meant to prevent passenger movement and allow for assessment of conditions and if necessary, secure the airplane for an evacuation. The flight crew will repeat this command if the FAs make them aware passengers are standing up. When FAs hear the “remain seated” command, according to the FA operating manual and their training, when the airplane comes to a stop, they will release their seatbelts and get out of their jumpseat and assess conditions inside and outside of their assigned exit(s) but will not initiate an evacuation. The FA operating manual permits FAs to initiate an evacuation independently if they believe that there is an imminent threat to the safety of the cabin and cannot reach the flight deck via the interphone. According to the FDR, during the takeoff roll, the indicated airspeed reached a maximum of 125 kts before decreasing. At 0815:30, the aircraft came to a complete stop on runway 15R. Three FAs were assigned to this flight; the purser (FM1), and two aft flight attendants—FA2 at Door 2R and FA1 at Door 2L. After the flight crew made the PA announcement instructing passengers to remain seated, the purser and FA2 repeatedly instructed passengers to “remain seated,” but heard multiple individualsshouting, “fire on the engine, let me get out!”—specifically referencing the right engine. This led to widespread panic among passengers seated in the aft cabin, many of whom stood up and began retrieving personal items. FA2 and the purser worked to calm the passengers, directing them to remain seated and return their belongings to the overhead bins. Both aft FA’s reinforced these instructions via PA announcement: “Please remain seated until further information from the captain.” According to Airbus’s CCOM 14-030, Evacuation Guidelines - Assessing the Outside Conditions chapter, the crew must assess the outside conditions, checking that the slide deployment area is clear of smoke, fire, or obstacles and engines aren’t running. According to United Airlines, in a situation where flight attendants must take immediate action in the interest of safety, flight attendants should attempt to contact the pilots prior to initiating an evacuation. They must also assess conditions (look for fire or other hazards inside and outside the aircraft) and shout: “STAND BACK!” while assessing exit. If the route is usable, proceed with evacuation and then continue to assess conditions throughout the evacuation. For a FA to detect a running engine, an FA would need to utilize auditory cues or establish contact with the flight deck to determine if an engine is running. According to cabin crew statements, FA1 assessed the outside conditions through the 2L and 2R door viewing windows and observed no obstructions, fire, smoke, or other abnormalities. The cabin crew statements did not include any information regarding if FA1 tried to evaluate whether the left engine was still running. FA1 then attempted to assess the economy cabin; however, passengers began shouting “fire” while climbing over seats and obstructing the aisle with carry-on baggage as they moved toward the aft galley. Due to the passenger congestion, there was no physical access from the aft galley into the economy cabin to further evaluate conditions. The passengers did not comply with crew instructions to remain seated. Additionally, three tall and large-in-size male passengers moved toward the aft exit, insisting on evacuating. According to cabin crew statements, FA1 had to take a couple steps back until she was up against the aft lavatory, located next to the 2L door. One customer was very aggressive and vocal. He stated, “Open this door now!” while pointing at the 2L door, and added, “We need to get out—there is a fire!” FA1 continued to issue directions to the passengers; “Please stand back and stay clear of the galley and door area, the flights attendants and pilots are assessing conditions. I need to assess conditions, and I can only do that if everyone remains seated.” FA1 tried to reach the captain, via interphone, and waited for him to answer, then tried the purser. FA1 was unsuccessful in getting any response. FA1 then told FA2 they needed to do a flight attendant-initiated evacuation, and FA2agreed. FA2 asked which side to use, and FA1 confirmed the left side. FA2 blocked door 2R, while FA1 opened door 2L, in the armed position. FA1 continued to provide stand back commands and attempted to observe the slide’s full deployment. However, as soon as the door opened, the three male passengers moved past her and started sliding down the 2L slide before it was completely deployed. After they went down the slide, it started to deflate. She then blocked the 2L exit with the exit block “stand back” command and instructed the rest of the passengers to wait as the slide was no longer functional. The aft FAs reported that the evacuation alarm was not activated because the passengers in the aft were already beginning to move towards an emergency exit. The evacuation alarm serves as an auditory signal to passengers and crew that an emergency evacuation is required. About the same time in the forward cabin, the purser observed passengers towards the middle and back sections of the airplane standing up, opening overhead bins, and standing on their seats. The purser issued a command over the PA instructing all passengers to take their seats. Immediately following this announcement, the purser heard someone yell “fire.” The purser subsequently proceeded to the overwing exit area to assess the situation. By the time the purser got there, passengers were yelling “fire.” Without sufficient time to conduct a full assessment, the purser returned to the front of the aircraft and placed an emergency call to the flight deck. At 0815:49, the flight crew initiated the rejected takeoff checklist. Shortly thereafter, the procedure was interrupted by a call from a flight attendant, who relayed that several passengers had reported observing a fire in the right (number 2) engine. In response, the crew transitioned to the Engine Fire Checklist. Subsequent coordination with cabin crew confirmed that no smoke was present within the passenger cabin. At 0816:45, the flight crew contacted ATC to report the situation and requested ARFF assistance. According to United, their emergency procedures start with a Quick Reference Checklist (QRC) which includes selected emergency procedures requiring immediate crew response. The pilots will perform the QRC procedure and subsequently proceed to the non-normal procedures presented by ECAM. The QRC contains the checklist for rejected takeoff which includes a decision point for if an evacuation is required. At 0816:55, the crew received a call from a flight attendant reporting smoke in the rear of the aircraft and that they had opened the aft left door (2L). A review of airport video footage revealed that about 1.5 minutes after the airplane came to a stop, the evacuation slide at door 2L deployed and rapidly inflated. Immediately upon deployment, the slide was blown aft and began to twist violently. The slide remained attached to the doorway, and flapped up and down, which resulted in the end of the slide repeatedly bouncing off theground and then rising so that it was horizontal and aft of the 2L door. This erratic motion continued for approximately 100 seconds, during which several passengers egressed, using the slide during the moments it touched the ground. The FDR information showed that the left engine, located on the left wing, forward of the 2L door/slide, was still operating at the time. After FA1 determined that door 2L was unsafe for evacuation and blocked it, FA2 evaluated conditions outside door 2R. He observed smoke but no visible flames, and initiated evacuation from that door. At approximately 0817:41, the video footage indicated the 2R door was opened. The 2R door slide pack was observed to be deployed normally. Passengers were observed exiting the 2R door via the slide. Most passengers attempted to bring their belongings, requiring FA2 to intervene and place roller bags on the galley surface to maintain evacuation flow. Ground personnel assisted at the slide bottom, guiding passengers to a safe distance. On most aircraft in the United fleet, the over wing exits are not a primary exit for FAs to open. Customers would open the over wing exits, if necessary, in an emergency. FAs would make their way to open them after opening doors, time and conditions permitting. In the case of the event airplane, this would be FA2. FA2 was also responsible for the 2R door and was performing primary evacuation functions at that door during the evacuation. At 0818:06, the flight crew contacted the cabin crew to assess the extent of visible smoke. The purser informed the captain that passengers had reported seeing “fire” on the airplane’s right engine and wing. To assess the extent of visible smoke, the purser turned the cabin lights to bright and reported that there was “light smoke” in the aft of the cabin. The purser subsequently saw a “rush of light” enter the aft galley and saw passengers start to exit through the 2L door. The purser informed the captain that passengers were now evacuating in the rear of the aircraft and asked whether to initiate evacuation from the front. According to purser, the captain responded in the affirmative and instructed to use only door 1L, since the fire was on the right side of the aircraft. The flight crew then communicated with the aft cabin flight attendant, who confirmed visible smoke outside the aircraft, on the right side, and stated that passengers observed fire and began evacuating. The initial attempt to evacuate through the 2L door was unsuccessful due to a deflated slide, prompting the use of the 2R door instead. The flight crew subsequently instructed that the evacuation should proceed via the left side of the aircraft. At 0819:19, the captain instructed the FO to initiate the evacuation checklist. According to the captain, at that time, there were already people visible outside, on the left side of the airplane, and firefighters were present, near their vehicles. Five seconds later, at 0819:24, the forward flight attendantqueried the flight crew regarding deployment of the forward left door (1L) evacuation slide, and the crew confirmed the deployment. According to United, the Digital Aircraft Integrated Data System (AIDS) Recorder (DAR) recorded that the 1L (Left Forward Cabin Door) was opened at 0819:47. The captain indicated that when the FA communicated with him about the evacuation at 1L, they immediately started to shut down the left engine. At 0821:04, the flight data recorder stopped recording. It stops recording when all engine master switches are selected to the “off” position. At the last available sample, the left engine was running at a power setting consistent with ground idle. The auxiliary power unit (APU) was off. The captain also indicated that when the 2L and 2R doors opened, without his command, the left engine was still running. While executing the evacuation checklist, ARFF personnel confirmed, via the radio, that there was no fire on the aircraft's exterior. After visually inspecting the cabin and confirming the absence of fire and smoke, the captain halted the evacuation with 15 passengers still onboard, to prevent injury. These remaining passengers were later deplaned via airstairs. Following the evacuation, the cabin and flight crew deplaned and the captain spoke with the aft FAs. They informed him that the evacuation was initiated because three passengers got out of their seats, after repeatedly being told to remain seated, came to the rear of the aircraft, and demanded that the door be opened because "the plane was on fire." Door 2L was initially opened, but that slide did not properly deploy, however three passengers exited through that door. FA2 then opened door 2R and passengers proceeded to evacuate via the fully inflated slide. By then, the right engine had been shutdown. Aft (2L) Evacuation Door Slide Examination All evacuation door slides were removed from the airplane and initially inspected by United Airlines, see figure 2, and then sent to the slide manufacturer’s engineering center located in Belmar, New Jersey for further examination. Figure 2. Photo of all evacuation door slides after removal. (Source: United Airlines) Initial inspection of the 2L slide found it to be in good condition except for a torn air holding “communication” patch assembly between the side support tube and the main sill tube of the assembly, see figure 3. The communication patch is an assembly of several fabric layers that are cemented together and then reinforced with a sewn stitch line around the cemented area. This communication patch assembly is designed to serve two functions to support inflation of a slide. The first way is to provide an interior pathway for inflation gas to flow from the main body of the slide into the side support tube during the inflation process. The second function of the communication patch assembly is to provide structural support to link the side support tube to the slide body. Figure 3. Photo of the breach of the 2Lslide. (Source: United Airlines) A close-up view of the separation in the communication patch assembly is shown in figure 4. Figure 4. Communication patch assembly separation. (Source: Safran) Examination of the separated area on the communication patch found that the reinforcement stitching that links the two sides of the communication patch assembly was ripped apart. In the cemented area of the communication patch assembly, the fabric coating on the support tube side of the communication patch assembly had peeled away and remained cemented to the sill tube side of the communication patch assembly. According to Safran, when evacuation slides are tested with wind speeds up to 25 knots, per 14 Code of Federal Regulations 25.810 requirements, they generally experience less movement, compared to the subject event. According to IAE, the exhaust jet velocities at idle as published in the V2500-A5 Operating Instructions exceed 25 knots. Engine Examination A borescope inspection of the right engine following the incident revealed extensive HPC 3rd stage rotor blade damage, including one HPC 3rd stage blade that was fractured and separated below the blade platform. The engine was removed from the airplane and shipped to United Airlines San Francisco, CA maintenance facility for teardown examination. The teardown examination confirmed the HPC 3rd stage blade separation and identified additional downstream HPC impact damage, consistent with loose blade fragments entering the gas path following the initial failure. The fractured HPC 3rd stage blade root and the adjacent HPC 3rd stage blades on each side of the failed blade were examined by United Airlines materials laboratory. The analysis determined the primary fracture origin was located below the blade platform on the concave side root pressure face, approximately 0.12 inch from the leading edge. The fracture surface features indicated the failure mode HCF. A secondary HCF fracture progression was also observed from the convex region near the forward edge of the balance hole, where indications of shot peening were observed. Mid-span shroud, also referred to as clapper, wear was present on both blades adjacent to the failed blade. Mid-span shroud wear is known to result in reduced blade engagement that affects blade steady state stresses during operation and can cause crack initiation and eventual blade fracture. The engine manufacturer, IAE, released SB 72-0487 in June 2005, to introduce a redesigned HPC 3rd stage blade with improved clapper design features. The redesigned blade reduced the rate of failures but did not eliminate failure mode across the V2500 fleet. According to United Airlines, the incident engine was in compliance with SB 72-0487 Revision 2 and had new redesigned HPC 3rd stage blades installed in March 2009. At the time of the incident, the right engine had accumulated 40,615 hours and 19,536 cycles since the new blades were installed. Subsequent to the March 2009 shop visit of theincident engine, in October of 2024 IAE released Service Bulletin 72-0716 with a new clapper hard coating application process to further improve clapper wear characteristics and improve blade durability. Evacuation Multiple flight attendants reported that, despite repeated commands to “remain seated,” several passengers in the aft cabin stood up, retrieved personal belongings, and moved toward the rear exits. Three male passengers, described by cabin crew as physically large and assertive, refused to comply with flight attendant directions, verbally demanded that an exit be opened, and insisted that the airplane was on fire. According to cabin crew statements, these passengers continued toward the aft exits despite being told that the situation was still being assessed and that evacuation had not been authorized by the flight crew. Flight attendant statements further indicated that these passengers used physical proximity and verbal pressure to compel access to the 2L door, exited the aircraft via the 2L slide despite being advised that the slide was unstable, and did not remain at the bottom of the slide to assist subsequent evacuees. Cabin crew reported that these actions contributed to increased panic among other passengers in the aft cabin and complicated efforts to maintain order and control during the rejected takeoff response. Passengers evacuating airplanes with carry-on baggage has been a recurring concern. In our June 2000 safety study on emergency evacuations of commercial airplanes, the NTSB stated that flight attendants had reported that their attempts to maintain a constant flow of passengers out an emergency exit “were often thwarted by passengers’ insistence on retrieving their carry-on luggage before evacuating.” Flight attendants are trained to instruct passengers not to evacuate with carry-on baggage because doing so could potentially slow the egress of passengers during an evacuation and block an exit during an emergency. Although the NTSB’s safety study found that passengers exiting with carry-on baggage was “the most frequently cited obstruction to evacuation,” the NTSB has not identified any evacuations in which delays related to carry-on baggage resulted in injuries. Also, the NTSB is not aware of any study performed that (1) measured potential delays associated with passengers retrieving and carrying baggage during an emergency evacuation and (2) determined the appropriate countermeasures to mitigate any related potential safety risks. As a result of findings from our safety study, the NTSB issued Safety Recommendation A-00-88, which asked the FAA to “develop advisory material to address ways to minimize the problems associated with carry-on luggage during evacuations.” In January 2002, the NTSB classified the recommendation “Closed— Acceptable Action” because the FAA had revised Order 8400.10 to direct Principal Operations Inspectors (POIs) to encourage their assigned certificate holders to provide, in crewmembermanuals and training programs, clear direction and guidance to minimize the problems associated with passengers evacuating with carry-on baggage during emergencies. (This information was subsequently incorporated into FAA Order 8900.1.) In addition, advisory circular (AC) 121-24C, “Passenger Safety Information, Briefing and Briefing Cards,” provides guidance to Part 121 carriers regarding the items that should be included in oral passenger briefings and on passenger briefing cards. Specifically, Appendix 1 states that oral briefings must be supplemented with briefing cards and that the content of the briefing cards should, among other things, “inform passengers that in an emergency situation, they should not bring carry-on baggage to the exit.” Further, AC 121-29B, “Carry-On Baggage,” states, in paragraph (k), that air carriers should provide training to all crewmembers regarding the carrier’s approved carry-on baggage program, including how to handle carry-on baggage during an emergency. One of the Safety Recommendations issued to the FAA as a result of NTSB Aviation Accident Report “Uncontained Engine Failure and Subsequent Fire American Airlines Flight 383 Boeing 767-323, N345AN Chicago, Illinois October 28, 2016,” was A-18-009. This recommendation stated: Conduct research to (1) measure and evaluate the effects of carry-on baggage on passenger deplaning times and safety during an emergency evacuation and (2) identify effective countermeasures to reduce any determined risks, and implement the countermeasures. On September 16, 2025, the FAA issued SAFO 25003 addressing safety risks associated with passenger noncompliance during emergency evacuations, specifically the retrieval or retention of carry-on baggage and personal items. According to operational data and post-event analyses cited in the SAFO, attempts by passengers to retrieve belongings during evacuations have been shown to delay egress, increasing the likelihood of injury and reducing survivability in time-critical events, including those involving fire or structural damage. SAFO 25003 recommends that operators review and, as necessary, enhance evacuation procedures, passenger safety briefings, and educational materials to reinforce the importance of leaving all personal items behind during an evacuation. The SAFO further recommends the use of operators’ Safety Management Systems to identify and mitigate evacuation-related hazards, the adoption of standardized messaging in safety briefings, and the implementation of passenger outreach strategies, including visual aids and universally recognizable symbols, to promote compliance during emergency evacuations.