NYC04TA103

NTSB accident investigation · McDonnell Douglas DC-10-30 · Atlantic Ocean (Atlantic Ocean) · April 11, 2004

Accident · No injuriesFinal report
Date
April 10, 2004, 22:58 local (Apr 11, 2004, 02:58 UTC)
Place
Atlantic Ocean (Atlantic Ocean)
Injuries
252 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N14075McDonnell Douglas DC-10-30
Weather
Visual (VMC) · Night
Status
Completed · report December 3, 2004
Report
Approved by Office Director
Parties
FAA AAI-100
FAA report
20040410006949A
Case key
59034

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The failure of the number two upper forward right engine cowling attachment, which resulted in substantial damage to the right inboard elevator. A factor was the inadequate procedures in the airliner maintenance manual.

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.

Miscellaneous/otherCruise
Procedure inadequateManufacturerFactor
Cooling system,cowling - failureCause

Analysis

During cruise flight, the crewmembers heard a "bang" from the rear of the cabin, and the airplane momentarily shuddered and bounced. After landing uneventfully at their destination airport, the crewmembers observed that the number two right engine cowling had separated and struck the right inboard elevator. Inspection of the airplane revealed that the engine cowling upper forward hinge required three bolts. However, only one bolt remained attached, and there was no evidence that the other two bolts tore away during flight. Fretting was observed in the area of the bolt holes, consistent with an oscillation over a period of time, due to the absence of two bolts. The airliner maintenance manual required a general inspection of the area, but did not specifically mention cowling hinge bolts. In addition, the hinges were located in an area that was not easily accessible to maintenance personnel.

Factual narrative

On April 10, 2004, about 2258 eastern daylight time, a McDonnell Douglas DC-10-30, N14075, operated by World Airways Inc., as flight 725, was substantially damaged during cruise flight over the Atlantic Ocean. The 3 cockpit crewmembers, 9 cabin crewmembers, and 240 passengers were not injured. Night visual meteorological conditions prevailed for the flight that departed Naples, Italy; destined for Norfolk Naval Station (NGU), Norfolk, Virginia. An instrument flight rules flight plan was filed for the public use non-scheduled passenger flight.

The captain reported that the airplane was in cruise flight at 32,000 feet. The airplane "shuddered and bounced" for a half-second, and then returned to stable flight. At that time, a flight attendant heard a "bang" from the rear of the airplane. The cockpit crew then felt a slight vibration, and noted a fuel burn of approximately 1,000 pounds per hour more than expected. However, all cockpit controls and instruments appeared normal.

The flight proceeded to NGU and landed uneventfully about 0300, on April 11. A subsequent inspection of the airplane revealed that the right engine cowling had separated from the number two engine. Approximately 40 percent of the right inboard elevator had separated, consistent with the elevator being struck by the engine cowling.

Further inspection of the airplane by a Federal Aviation Administration (FAA) investigator revealed that the engine cowling upper forward hinge required three bolts. However, only one bolt remained attached, and the investigator did not observe any evidence that the other two bolts tore away during flight. The investigator also noted fretting in the area of the bolt holes, consistent with an oscillation over a period of time, due to the absence of two bolts.

The FAA investigator added that the airliner maintenance manual required a general inspection of the area, but did not specifically mention cowling hinge bolts. In addition, the hinges were located in an area that was not easily accessible to maintenance personnel. The investigator subsequently submitted a safety recommendation to have the cowling hinge bolts inspected every "D" check.

Aircraft

Registration
N14075
Reported as
McDonnell Douglas DC-10-30
Category
Airplane
Serial number
46922
Airframe hours
96,122
Engines
General Electric CF6-50C2, 53,000 lbs thrust, turbo fanGeneral Electric CF6-50C2, 53,000 lbs thrust, turbo fanGeneral Electric CF6-50C2, 53,000 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Public aircraft · Public use
Registered owner
World Airways Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · April 5, 2004 · 128 hours before
Departed
LIRN · Naples
Destination
KNGU · Norfolk, VA
Flight plan
IFR

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
53
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
August 9, 2003
Seat
Left
Flight hours
8,530 total · 3,200 in this make and model · 3,790 as pilot in command · 92 in the last 90 days · 52 in the last 30 days · 9 in the last 24 hours
Role
Co-pilot
Age
41
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
August 19, 2003
Seat
Right
Flight hours
111 in the last 90 days · 77 in the last 30 days · 9 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
70° at 6 knots
Visibility
6 statute miles
Lowest ceiling
3,000 ft broken
Temperature
52 °F, dew point 43 °F
Altimeter
30.01 inHg
Observed at
NGU

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.