Individually Owned: 151,845
Corporate Owned: 143,699
Hartsfield - Jackson Atlanta I Airport
Aircraft Accident/Incident Report
Atlanta, Georgia 30354
Monday, October 10, 2011 15:03 EDT
NTSB Narrative Summary Released at Completion of Accident
The diffuser case of a Pratt & Whitney PW2037(M) engine installed on a B757-200 airplane ruptured during takeoff roll at Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia (ATL). The force of the case rupture caused the hinge-mounted core cowl halves to distort and strike the leading edge and underside of the airplane's left wing, resulting in minor airplane damage. Metallurgical investigation and review of the engine's maintenance records determined that cracks in the engine's diffuser case rear flange (M-flange) and cracks in the HPT case forward flange (M-flange) were not detected when the cases underwent fluorescent penetrant inspection (FPI) during the engine's last shop visit, 3,479 cycles before the event. The undetected cracks continued to propagate, leading to the in-service diffuser case rupture. The reason for the ineffective inspection was not determined, but was narrowed to chronological- and operator-based scenarios. A suspect population of 50 engines was identified that included sub-populations for both possibilities. The FAA published airworthiness directive (AD) 2014-05-32, requiring the M-flanges of PW2037, PW2037D, PW2037M, PW2040, PW2040D, PW2043, PW2143, PW2240, PW2337, PW2643, and F117-PW-100 engines in the identified suspect population to undergo eddy current inspection within 100 flight cycles or 30 days. No additional cracks were found. As a result of the investigation, the FAA published airworthiness directive (AD) 2014-05-32, which requires the M-flanges of PW2000 engines with certain diffuser and HPT cases installed to undergo eddy current inspection within 100 flight cycles or 30 days. AD 2014-05-32 also requires that high-sensitivity FPI penetrant be used when accomplishing FPI of the PW2037, PW2037D, PW2037M, PW2040, PW2040D, PW2043, PW2143, PW2240, PW2337, PW2643, and F117-PW-100 diffuser case M-flange and the HPT case M-flange. In addition, AD 2014-05-32 makes the performance of diffuser and HPT case M-flange high-sensitivity FPI at every piece part opportunity an airworthiness limitation for PW2037, PW2037D, PW2037M, PW2040, PW2040D, PW2043, PW2146, PW2240, PW2337, PW2643, and F117-PW-100 engines.
NTSB Probable Cause Narrative
the return to service of overhauled airplane engine parts with undetected fatigue cracks, resulting in complete loss of engine power and uncontained engine failure. A contributing factor was the inadequate diffuser and HPT case inspection procedure.
Event Information
| Type of Event | Incident |
| Event Date | 10/10/2011 |
| Event Day of the Week | Monday |
| Time of Event | 1503 |
| Event Time Zone | Eastern Daylight Time |
| Event City | Atlanta |
| Event State | GEORGIA |
| Event Country | -- |
| Zipcode of the event site | 30354 |
| Event Date Year | 2011 |
| Event Date Month | 10 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 334548N |
| Event Location Longitude | 0842406W |
| Event Location Airport | HARTSFIELD - JACKSON ATLANTA I |
| Event Location Nearest Airport ID | ATL |
| Indicates whether the acc/inc occurred off or on an airport | On Airport |
| Distance from airport in statute miles | 8 |
| Degrees magnetic from airport | 10 |
| Airport Elevation | 1026 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Unknown |
| Time of the weather observation | |
| Direction of event from weather observation facility (degrees) | -- |
| Weather Observation Facility ID | -- |
| Elevation of weather observation facility | -- |
| Distance of event from weather observation facility (units?) | -- |
| Time Zone of the weather observation | -- |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | -- |
| Sky Condition for Lowest Ceiling | -- |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | -- |
| Air Temperature at event time (in degrees celsius) | -- |
| Dew Point at event time (in degress fahrenheit) | -- |
| Wind Direction (degrees magnetic) | -- |
| Variable Wind Indicator | -- |
| Wind Speed (knots) | -- |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | -- |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | -- |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | None |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 182 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 33301 |
| NTSB Notification Source | Delta Air Lines |
| NTSB Notification Date | -- |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | -- |
| Date of most recent change to record | Aug 15 2014 4:28PM |
| User who most recently changed record | horc |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N553NW |
| NTSB Number | ENG12IA001 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 121: Air Carrier |
| Type of Flight Plan filed | Unknown |
| Flight plan Was Activated? | -- |
| Damage | Minor |
| Aircraft Fire | Ground |
| Aircraft Explosion | Ground |
| Aircraft Manufacturer's Full Name | BOEING |
| Aircraft Model | 757-251 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 26500 |
| Certified Max Gross Weight | -- |
| Aircraft Category | Airplane |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 178 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | -- |
| Date of Last Inspection | -- |
| Airframe hours since last inspection | -- |
| Airframe Hours | -- |
| ELT Installed | Unknown |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | -- |
| Aircraft Owner Name | DELTA AIR LINES INC |
| Aircraft Owner Street Address | ATTN: TREASURER DEPT 856 |
| Aircraft Owner City | ATLANTA |
| Aircraft Owner State | GA |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 30354-1989 |
| Operator is an individual? | No |
| Operator Name | Delta Air Lines Inc |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | ATTN: TREASURER DEPT 856 |
| Operator City | ATLANTA |
| Operator State | GA |
| Operator Country | USA |
| Operator Zip code | 30354-1989 |
| Operator Code | DAL |
| Owner has at least one certificate | Yes - certificate holder |
| Other Operator of large aircraft? | -- |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | Scheduled |
| Indicates Domestic or International Flight | Domestic |
| Operator carrying Pax/Cargo/Mail | Passenger Only |
| Type of Flying (Per_Bus / Primary) | -- |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | Yes |
| Departure Airport Code | ATL |
| Departure City | Atlanta |
| Departure State | GA |
| Departure Country | USA |
| Departure Time | 1503 |
| Departure Time Zone | EDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | DFW |
| Destination City | Dallas |
| Destination State | TX |
| Destination Country | USA |
| Specific Phase of Flight | -- |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jul 22 2014 12:08PM |
| User who most recently changed record | horc |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | N/A |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |