# NTSB FTW97IA144: Boeing 767-232, N105DA, Dfw Airport, TX, March 27, 1997 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: March 27, 1997, 08:45 local (14:45 UTC) - Place: Dfw Airport, TX - Location: 32.9921° N, 96.9075° W: Placed by OpenAirDocs from NTSB’s distance and direction from DALLAS-FORT WORTH INTL (DFW), within about 3 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=32.9921&lon=-96.9075&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 198 uninjured - Status: Completed, report November 10, 1998 - Report: Approved by Office Director - NTSB case key (mKey): 20067 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW97IA144 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/20067/pdf - Page: https://openairdocs.org/ntsb/FTW97IA144 ## Probable cause The manufacturer's improper installation of the flap, which resulted in fatigue cracking of the flap attach bolts and separation of the flap. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, approach - flight control,flap attachment (cause) - maintenance,installation - improper, manufacturer (cause) - miscellaneous,bolt/nut/fastener/clamp/spring - fatigue (cause) - miscellaneous,bolt/nut/fastener/clamp/spring - cracked (cause) - flight control,flap - separation ## Analysis During the landing approach, with the flaps extended to 15 degrees and the spoilers deployed, an 18-foot section of the right outboard flap separated from the trailing edge of the right wing. After making a flyby of the tower to allow controllers to view the extent of the damage, the flightcrew landed the airplane without further incident. The flap separation resulted from fatigue cracking of the four aft bolts fastening the flap to the inboard flap carriage support beam. The relief shoulders on three of the bolts exhibited thread contact marks which indicated that the attachment nuts were inserted all the way down to the relief shoulders. Either the bolt grip lengths were longer than necessary for this installation, or not enough shims were installed under the heads of the bolts or attachment nuts. Under these circumstances, the bolts most likely did not receive sufficient preload in tension, since the nuts probably bottomed onto the relief shoulders before the preload could be produced. Maintenance records indicated that the flap had not been removed from the wing since manufacture of the airplane in 1982 and had accumulated 45,577 flight hours and 22,155 flight cycles. ## Factual narrative HISTORY OF FLIGHT On March 27, 1997, approximately 0845 central standard time, a section of the right outboard flap separated from a Boeing 767-232, N105DA, during the airplane's approach to the Dallas/Fort Worth International Airport (DFW), Texas. The airplane was being operated by Delta Air Lines, Inc., under Title 14 CFR Part 121, as scheduled domestic passenger flight 691, from Orlando, Florida, to DFW. After making a flyby of the tower to allow controllers to view the extent of the damage, the flightcrew landed the airplane without further incident. There were no injuries to the 189 passengers or the 9 crewmembers aboard the airplane. The separated flap section came to rest in an open field in Carrollton, Texas, and there were no injuries to ground personnel. In a written statement provided to the NTSB investigator-in-charge (IIC), the captain of flight 691 reported that the takeoff and departure from Orlando were "routine, as were all aspects of the enroute phase of the flight." During the descent for landing on runway 17C at DFW, with the spoilers fully deployed and the flaps extended to 5 degrees, the first officer, who was the pilot flying, called for 15 degrees of flaps. The captain set the flaps at 15 degrees, and "a few moments later [he] felt a strong jolt." He noted that the first officer was using "a significant amount of left aileron" and had disengaged the autopilot and retracted the spoilers. The captain stated that "despite the unusual control inputs required, [the first officer] had the aircraft under control." He further stated that "there were no cockpit indications of a spoiler or flap problem." According to the captain, a few seconds after the event, he received an intercom communication from the mid-station flight attendant reporting that a portion of the right wing had separated. He informed air traffic control that the flight was experiencing a problem and requested a flyby of the tower. Following a low pass "between 1,000 and 1,500 feet MSL" along the centerline of Runway 17L, the tower controller informed the flight that there was "something sticking up from [the] right wing." The captain declared an emergency and requested a visual approach to the longest available runway. The flight was cleared to land on runway 17R, and the approach was flown at "180 KIAS" (knots indicated airspeed), at which speed "the aircraft was controllable and stable." Following the landing, which the captain characterized as "flat and smooth," the flight "taxied in and shut down without further problems." DAMAGE TO AIRCRAFT Examination of the airplane by FAA inspectors and Delta maintenance personnel revealed that approximately 18 feet of the right outboard flap had separated from the trailing edge of the right wing. The inboard and outboard flap carriage assemblies remained affixed to the wing, and the outboard 14 feet of the flap remained attached to the outboard flap carriage support beam. Collateral damage included separation of the trailing edge of the #9 spoiler and damage to the trailing edge of the #12 spoiler. The separated section of the flap, which was recovered from an open field approximately 10 miles northeast of DFW, extended from the inboard flap edge at Wing Butt Line (WBL) 355 to approximately 1 foot inboard of the outboard flap carriage support beam at WBL 622. Further examination of the separated section revealed that the six bolts which fastened the lower surface of the flap to the inboard flap carriage support beam at WBL 456 had fractured. The lower pieces of the bolts (threaded portions) and the nuts used to secure the bolts were not recovered. The upper piece of each fractured bolt (head and shank portion) was found protruding through its respective attaching hole in the lower surface of the separated flap section. Portions of the fracture surfaces on three of the four aft bolts displayed dark discoloration. The fracture surfaces on the two forward bolts and the other aft bolt were unremarkable. All six of the bolts were removed, and at the request of the NTSB IIC, delivered by Delta to the NTSB Materials Laboratory, Washington, DC, for metallurgical examination. AIRCRAFT INFORMATION N105DA, a Boeing 767-232, serial number 22217, was manufactured on January 8, 1983. The airplane had accumulated 45,577 hours and 22,155 flight cycles at the time of the incident. According to Delta safety personnel, the airplane's maintenance records did not indicate any removal of the right outboard flap from the wing since Delta accepted delivery of the airplane from Boeing on January 19, 1983. In response to questions raised by the IIC regarding recurring inspection procedures, a Boeing representative stated that a visual inspection of the outboard flap attachment bolts was "called out at "C" check intervals," specifically a visual inspection at "1C" checks and a detailed visual inspection at "4C" checks. The representative further stated that "there was no routine maintenance called out to check the bolt torque." The most recent "1C" check of the airplane was performed on October 22, 1996, at an airframe total time of 44,167 hours (1,410 hours before the incident). On February 15, 1997, at an airframe total time of 45,294 hours (283 hours before the incident), the airplane underwent a service check. The last maintenance inspection performed prior to the incident was a layover check on March 26, 1997. (Delta accomplishes "C" checks, service checks, and layover checks at intervals of 4,000 hours, 400 hours, and once per day, respectively.) According to a Delta representative, both the layover check and the service check provided for a visual inspection of the wings, and both checks required inspection of the flaps for general condition and security. No discrepancies with the right outboard flap were noted during the performance of these three inspections. FLIGHT RECORDERS The cockpit voice recorder (CVR) was not readout. At the request of the NTSB IIC, the Digital Flight Data Recorder (DFDR) was readout by Delta, and a file containing the raw data was sent to the Safety Board's laboratory in Washington, DC, for evaluation. For details of the DFDR evaluation refer to the Flight Data Recorder Factual Report. The recorded parameters included left and right trailing edge flap positions, left and right inboard aileron positions, and left and right outboard aileron positions. The recorded parameters did not include spoiler position or control wheel position. The tabular data indicated that the flaps reached 15 degrees extension at FDR subframe reference number 8916. Flap separation occurred 1 minute 54 seconds later, between FDR subframe reference numbers 9030 and 9031, when the airplane was at an altitude of approximately 5,000 feet MSL and an airspeed of 208 knots. During the next 11 seconds (9031 to 9042), the airplane rolled right to a maximum roll angle of 15.12 degrees right wing low and then returned to a wings level attitude. Prior to flap separation, the right and left inboard ailerons were deflected to -10 and -8 degrees respectively. (With reference to aileron positions, negative numbers indicate trailing edge down deflection.) The inboard ailerons droop 10 degrees when the flaps are extended beyond 5 degrees. The deflection limits for the inboard ailerons are +20 and -20 degrees. Immediately after flap separation, the right inboard aileron deflected to and maintained -20 degrees, its maximum down limit. The left inboard aileron initially deflected to +13.5 degrees and then varied from +10 to +16 degrees before stabilizing around +14 degrees. Prior to flap separation, the right and left outboard ailerons were deflected to +2 and 0 degrees respectively. The deflection limits for the outboard ailerons are +30 and -15 degrees. Immediately after flap separation, the right outboard aileron deflected to and remained approximately -10 degrees ## Aircraft - Registration: N105DA (not matched to a registry record) - Reported make and model: Boeing 767-232 - Category: Airplane - Serial number: 22217 - Airframe hours: 45577 - Engines: GE CF6-A2 48670 lbs thrust turbo fan - Damage: Minor damage - Flight: Part 121 - Registered owner: Delta Air Lines, Inc. - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, February 15, 1997, 283 hours before - Departed: MCO, ORLANDO, FL - Destination: DFW - Flight plan: IFR - Airport: DFW, Dallas-Ft. Worth Intl, runway 17R, 13,400 × 200 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; commercial, airline transport, flight engineer; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 15,000 total, 150 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: 8,500 ft broken - Temperature: 57 °F, dew point 46 °F - Altimeter: 30.00 inHg - Observed at: DFW, 9 nm away ## 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 19970327007469I](https://openairdocs.org/incident/19970327007469I), Mar 27, 1997: Boeing 767232, Dallas-Ft Worth, TX, Minor damage. Narrative: on approach to dfw airport, as the aircraft descended through 11,000 feet and flaps were extended to 15 degrees, the flight crew felt and heard a… 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.