# NTSB NYC96IA036: Boeing 747-240, Jamaica, NY, December 7, 1995 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: December 6, 1995, 21:50 local (Dec 7, 1995, 02:50 UTC) - Place: Jamaica, NY - Location: 40.6915° N, 73.8057° W: Placed by OpenAirDocs: center of Jamaica, NY, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=40.6915&lon=-73.8057&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 255 uninjured - Status: Completed, report July 31, 1998 - Report: Approved by Office Director - Safety recommendations: Yes - NTSB case key (mKey): 39101 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC96IA036 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/39101/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=39101 - Page: https://openairdocs.org/ntsb/NYC96IA036 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, takeoff - initial climb - 1 engine - turbine assembly,shaft - fatigue (cause) - maintenance,inspection - inadequate, company maintenance personnel (cause) ## 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 (not matched to a registry record) - Reported make and model: Boeing 747-240 - Category: Airplane - Engines: GE CF6-50E2 50400 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. - Pilot; age 59; 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 files) The files NTSB released with the investigation on July 17, 1997, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=39101. 7.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 731 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443765&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Factual Report of Group Chairman (Field Notes) (item 2, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443766&FileExtension=.PDF&FileName=Factual%20Report%20of%20Group%20Chairman%20(Field%20Notes)-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 3, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443767&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Powerplants Group Chairman's Factual Report (item 4, .PDF, 850 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443768&FileExtension=.PDF&FileName=Powerplants%20Group%20Chairman%27s%20Factual%20Report-Redacted.PDF - Powerplants Group Chairman's Factual Report - Attachments (item 5, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064086&FileExtension=.PDF&FileName=Powerplants%20Group%20Chairman%27s%20Factual%20Report%20-%20Attachments-Master.PDF - Powerplant Report Photo #1 Left side of airplane showing engines No. 1 and 2 (item 6, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064049&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%231%20%20Left%20side%20of%20airplane%20showing%20engines%20No.%201%20and%202-Master.PDF - Powerplant Report Photo #2 View of left wing of airplane showing engines No. 1 and 2 (item 7, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064050&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%232%20View%20of%20left%20wing%20of%20airplane%20showing%20engines%20No.%201%20and%202%20%20%20%20%20%20%20%20%20%20-Master.PDF - Powerplant Report Photo #3 Left side of No. 2 engine (item 8, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064051&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%233%20Left%20side%20of%20No.%202%20engine-Master.PDF - Powerplant Report Photo #4 Right side of N0. 2 engine (item 9, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064052&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%234%20Right%20side%20of%20N0.%202%20engine-Master.PDF - Powerplant Report Photo #5 View of Stage 1 vane trailing edges, vane support, and toroid (item 10, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064053&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%235%20View%20of%20Stage%201%20vane%20trailing%20edges,%20vane%20support,%20and%20toroid-Master.PDF - Powerplant Report Photo #6 Right side of No. 1 engine cowling (item 11, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064054&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%236%20Right%20side%20of%20No.%201%20engine%20cowling-Master.PDF - Powerplant Report Photo #7 Damaged fan blade in No. 1 engine (item 12, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064055&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%237%20Damaged%20fan%20blade%20in%20No.%201%20engine-Master.PDF - Powerplant Report Photo #8 View of No. 2 engine from No. 1 engine inlet (item 13, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064056&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%238%20View%20of%20No.%202%20engine%20from%20No.%201%20engine%20inlet-Master.PDF - Powerplant Report Photo #9 View of left wing main landing gear door showing hole (item 14, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064057&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%239%20View%20of%20left%20wing%20main%20landing%20gear%20door%20showing%20hole-Master.PDF - Powerplant Report Photo #10 Close up of hole in left wing main landing gear door (item 15, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064058&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2310%20Close%20up%20of%20hole%20in%20left%20wing%20main%20landing%20gear%20door-Master.PDF - Powerplant Report Photo #11 View of left wing leading edge over No. 2 engine showing damage to the leading edge (item 16, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064059&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2311%20View%20of%20left%20wing%20leading%20edge%20over%20No.%202%20engine%20showing%20damage%20to%20the%20leading%20edge%20-Master.PDF - Powerplant Report Photo #12 View of damage to left wing rib bay bulkhead behind leading edge flap (item 17, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064060&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2312%20View%20of%20damage%20to%20left%20wing%20rib%20bay%20bulkhead%20behind%20leading%20edge%20flap-Master.PDF - Powerplant Report Photo #13 Fractured fan mid shaft and air duct with an exemplar fan mid shaft and air duct for comparison (item 18, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064061&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2313%20Fractured%20fan%20mid%20shaft%20and%20air%20duct%20with%20an%20exemplar%20fan%20mid%20shaft%20and%20air%20duct%20for%20comparison-Master.PDF - Powerplant Report Photo #14 Fan mid shaft piece No. 1 (item 19, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064062&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2314%20Fan%20mid%20shaft%20piece%20No.%201-Master.PDF - Powerplant Report Photo #15 Fan mid shaft pieces No. 2 and 3 (item 20, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064063&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2315%20Fan%20mid%20shaft%20pieces%20No.%202%20and%203-Master.PDF - Powerplant Report Photo #16 Fan mid shaft pieces No. 4 and 5 (item 21, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064064&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2316%20Fan%20mid%20shaft%20pieces%20No.%204%20and%205%20-Master.PDF - Powerplant Report Photo #17 Fan mid shaft pieces No. 6 and 8 (item 22, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064065&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2317%20Fan%20mid%20shaft%20pieces%20No.%206%20and%208-Master.PDF - Powerplant Report Photo #19 Fan mid shaft piece No. 7 (item 23, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064066&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2319%20Fan%20mid%20shaft%20piece%20No.%207-Master.PDF - Powerplant Report Photo #19 Fan mid shaft piece No. 9 (item 24, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064067&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2319%20Fan%20mid%20shaft%20piece%20No.%209-Master.PDF - Powerplant Report Photo #20 Fan mid shaft piece No. 10 (item 25, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064068&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2320%20Fan%20mid%20shaft%20piece%20No.%2010-Master.PDF - Powerplant Report Photo #21 Close up of fan mid shaft showing multiple fractures (item 26, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064069&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2321%20Close%20up%20of%20fan%20mid%20shaft%20showing%20multiple%20fractures-Master.PDF - Powerplant Report Photo #22 Close up of rear section of fan mid shaft showing rubs and crack (item 27, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064070&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2322%20Close%20up%20of%20rear%20section%20of%20fan%20mid%20shaft%20showing%20rubs%20and%20crack-Master.PDF - Powerplant Report Photo #23 Left side of forward compressor stator case showing 1/4 inch wide gap (item 28, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064071&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2323%20Left%20side%20of%20forward%20compressor%20stator%20case%20showing%201%2F4%20inch%20wide%20gap-Master.PDF - Powerplant Report Photo #24 High pressure compressor rotor (item 29, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064072&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2324%20High%20pressure%20compressor%20rotor-Master.PDF - Powerplant Report Photo #25 Close up of high pressure compressor blades Stages 1 through 6 (item 30, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064073&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2325%20Close%20up%20of%20high%20pressure%20compressor%20blades%20Stages%201%20through%206-Master.PDF - Powerplant Report Photo #26 Close up of high pressure compressor blades Stages 4 through 12 (item 31, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064074&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2326%20Close%20up%20of%20high%20pressure%20compressor%20blades%20Stages%204%20through%2012-Master.PDF - Powerplant Report Photo #27 High pressure compressor Stage 1 disk (item 32, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064075&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2327%20High%20pressure%20compressor%20Stage%201%20disk-Master.PDF - Powerplant Report Photo #28 High pressure compressor Stage 2 disk (item 33, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064076&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2328%20High%20pressure%20compressor%20Stage%202%20disk-Master.PDF - Powerplant Report Photo #29 High pressure compressor front stator vane case and stator vanes (item 34, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064077&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2329%20High%20pressure%20compressor%20front%20stator%20vane%20case%20and%20stator%20vanes-Master.PDF - Powerplant Report Photo #30 No. 3 bearing rollers (item 35, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064078&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2330%20No.%203%20bearing%20rollers-Master.PDF - Powerplant Report Photo #31 Close up of No. 3 bearing rollers (item 36, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064079&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2331%20Close%20up%20of%20No.%203%20bearing%20rollers-Master.PDF - Powerplant Report Photo #32 Compressor rear frame showing overlapping fracture (item 37, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064080&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2332%20Compressor%20rear%20frame%20showing%20overlapping%20fracture-Master.PDF - Powerplant 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 comparison (item 38, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064081&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2333%20Fractured%20Stage%204%20low%20pressure%20turbine%20blade%20showing%20groove%20rubbed%20in%20rear%20face%20of%20root%20with%20exemplar%20Stage%204%20low%20pressure%20turbine%20blade%20for%20comparison-Master.PDF - Powerplant Report Photo #34 Low pressure turbine case at 12 o'clock (item 39, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064082&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2334%20Low%20pressure%20turbine%20case%20at%2012%20o%27clock-Master.PDF - Powerplant Report Photo #35 Low pressure turbine case at 3 o'clock (item 40, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064083&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2335%20Low%20pressure%20turbine%20case%20at%203%20o%27clock-Master.PDF - Powerplant Report Photo #36 Low pressure turbine case at 6 o'clock (item 41, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064084&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2336%20Low%20pressure%20turbine%20case%20at%206%20o%27clock-Master.PDF - Powerplant Report Photo #37 Low pressure turbine case at 9 o'clock (item 42, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40064085&FileExtension=.PDF&FileName=Powerplant%20Report%20Photo%20%2337%20Low%20pressure%20turbine%20case%20at%209%20o%27clock-Master.PDF 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.