NYC96IA036

NTSB incident investigation · Boeing 747-240 · Jamaica, NY · December 7, 1995

Incident · No injuriesIncident investigationFinal report
Date
December 6, 1995, 21:50 local (Dec 7, 1995, 02:50 UTC)
Place
Jamaica, NY
Injuries
255 uninjured
Damage
Minor damage
Phase of flight
Initial climb
Aircraft
APBAKBoeing 747-240
Weather
Visual (VMC) · Night/dark
Status
Completed · report July 31, 1998
Report
Approved by Office Director
Safety recommendations
Yes
Case key
39101

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

failure of the number two engine fan mid shaft, due a fatigue fracture caused by a previous bearing failure, and failure of the operator's maintenance personnel to detect the cracks during subsequent inspections.

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 power(total) - mech failure/malfTakeoff - initial climb
1 engine
Turbine assembly,shaft - fatigueCause
Maintenance,inspection - inadequateCompany maintenance personnelCause

Analysis

After takeoff, about 1,000 ft agl, the crew of the Boeing 747-240 heard a 'thudding noise,' followed by a loss of power in the number two engine. An engine shut down was completed, and an uneventful landing was made at the departure airport. The airplane was equipped with General Electric CF6-50E2 engines. Examination revealed that the low pressure turbine module, which included a portion of the fan mid shaft (FMS) and turbine rear frame, was missing. The airplane sustained damage to the left wing leading and tailing edge flaps, the left main wing landing gear doors, and the number one engine. Examination of the number two engine revealed a fracture face on the forward end of the FMS that showed multiple fatigue origins and circumferential cracks. There were also areas on the FMS that were heat affected. The FMS had previously been installed in a CF6-50 engine that had sustained a failure of the number 3 bearing inner race. The engine had been inspected by company personnel, and records did not reflect that they inspected the FMS for heat affected material. Fatigue cracks located in the heat-affected areas were found to have Sermetel paint and debris in the cracks.

Factual narrative

On December 6, 1995, about 2150 eastern standard time, a Boeing 747-240, APBAK, operated by the Pakistan Government as Flight 722, sustained minor damage during an uncontained engine failure after takeoff from the John F. Kennedy International Airport (JFK), Jamaica, New York. Visual meteorological conditions prevailed for the commercial passenger flight that departed, at 2148. The crew of 15, and 240 passengers, were not injured. An instrument flight rules flight plan had been filed for the flight conducted under 14 CFR Part 129.

The three flight crewmembers provided similar accounts of the event. In the Flight Engineer's statement, he said that the engine start and taxi were normal, and full power was applied before the airplane reached 80 knots. At that time all of the engine parameters were equal. During the climb, about 1,000 feet, a "thudding noise" was heard on the left side of the airplane. This was followed by all of the parameters of the number two engine falling to zero, which included the oil quantity. There was no engine fire warning light. An engine shut down was completed, and the airplane was vectored by the Air Traffic Controller while they "dumped" fuel. The airplane was then flown back to JFK, and completed an uneventful landing on runway 31L, at 2311. The airplane was taxied to the gate and the passengers deplaned. An emergency evacuation was not performed.

Two NTSB Powerplant Group Chairman were assigned to the accident at different times. The first Powerplant investigator conducted the on scene investigation. A second Powerplant investigator conducted the examination of the engine at the General Electric facility, Ontario, California.

The airplane had been equipped with General Electric CF6-50E2 engines. Examination of the airplane revealed that the low pressure turbine (LPT) module, which included a portion of the fan mid shaft (FMS), exhaust cone, exhaust nozzle, and turbine rear frame were missing. The LPT case had separated from the turbine mid frame. The airplane sustained damage to the wing adjacent to the number two engine, the left wing leading and tailing edge flaps, and to the left main wing landing gear door. Additional damage was observed to the number one engine nacelle, fan, and engine core.

The NTSB Powerplant Group Chairman's Factual report dated June 5, 1997, stated that the engine examination was conducted on January 3, 1996. The disassembly of the engine revealed that the FMS had multiple fractures between 21 and 26 inches aft of the forward end. The report also stated:

"...The visual and scanning electron microscope (SEM) examination of the fracture face on the forward end of the FMS showed there were multiple fatigue origins and circumferential cracks on the outer diameter (OD) of the shaft. The air duct forward and center stiffener rings were also found to have fatigue cracks that were parallel to the centerline of the air duct...GEAE's examination of the FMS showed that there were areas on the FMS OD that were heat affected, but the Sermetel paint over those area was not rubbed. Fatigue cracks that were located in the heat-affected areas were found to have Sermetel paint and debris in the cracks. GEAE provided the Safety Board with a summary of the maintenance history of the FMS that fractured. The FMS had previously been installed in a PIA CF6-50 engine that had sustained a No. 3 bearing inner race failure. The records did not show that PIA had inspected the FMS for heat affected material that would have occurred if the FMS had been rubbed following the bearing failure or at any of the subsequent maintenance exposures."

Aircraft

Registration
APBAK
Reported as
Boeing 747-240
Category
Airplane
Engine
GE CF6-50E2, 50,400 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 129
Operator
Pakistan International Airline, doing business as Pakistan Intl Airlines
Registered owner
Pakistan Government
Airworthiness certificate
Standard, Transport
Departed
JFK
Destination
Paris,France
Flight plan
IFR
Airport
JFK · John F Kennedy Intl

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
59
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
15,000 total · 4,000 in this make and model · 10,000 as pilot in command · 50 in the last 90 days · 32 in the last 30 days

Weather

Conditions
Visual (VMC) · Night/dark
Wind
260° at 7 knots
Visibility
20 statute miles
Lowest ceiling
2,500 ft overcast
Temperature
39 °F, dew point 18 °F
Altimeter
30.00 inHg
Observed at
JFK

Docket · 42

The files NTSB released with the investigation on July 17, 1997, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.1 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 731 KBFactual Report of Group Chairman (Field Notes)Item 2 · .PDF · 1.5 MBStatement of Party Representatives to NTSB InvestigationItem 3 · .PDF · 101 KBPowerplants Group Chairman's Factual ReportItem 4 · .PDF · 850 KBPowerplants Group Chairman's Factual Report - AttachmentsItem 5 · .PDF · 2.7 MBPowerplant Report Photo #1 Left side of airplane showing engines No. 1 and 2Item 6 · .PDF · 39 KBPowerplant Report Photo #2 View of left wing of airplane showing engines No. 1 and 2Item 7 · .PDF · 35 KBPowerplant Report Photo #3 Left side of No. 2 engineItem 8 · .PDF · 34 KBPowerplant Report Photo #4 Right side of N0. 2 engineItem 9 · .PDF · 40 KBPowerplant Report Photo #5 View of Stage 1 vane trailing edges, vane support, and toroidItem 10 · .PDF · 38 KBPowerplant Report Photo #6 Right side of No. 1 engine cowlingItem 11 · .PDF · 20 KBPowerplant Report Photo #7 Damaged fan blade in No. 1 engineItem 12 · .PDF · 26 KBPowerplant Report Photo #8 View of No. 2 engine from No. 1 engine inletItem 13 · .PDF · 31 KBPowerplant Report Photo #9 View of left wing main landing gear door showing holeItem 14 · .PDF · 26 KBPowerplant Report Photo #10 Close up of hole in left wing main landing gear doorItem 15 · .PDF · 29 KBPowerplant Report Photo #11 View of left wing leading edge over No. 2 engine showing damage to the leading edgeItem 16 · .PDF · 30 KBPowerplant Report Photo #12 View of damage to left wing rib bay bulkhead behind leading edge flapItem 17 · .PDF · 36 KBPowerplant Report Photo #13 Fractured fan mid shaft and air duct with an exemplar fan mid shaft and air duct for comparisonItem 18 · .PDF · 43 KBPowerplant Report Photo #14 Fan mid shaft piece No. 1Item 19 · .PDF · 30 KBPowerplant Report Photo #15 Fan mid shaft pieces No. 2 and 3Item 20 · .PDF · 33 KBPowerplant Report Photo #16 Fan mid shaft pieces No. 4 and 5Item 21 · .PDF · 33 KBPowerplant Report Photo #17 Fan mid shaft pieces No. 6 and 8Item 22 · .PDF · 30 KBPowerplant Report Photo #19 Fan mid shaft piece No. 7Item 23 · .PDF · 24 KBPowerplant Report Photo #19 Fan mid shaft piece No. 9Item 24 · .PDF · 31 KBPowerplant Report Photo #20 Fan mid shaft piece No. 10Item 25 · .PDF · 32 KBPowerplant Report Photo #21 Close up of fan mid shaft showing multiple fracturesItem 26 · .PDF · 39 KBPowerplant Report Photo #22 Close up of rear section of fan mid shaft showing rubs and crackItem 27 · .PDF · 31 KBPowerplant Report Photo #23 Left side of forward compressor stator case showing 1/4 inch wide gapItem 28 · .PDF · 50 KBPowerplant Report Photo #24 High pressure compressor rotorItem 29 · .PDF · 46 KBPowerplant Report Photo #25 Close up of high pressure compressor blades Stages 1 through 6Item 30 · .PDF · 34 KBPowerplant Report Photo #26 Close up of high pressure compressor blades Stages 4 through 12Item 31 · .PDF · 37 KBPowerplant Report Photo #27 High pressure compressor Stage 1 diskItem 32 · .PDF · 34 KBPowerplant Report Photo #28 High pressure compressor Stage 2 diskItem 33 · .PDF · 36 KBPowerplant Report Photo #29 High pressure compressor front stator vane case and stator vanesItem 34 · .PDF · 35 KBPowerplant Report Photo #30 No. 3 bearing rollersItem 35 · .PDF · 30 KBPowerplant Report Photo #31 Close up of No. 3 bearing rollersItem 36 · .PDF · 33 KBPowerplant Report Photo #32 Compressor rear frame showing overlapping fractureItem 37 · .PDF · 36 KBPowerplant Report Photo #33 Fractured Stage 4 low pressure turbine blade showing groove rubbed in rear face of root with exemplar Stage 4 low pressure turbine blade for comparisonItem 38 · .PDF · 27 KBPowerplant Report Photo #34 Low pressure turbine case at 12 o'clockItem 39 · .PDF · 33 KBPowerplant Report Photo #35 Low pressure turbine case at 3 o'clockItem 40 · .PDF · 31 KBPowerplant Report Photo #36 Low pressure turbine case at 6 o'clockItem 41 · .PDF · 32 KBPowerplant Report Photo #37 Low pressure turbine case at 9 o'clockItem 42 · .PDF · 28 KB