# NTSB FTW02IA027: Airbus Industrie A319-132, N814AW, Midland, TX, November 2, 2001 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: November 2, 2001, 07:34 local (13:34 UTC) - Place: Midland, TX - Location: 31.9425° N, 102.2019° W: Placed by OpenAirDocs at MIDLAND INTL AIR AND SPACE PORT (MAF), within about a mile (OpenAirDocs) - NTSB coordinates: 41.890979, -87.810623 (estimated), outside the stated state - Nearby events: https://openairdocs.org/map.md?lat=31.9425&lon=-102.2019&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 89 uninjured - Status: Completed, report December 3, 2004 - Report: Approved by Office Director - Parties: Bureau Enquetes - Accidents (BEA), Airbus Industrie, Federal Aviation Administration, Airline Pilots Association, International Aero Engines, America West Airlines - NTSB case key (mKey): 53708 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW02IA027 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/53708/pdf - Page: https://openairdocs.org/ntsb/FTW02IA027 ## Probable cause the #1 engine's fatigue failure of the #3 bearing due to the manufacturer's inadequate design of the high-pressure compressor stubshaft coating, which resulted in a loss of engine power and an emergency landing. ## 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, cruise - normal - 1 engine - turbine assembly,shaft bearing - fatigue (cause) - material defect(inadequate quality of material), manufacturer (cause) - turbine assembly,shaft bearing - failure,total (cause) - Forced landing, descent - emergency - precautionary landing - performed, flightcrew ## Analysis The transport airplane was in cruise flight at flight level 390 for 12 minutes when they received an "engine oil filter bypass" fault message on the engine centralized aircraft monitoring (ECAM) system; however, all of the engine parameters remained within limits. Subsequently, the oil pressure indication for the #1 (left) engine rose into the red band and a "high vibration and a thumping sound" was felt and heard. The flight crew then declared an emergency and diverted to another airport. The captain reported that during the landing roll, he moved both throttle levers into reverse, and simultaneously the cockpit and cabin began to fill with smoke. Air traffic controllers reported they observed white smoke emanating from the #1 engine during the landing roll. The captain stopped the airplane on the high-speed taxiway, turned off both engines, and an emergency evacuation ensued. The 1L and 2L doors were operated normally; however, the 1R door jammed when the flight attendant attempted to open it. Examination of the 1R door actuator and slide did not reveal the reason it failed to operate. Examination of the engine revealed that debris contamination of the #3 bearing initiated spallation of the bearing's outer ring raceway. Cyclic loading from the bearing balls passing over the growing raceway spall resulted in extensive fretting of the outer diameter surface of the outer ring, from which a fatigue crack was initiated. High-cycle fatigue progression radially through the outer ring was followed by rapid fracture and subsequent liberation of the outer ring fragments. The debris contamination more than likely came from the high-pressure compressor (HPC) stubshaft coating, which was liberated and entered the #3 bearing area causing it to fracture, and the engine to lose power. Research revealed this was one of five similar occurrences, which was traced down to a change in the manufacture process for the HPC stubshaft coating. The manufacturer has taken actions to alert operators of the existing problem. ## Factual narrative HISTORY OF FLIGHT On November 2, 2001, at 0734 central standard time, an Airbus Industrie A319-132 transport airplane, N814AW, operating as America West Airlines flight 786, experienced an engine anomaly while in cruise flight and diverted to the Midland International Airport (MAF), Midland, Texas. The captain, who held an airline transport pilot certificate, the first officer, who also held an airline transport pilot certificate, three cabin attendants, and 84 passengers were not injured. The airplane was registered to International Lease Finance Corporation of Los Angeles, California, and operated by America West Airlines of Phoenix, Arizona. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations Part 121 scheduled passenger flight. The flight originated from the George Bush Intercontinental Airport (IAH), Houston, Texas, at 0610, and was destined for the Phoenix Sky Harbor International Airport (PHX), Phoenix. According to the captain and first officer, the flight departed IAH and climbed to flight level 390. The flight had been in cruise at flight level 390 for 12 minutes when the flight crew received an "engine oil filter bypass" fault message on the electronic centralized aircraft monitoring (ECAM) system; however, all of the engine parameters remained within limits. The flight crew informed maintenance control of the indication, and decided that if the engine should develop further problems the flight would land at the nearest airport, which was MAF. As a precaution, the flight descended to flight level 350 and obtained the current ATIS (automated terminal information system) information at MAF. Subsequently, the oil pressure indication for the #1 (left) engine rose into the red band and a "high vibration and a thumping sound" was felt and heard. They stated that they did not detect any smoke or odor in the cockpit. The first officer referenced the quick reference handbook (QRH) and completed the "high engine vibration checklist." In accordance with the checklist, the captain moved the thrust lever for the #1 engine to the idle position. The flight crew then declared an emergency and diverted to MAF. When the flight crew notified the cabin crew of their action to divert, the cabin crew reported that there was a "thin film" of visible, odorless smoke in the area of the forward galley between the first class cabin and the cockpit. The flight crew then donned their oxygen masks. The captain reported that during the landing roll, on runway 16R, he moved both throttle levers into reverse and, simultaneously, the cockpit and cabin began to fill with smoke. The cabin attendants reported that during the landing roll the cabin began to fill with a "heavier" white smoke. The MAF air traffic control tower personnel added that, during the landing roll they observed white smoke emanating from the #1 engine. The captain stopped the airplane on the high speed taxiway, shut-down both engines, and an emergency evacuation ensued. According to the flight attendants (FA), the #1 and #2 FAs were seated on the forward jump seat (forward of the first class cabin). The captain signaled to evacuate, both FAs got up, and the #1 FA proceeded to the 1L door and the #2 FA proceeded to the 1R door. The 1L door opened and the slide deployed and inflated. The #2 FA reported that she pulled the 1R door handle up and felt the power assist begin to open the door. The slide cover opened and she could see the slide. The door opened approximately 12 inches and then stopped moving. The #2 FA then directed the passengers to exit through the 1L door. The #3 FA was seated on the aft jump seat. When the captain signaled the evacuation, she proceeded to the 2L door, pulled the door handle up, and the door began to open. The power assist was not as powerful as she expected, and she had to manually push the door open to engage the gust lock. The slide deployed and inflated, and passengers exited. The 2R door was not opened and the #3 FA reported that due to a low number of passengers, flow through the 2L door was good. There were no injuries during the evacuation. Prior to vacating the airplane, the captain observed the 1R door 3/4 open and the slide "partially out of the bustle." He stated that he then pushed the door "pretty hard," and the door then moved to the fully open position. The evacuation slide deployed and inflated. Maintenance personnel removed the slides and the airplane was towed to a hangar at the airport. PERSONNEL INFORMATION The captain held an airline transport pilot certificate and was type rated in the Airbus 319/320, Boeing 737, and the Swearingen 227. According to the NTSB Pilot/Operator Aircraft Accident Report Form, which was completed by America West Airlines, the captain had accumulated a total of 15,000 hours, of which 800 hours were in the A319. He held an FAA first-class medical certificate, with no limitations or waivers, which was issued on May 21, 2001. The first officer held an airline transport pilot certificate and was type rated in the BA-3100. According to the NTSB Pilot/Operator Aircraft Accident Report Form, the first officer had accumulated a total of 4,800 hours, of which 1,000 were in the A319. The three cabin attendants were based in Phoenix. AIRCRAFT INFORMATION The airplane was delivered to America West Airlines new, and was registered on July 27, 2000. It is equipped with two International Aero Engine Corporation (IAE) 2524-A5 engines, which are rated at 24,000lbs of thrust each. America West configured the airplane with 124 passenger seats and six crew seats. A review of maintenance records revealed no pertinent entries relating to the #1 engine's loss of power. On October 18th, 2001, the last "A" check was performed, during which all of the magnetic chip detectors (MCD) were reported to be clean. The airframe and engines had accumulated a total of 4,798 hours. The #1 engine (serial number V10778) had accumulated a total of 1,916 cycles. The IAE series of engines was developed through a consortium of four major engine manufacturers consisting of Pratt & Whitney, Rolls-Royce, Japanese Aero Engines Corporation, and MTU Aero Engines. The IAE 2524-A5 engine is an axial flow, two-shaft engine that incorporates a 4-stage low-pressure compressor (LPC), a 10-stage high-pressure compressor (HPC), a 2-stage high-pressure turbine (HPT), and a 5-stage low-pressure turbine (LPT). AERODROME INFORMATION MAF is located at 31 degrees 56.552 minutes north latitude and 102 degrees 12.115 minutes west longitude, at an elevation of 2,871 feet msl. The airport has two parallel runways oriented north-south, one runway oriented east-west, and one runway oriented northeast-southwest. Runway 16R (asphalt) is 9,501 feet long and 150 feet wide. METEOROLOGICAL INFORMATION At 0753, the weather observation facility at MAF reported the following weather conditions: clear skies, visibility 10 statute miles, wind from 230 degrees at 8 knots, temperature 17 degrees Celsius, dew point 12 degrees Celsius, and an altimeter setting of 30.06 inches of mercury. FLIGHT RECORDER INFORMATION The airplane was equipped with an Allied Signal Solid State Digital Flight Data Recorder (SSDFDR), serial number 5846. The recorder was sent to the NTSB's Vehicle Recorder Laboratory in Washington, DC, where it was found to be in good condition. The recorded data were extracted normally from the recorder and plotted for the entire engine event. TESTS AND RESEARCH Initial examination of the airplane and the #1 engine did not reveal evidence of an uncontained engine failure or fire; however, an oil film was observed on the exterior of the #1 engine cowling and along the fuselage. The scavenge oil filter and #1 engine's MCDs contained large quantities of metal particles. The oil pressure filte ## Aircraft - Registration: [N814AW](https://openairdocs.org/aircraft/N814AW), registered now, S/N 1281, built 2000 (OpenAirDocs) - Reported make and model: Airbus Industrie A319-132 - Registry model: [Airbus Industrie A319-132](https://openairdocs.org/model/airbus-industrie-a319-132) (registry code 3930340) (OpenAirDocs) - Registry engine: [IAE V2500SERIES](https://openairdocs.org/engine/iae-v2500series) (registry code 34601, turbo-jet) (OpenAirDocs) - Category: Airplane - Serial number: 1281 - Airframe hours: 4798 - Engines: International Aero Engines IAE-2524-A5 24000 lbs thrust turbo fan - Damage: No damage - Flight: Part 121 - Operator: America West Airlines Inc., doing business as America West - Registered owner: International Lease Finance Corporation - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, October 18, 2001 - Departed: IAH, Houston, TX - Destination: PHX, Phoenix, AZ - Flight plan: IFR - Airport: MAF, Midland International, runway 16R, 9,501 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: none; airline transport, flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 15,000 total, 800 in this make and model - Co-pilot; age 30; injuries: none; airline transport, commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: right; flight hours: 4,800 total, 1,000 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 54 °F - Altimeter: 30.05 inHg - Observed at: MAF ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20011102030469I](https://openairdocs.org/incident/20011102030469I), Nov 2, 2001: Airbus A319132, Midland, TX. (-23) On November 2, 2001, at 0734 central standard time, an Airbus industries A319-132 transport airplane, N814AW, operating as america west airlines flight… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.