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Uncontained Engine Failure, Delta Air Lines Flight 1288, Mcdonnell Douglas MD-88, N927DA, Pensacola, Florida, July 6, 1996

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Uncontained Engine Failure, Delta Air Lines Flight 1288, Mcdonnell Douglas MD-88, N927DA, Pensacola, Florida, July 6, 1996 { PB98-910401 NTSB/AAR-98/01 DCA96MA068 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT UNCONTAINED ENGINE FAILURE DELTA AIR LINES FLIGHT 1288 MCDONNELL DOUGLAS MD-88, N927DA PENSACOLA, FLORIDA JULY 6, 1996 6725C ——— — / The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (202)382-6735 (800)877-6799 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600 NTSB/AAR-98/01 PB98-910401 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT UNCONTAINED ENGINE FAILURE DELTA AIR LINES FLIGHT 1288 McDONNELL DOUGLAS MD-88, N927DA PENSACOLA, FLORIDA JULY 6, 1996 Adopted: January 13, 1998 Notation 6725C Abstract: This report explains the accident involving Delta Air Lines flight 1288, an MD-88, which experienced an uncontained engine failure during the initial part of its takeoff roll at Pensacola Regional Airport in Pensacola, Florida, on July 6, 1996. Safety issues in the report include the limitations of the blue etch anodize process, manufacturing defects, standards for the fluorescent penetrant inspection process, the performance of nondestructive testing, the use of alarm systems for emergency situations, and instructions regarding emergency exits. Safety recommendations concerning these issues were made to the Federal Aviation Administration. CONTENTS EXECUTIVE SUMMARY..........................................................................................................vi 1. FACTUAL INFORMATION..................................................................................................1 1.1 History of Flight....................................................................................................................1 1.2 Injuries to Persons.................................................................................................................4 1.3 Damage to Airplane..............................................................................................................4 1.4 Other Damage.......................................................................................................................6 1.5 Personnel Information...........................................................................................................6 1.5.1 The Captain.................................................................................................................................6 1.5.2 The First Officer..........................................................................................................................8 1.5.3 Flight Attendants.........................................................................................................................8 1.6 Airplane Information.............................................................................................................8 1.6.1 Airplane Engines.........................................................................................................................9 1.6.2 Left Engine Compressor Fan Hub Manufacture and History......................................................9 1.7 Meteorological Information................................................................................................13 1.8 Aids to Navigation..............................................................................................................13 1.9 Communications.................................................................................................................13 1.10 Airport Information...........................................................................................................14 1.11 Flight Recorders................................................................................................................14 1.12 Wreckage and Impact Information....................................................................................15 1.13 Medical and Pathological Information..............................................................................17 1.14 Fire....................................................................................................................................19 1.14.1 Emergency Response...............................................................................................................19 1.15 Survival Aspects................................................................................................................20 1.15.1 General....................................................................................................................................20 iii 1.15.2 The Evacuation........................................................................................................................20 1.15.3 Previous Safety Board Recommendations...............................................................................22 1.16 Tests and Research............................................................................................................26 1.16.1 Metallurgical Examination......................................................................................................26 1.16.2 Examination of Volvo’s Tierod Hole Drilling Processes........................................................31 1.16.3 Review of Fan Hub Inspection Procedures Following Manufacture.......................................32 1.16.4 Followup Drilling Tests Conducted by Volvo.........................................................................35 1.17 Organizational and Management Information..................................................................35 1.18 Additional Information......................................................................................................36 1.18.1 Fan Hub Cleaning and FPI Preparation Processes Used by Delta...........................................36 1.18.1.1 Cleaning..........................................................................................................................................37 1.18.1.2 Dye/Developer Application............................................................................................................38 1.18.1.3 Inspection........................................................................................................................................39 1.18.2 FPI Inspector Training at Delta...............................................................................................40 1.18.3 FAA Oversight and Review of Delta’s FPI Process................................................................41 1.18.4 FAA Accident/Incident Records on JT8D-200 Engines..........................................................43 1.18.5 Safety Board Recommendations Subsequent to the Accident................................................43 1.18.6 FAA Responses to Recommendations A-96-74 through -77 and Subsequent Safety Board Responses and Actions.......................................................................................................................44 1.18.7 Related Safety Board Recommendations from the Accident Involving United Airlines Flight 232, Sioux City, Iowa.........................................................................................................................49 1.18.8 Other Uncontained Engine Failures.........................................................................................50 1.18.9 Results of FAA-Sponsored Titanium Rotating Components Review Team...........................52 2. ANALYSIS..............................................................................................................................55 2.1 General................................................................................................................................55 2.2 Fan Hub Fracture.................................................................................................................55 iv 2.3 Analysis of Volvo’s Inspection Procedures ........................................................................ 57 2.4 Failure of Delta Maintenance to Detect Cracking in the Accident Hub ............................. 58 2.4.1 Part Cleaning, Drying, Processing, and Handling .....................................................................59 2.4.2 Human Factors Related to Inspector Performance ....................................................................62 2.4.2.1 Lack of a Formal Method to Ensure Completeness of Search and Diagnostic Followup................. 63 2.4.2.2 Low Expectation of Finding a Crack and Decreased Vigilance ....................................................... 64
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