FTW97IA045

NTSB incident investigation · McDonnell Douglas MD-82 · Dfw Airport, TX · November 23, 1996

Incident · Minor injuriesIncident investigationFinal report
Date
November 23, 1996, 16:22 local (22:22 UTC)
Place
Dfw Airport, TX
Injuries
3 minor, 116 uninjured
Damage
Minor damage
Phase of flight
Takeoff
Aircraft
N3507AMcDonnell Douglas MD-82
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 1998
Report
Approved by Office Director
Case key
20061

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

The failure of the low pressure turbine shaft. A factor was the coke build up on the low pressure turbine shaft.

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 powerTakeoff - aborted
Turbine assembly,shaft - otherFactor
Turbine assembly,shaft - failureCause
Turbine assembly - other

Analysis

The airplane was departing when a thump was felt with a slight left nose pull, and the pilots aborted the takeoff. The pilots taxied clear of the runway and came to a stop. Several flight crews on the ground reported on the tower frequency that the incident airplane's left engine was on fire. The captain initiated evacuation of the airplane. The Airport Rescue and Fire Fighting (ARFF) personnel reported that the engine fire was confined to the tailpipe area. Turbine blades had separated from the number 4 turbine disk, penetrated the engine case, and subsequently damaged the engine pylon and empennage area. The teardown examination of the engine revealed that the Low Pressure Turbine (LPT) shaft was deformed and fractured into two pieces. Heavy coke deposits were identified on both the outer diameter of the LPT shaft and the inner diameter of the center tube. The two pieces of the LPT shaft were twisted and subjected to 'considerable' permanent deformation. The amount of plastic deformation was indicative of exposure to high temperatures. Additionally, the High Pressure Turbine shaft was found with a (one of three) 4 1/2 bearing stack retention pin missing.

Factual narrative

History of flight

On November 23, 1996, at 1622 central standard time, an MD-82, N3507A, sustained an uncontained engine failure during takeoff roll at DFW Airport, Texas. The 2 pilots, 3 flight attendants, and 111 passengers were not injured; however, 3 passengers sustained minor injuries during the emergency evacuation of the airplane. The airplane was being operated by American Airlines as flight 1447 under Title 14 CFR Part 121. Visual meteorological conditions prevailed for the scheduled international passenger flight which was originating at the time of the incident. An IFR flight plan had been filed with Acapulco, Mexico, as the intended destination.

According to the captain, the airplane was departing on runway 17R when "on takeoff roll (approximately 120 knots), a thump was felt with a slight left nose pull." The onboard flight data recorder indicated that the pilots aborted the takeoff at 124.5 knots (V1 was 132 knots). The pilots taxied clear of the runway and came to a stop on taxiway L3. The flight attendants in the cabin area reported that there was "smoke and smoke odor" in the cabin. Several flight crews on the ground at DFW airport reported on the tower frequency that the incident airplane's left engine was on fire. The captain stated that, after he received these radio communications (about his left engine being on fire), he initiated evacuation of the airplane.

The flight attendants reported that the captain told them not to use the left aft emergency exit. The rear tail cone was deployed, the rear stairs were lowered, and a flight attendant estimated that approximately 40 to 60 individuals used them for evacuation. Another flight attendant reported that smoke was observed outside of the right over wing exits and she "commanded that the right window exits be blocked." She further reported that the left over wing exits were used to evacuate approximately 30 to 40 individuals. The third flight attendant deployed the left forward slide and she estimated that approximately 50 individuals evacuated through that exit.

A witness reported that "it took the fire equipment approximately 4 minutes to arrive at the airplane." The Airport Rescue and Fire Fighting (ARFF) personnel reported that the engine fire was confined to the tailpipe area and was extinguished in approximately 2 minutes.

Injuries to persons

After the evacuation was completed, three women requested medical assistance. Two of the women received treatment by paramedics and then continued their trip. The third woman was taken to a local hospital for x-rays and she continued her trip that evening.

Damage to airplane

Examination of the airplane revealed that all the turbine blade airfoils had separated from their roots in the number 3 and 4 turbine disks, and the engine case had one 12 inch by 3 inch hole in it on the inboard side of the turbine section. The cowling was punctured, the lower side of the engine pylon had sustained "impact damage," and the unpressurized empennage area had two puncture holes each approximately one quarter inch square.

The left engine was removed from the airplane and shipped to American Airlines Maintenance and Engineering Center in Tulsa, Oklahoma for disassembly and examination. The teardown examination of the engine revealed that the Low Pressure Turbine (LPT) shaft was deformed and fractured into two pieces. The adjacent 17 inch long High Pressure Turbine (HPT) center tube was found twisted and broken into several pieces. Extensive coke deposits were identified on both the outer diameter of the LPT shaft, and the front and aft ends of the inner diameter of the center tube. The designed clearance between the LPT shaft and the center tube is 93 mils; shaft variations due to vibrations and maneuvering loads will utilize 30 to 40 mils of that space (see the enclosed Powerplant Group Chairman's Report for details of the examination which was accomplished on December 4, 1996).

Aircraft information

The aircraft was built in 1989 and had two Pratt & Whitney JT8D-217C axial flow jet engines (21,000 pounds of thrust each) mounted on the empennage. The left engine had accrued a total of 25,072 hours of time, and the last major overhaul was performed 6,407 hours before the incident. Aircraft records indicated that the engine had no abnormal oil usage nor any unusual vibrations reported prior to the failure.

Tests and research

The NTSB Materials Laboratory examined the two pieces of the LPT shaft. According to the Materials Laboratory Report, the broken ends of the shaft were twisted and subjected to "considerable" permanent deformation. The amount of plastic deformation was indicative of exposure to high temperatures. The surfaces of the shaft adjacent to the fracture were dark blue to black and soot deposits were present. The fracture surface was also discolored dark blue (see the attached NTSB Metallurgist Group Chairman Report for details).

Pratt & Whitney requested that parts from the engine be sent to their facility in East Hartford, Connecticut, for further evaluation (see attached letter). Their staff did identify an anomaly; the HPT shaft was found with a (one of three) 4 1/2 bearing stack retention pin missing. Coke deposits were found inside and around the missing pin hole.

Additional data

Subsequent to this event, Pratt & Whitney initiated and is still involved (as this report is being written) in a study of the coke depositional processes, i.e., the temperature range, the oil particle size, and depositional surface characteristics. The project completion date is proposed for the end of 1998. Pratt & Whitney is also designing and testing a double-walled HPT center tube which engineers believe will reduce the coking on the LPT shaft.

The airplane was released to an American Airlines representative on November 24, 1996; the engine parts that were analyzed by Pratt & Whitney were released to American Airlines on November 17,1997.

Aircraft

Registration
N3507A
Reported as
McDonnell Douglas MD-82
Category
Airplane
Serial number
49801
Airframe hours
20,780
Engine
P&W JT8D-217C, 21,000 lbs thrust, turbo jet
Damage
Minor damage
Fire
On-Ground
Flight
Part 121
Operator
American Airlines
Registered owner
Wilmington Trust Corp
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · November 11, 1996 · 24 hours before
Departed
DFW
Destination
ACP · Acapulco
Flight plan
IFR
Airport
DFW · Dallas-Fort Worth Intl, runway 17R, 13,400 × 200 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
42
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
10,901 total · 5,901 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 10 knots
Visibility
5 statute miles
Lowest ceiling
5,500 ft broken
Temperature
66 °F, dew point 63 °F
Altimeter
29.00 inHg
Observed at
DFW, 1 nm away

Other investigations on N3507A · 1

Matched to the same aircraft by N-number and date.