NYC08IA290

NTSB incident investigation · Boeing 747-209B · Bogota, Colombia · August 26, 2008

Incident · No injuriesIncident investigationFinal report
Date
August 26, 2008, 06:35 local (06:35 UTC)
Place
Bogota, Colombia
Injuries
5 uninjured
Damage
No damage
Phase of flight
Takeoff
Aircraft
N715CKBoeing 747-209B
Defining event
Takeoff: Loss of engine power (partial)
Weather
Visual (VMC) · Night
Status
Completed · report May 19, 2011
Report
Approved by Office Director
Parties
Kalitta Air, The Boeing Company, Pratt & Whitney, AAI-100, Accredited Representative - Colombia
Case key
68852

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

On this page

Probable cause

The combination of fan blade edge contour, variable blade trim, and the high altitude, which resulted in an engine surge.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Power plantAircraft › Aircraft power plant · MalfunctionBoeing 747-209B: 1 caseAll aircraft: 198 casesProbable cause
Temp/humidity/pressure: high density altitudeEnvironmental issues › Conditions/weather/phenomena · Effect on operationBoeing 747-209B: 1 caseAll aircraft: 278 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Just after takeoff from a high-altitude airport, as the landing gear were being retracted, a “loud bang” emanated from the vicinity of the No. 3 turbofan engine. The exhaust gas temperature rose, followed by three or four lesser bangs, all of which indicated an engine stall/surge. The engine was secured in accordance with the checklist procedure, fuel was dumped, and the airplane returned to the airport without further incident. On-wing test bed testing first established a performance baseline for the engine, which was then tested with newly overhauled fan blades installed, and subsequently tested with a newly overhauled fan case installed in order to assess the effects of changing fan blade geometry and fan blade-to-fan case clearance. Initial testing of the engine did not result in an engine surge or any engine exceedences. An engine vane control trim check revealed that it was within the parameters for most of the engine power range, except for above the 90 percent corrected N2 speed, where it was slightly below the minimum value. Because the results did not significantly impact testing, the engine was not re-trimmed prior to testing the engine with new fan blades and a new fan case. Tests revealed that fan blade contour and shape had a bigger influence on the engine’s surge margin and low pressure compressor (LPC) stability line than the fan blade-to-fan case clearance variations within the range of test conditions. Fan blades that were within the engine manual limits – rounder leading edges with little to no erosion and proper chord length – had improved LPC efficiency and engine stability. The last engine test was conducted with the compressor variable vanes re-trimmed open, and within limits at the high speed range, with the results indicating further improvement in LPC efficiency and stability. While no single variable likely resulted in the engine surge, several variables, including blade edge contour, variable blade trim and high altitude, likely combined to produce the stall/surge.

Factual narrative

On August 26, 2008, about 0635 coordinated universal time (0135 local time), a Boeing 747-209B, N715CK, operated by Kalitta Air as Centurion Air Cargo flight 164, experienced a power loss from the number 3 engine shortly after takeoff. None of the five crewmembers were injured, and there was no damage to the airplane. Night visual meteorological conditions prevailed. The airplane was operating on an instrument flight rules flight plan from Eldorado International Airport (SKBO), Bogota, Colombia, to Miami International Airport (KMIA), Miami, Florida, in accordance with Title 14 Code of Federal Regulations Part 121. Under the provisions of Annex 13 to the Convention on International Civil Aviation, and by mutual agreement, the Colombian Government delegated the incident investigation to the United States. Aeronautica Civil de Colombia designated an accredited representative to the investigation on behalf of the Colombian Government. According to flight crew statements, just after departure, as the landing gear were being retracted, a “loud bang” emanated from the vicinity of the number 3 engine, followed by an excessive exhaust gas temperature (EGT) and “three or four lesser bangs.” The engine was secured “in accordance with the checklist procedure,” fuel was dumped, and the airplane returned to the airport without further incident. A post-flight walk-around inspection of the number 3 engine revealed no visible damage. The airplane was powered by four Pratt and Whitney (P&W) JT9D-7Q engines. The operator reported that the number 3 engine, ESN P702121, had operated 210 hours since overhaul. A Powerplants Group was formed to further examine the engine. According to the Group Chairman's factual report, the number 3 engine was removed from the airplane and shipped to the Kalitta Air engine facility in Oscoda, Michigan for on-wing testing on a Boeing 747-200 test bed. Before engine testing was conducted, the engine was inspected via borescope to determine internal hardware condition and if the engine was capable of being tested safely. Inspection did not reveal any mechanical failures within the engine, or thermal distress in the combustion or turbine sections beyond serviceable limits. Several high pressure compressor blades were found to be nicked or torn beyond engine manual limits and were repaired (blended in-situ) before the engine was run. Fan blade leading edge impressions were also made to evaluate leading edge contour and profile and their impact on engine performance and stability. The engine was tested in accordance with the P&W "Test Number 12" performance evaluation listed in the JT9D-7Q engine maintenance manual to first establish a performance baseline for the engine, and to sequentially test the engine with newly overhauled fan blades installed, then with a newly overhauled fan case installed, in order to assess the effects of changing fan blade geometry and fan blade-to-fan case clearance. Initial baseline testing of the enginerevealed that the engine did not surge, nor were there any engine exceedences. An engine vane control trim check was performed and revealed that it was within the parameters for most of the engine power range, except for above 90 per cent corrected N2 speed, where it was slightly below the minimum value. It was determined that the results did not significantly impact the engine testing, so the engine was not re-trimmed prior to testing the engine with new fan blades and a new fan case. Based on the range of hardware conditions tested, the tests revealed that fan blade contour and shape had a bigger influence on the engine’s surge margin and low pressure compressor (LPC) operating line than the fan blade-to-fan case clearance variations within the range of test conditions. Fan blades that were within the engine manual limits – rounder leading edges with little to no erosion and proper chord length – had improved LPC efficiency and engine stability. The last engine test was conducted with the compressor variable vanes re-trimmed open, and within limits at the high speed range. The results revealed that LPC efficiency and stability further improved above and beyond the improvement from the overhauled fan blades.

Aircraft

Registration
N715CK
Reported as
Boeing 747-209B
Category
Airplane
Serial number
22447
Airframe hours
87,617
Engines
Pratt & Whitney JT9D-7Q, 51,100 lbs thrust, turbo fanPratt & Whitney JT9D-7Q, 51,100 lbs thrust, turbo fanPratt & Whitney JT9D-7Q, 51,100 lbs thrust, turbo fanPratt & Whitney JT9D-7Q, 51,100 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Kalitta Flying Service Inc, doing business as Kalitta Air
Registered owner
Kalitta Air
Airworthiness certificate
Standard, Transport
Departed
SKBO · Bogota
Destination
KMIA · Miami, FL
Flight plan
IFR
Airport
SKBO · El Dorado International, runway 31L, 12,467 × 148 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 · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
55
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
September 30, 2008
Seat
Left
Flight hours
14,147 total · 2,591 in this make and model · 8,895 as pilot in command · 124 in the last 90 days · 65 in the last 30 days
Role
Co-pilot
Age
29
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
August 30, 2007
Seat
Right
Flight hours
2,000 total · 499 in this make and model · 200 as pilot in command · 118 in the last 90 days · 17 in the last 30 days
Role
Flight engineer
Injuries
None
Seat
Center

Weather

Conditions
Visual (VMC) · Night
Wind
280° at 5 knots
Visibility
10 statute miles
Lowest ceiling
7,000 ft broken
Temperature
52 °F, dew point 52 °F
Altimeter
30.29 inHg
Observed at
SKBO

Docket · 31

The files NTSB released with the investigation on October 29, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.8 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 567 KBKalitta Initial Incident ReportItem 2 · .PDF · 78 KBAdditional Crew CommentsItem 3 · .PDF · 148 KBFDR Data Subset (13 Parameters)Item 4 · .PDF · 746 KBPowerplants 8 - Factual Report of Group ChairmanItem 5 · .PDF · 484 KBPowerplants 8 - Attachment 1: P&W Borescope Inspection Results for Engine SN 702121 dated Sept. 29, 2008 & Nov. 12, 2008Item 6 · .PDF · 916 KBPowerplants 8 - Attachment 2: Additional borescope inspection results for Engine SN 702121 dated September 30, 2008 and an assessment of the fan case and fan blade clearance dated June 11, 2010Item 7 · .PDF · 1.4 MBPowerplants 8 - Attachment 3: P&W fan blade leading edge impressions and final evaluation for Engine SN 702121dated May 26, 2009Item 8 · .PDF · 447 KBPowerplants 8 - Attachment 4: Test Plane for Engine SN 702121 Test 12 Performance TestItem 9 · .PDF · 42 KBPowerplants 8 - Attachment 5: Test 1 first run Recorded Data Engine SN 702121Item 10 · .PDF · 87 KBPowerplants 8 - Attachment 6: Test 1 first run Kalitta Calculated Data Engine SN 702121Item 11 · .PDF · 76 KBPowerplants 8 - Attachment 7: Initial Engine Vane Position Trim Tracking Plot for Engine SN 702121Item 12 · .PDF · 61 KBPowerplants 8 - Attachment 8: Test 1 second run Recorded Data Engine SN 702121Item 13 · .PDF · 87 KBPowerplants 8 - Attachment 9: Test 1 second run Kalitta Calculated Data Engine SN 702121Item 14 · .PDF · 76 KBPowerplants 8 - Attachment 10: Newly Overhauled Fan Blade Data for Test 2 for Engine SN 702121Item 15 · .PDF · 78 KBPowerplants 8 - Attachment 11: Test 2 first run Recorded Data Engine SN 702121Item 16 · .PDF · 86 KBPowerplants 8 - Attachment 12: Engine Vibration Survey with Newly Overhauled Fan Blade and original Fan Case for Engine 702121Item 17 · .PDF · 299 KBPowerplants 8 - Attachment 13: Test 2 first run Kalitta Calculated Data Engine SN 702121Item 18 · .PDF · 75 KBPowerplants 8 - Attachment 14: Test 2 second run Recorded Data Engine SN 702121Item 19 · .PDF · 86 KBPowerplants 8 - Attachment 15: Test 2 second run Kalitta Calculated Data Engine SN 702121Item 20 · .PDF · 75 KBPowerplants 8 - Attachment 16: Engine Vibration Survey with Newly Overhauled Fan Blade and New Fan Case for Engine 702121Item 21 · .PDF · 299 KBPowerplants 8 - Attachment 17: Test 3 first run Recorded Data Engine SN 702121Item 22 · .PDF · 81 KBPowerplants 8 - Attachment 18: Test 3 first run Kalitta Calculated Data Engine SN 702121Item 23 · .PDF · 78 KBPowerplants 8 - Attachment 19: Test 3 second run Recorded Data Engine SN 702121Item 24 · .PDF · 81 KBSystems 9 - Attachment 20: Test 3 second run Kalitta Calculated Data Engine SN 702121Item 25 · .PDF · 78 KBPowerplants 8 - Attachment 21: Engine Vane Position Re-Trim Tracking Plot for Engine SN 702121Item 26 · .PDF · 61 KBPowerplants 8 - Addendum 22: Engine Re-trim Recorded Data Engine SN 702121Item 27 · .PDF · 69 KBPowerplants 8 - Attachment 23: Engine Re-trim Kalitta Calculated Data Engine SN 702121Item 28 · .PDF · 70 KBPowerplants 8 - Addendum 24: P&W’s evaluation of the on-wing testing data from engine SN 702121 dated February 10, 2010Item 29 · .PDF · 1.9 MBStatement of Party Representatives to NTSB InvestigationItem 30 · .PDF · 78 KBIncident Delegation EmailsItem 31 · .PDF · 54 KB