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B762, Los Angeles USA, 2006

Summary

On June 2, 2006, an American Airlines Boeing 767-200ER fitted GE CF6-80A engines experienced an
uncontained failure of the high pressure turbine (HPT) stage 1 disc in the No. 1 engine during a high-
power ground run carried out in designated run up area at Los Angeles for maintenance purposes
during daylight normal visibility conditions. The three maintenance personnel on board the aircraft as
well as two observers on the ground were not injured but both engines and the aircraft sustained
substantial damage from the fuel-fed fire which occurred as an indirect result of the failure.

Event Details

When June 2006

Actual or Potential AW (/index.php/AW), FIRE (/index.php/FIRE), GND

Event Type (/index.php/GND)

Day/Night Day

Flight Conditions On Ground - Normal Visibility

Flight Details

Aircraft BOEING 767-200ER (/index.php/B762)

Operator American Airlines (/index.php/American_Airlines)

Domicile United States (/index.php/United_States)

Type of Flight

Take off Commenced No

Flight Airborne No

Flight Completed No

Flight Phase Standing

STD (/index.php/STD)

Location - Airport

Airport Los Angeles (/index.php/KLAX)

General

Tag(s) Inadequate Airworthiness Procedures

FIRE

Tag(s) Fire-Power Plant origin

GND

Tag(s) Engine Ground Running

EPR

Emergency Evacuation,
Tag(s)
RFFS Procedures

AW

System(s) Engine - General

 OEM Design fault,
Contributor(s) Damage Tolerance,
Component Fault in service

Outcome

Damage or injury Yes

Aircraft damage Major

Injuries

Fatalities ()

Causal Factor Group(s)

Group(s) Aircraft Technical

Safety Recommendation(s)

Aircraft Operation,
Group(s)
Aircraft Airworthiness

Investigation Type

Type Independent

Description
On June 2, 2006, an American Airlines Boeing 767-200ER (/index.php/B762) fitted
GE CF6-80A engines experienced an uncontained failure
(/index.php/Uncontained_Engine_Failure) of the high pressure turbine (HPT) stage 1
disc in the No. 1 engine during a high-power ground run carried out in designated
run up area at Los Angeles for maintenance purposes during daylight normal
visibility conditions. The three maintenance personnel on board the aircraft as well
as two observers on the ground were not injured but both engines and the aircraft
sustained substantial damage from the fuel-fed fire which occurred as an indirect
result of the failure.

Investigation
Although there was no intention of flight, an Investigation into the event was
carried out by the NTSB (/index.php/NTSB). It was established that maintenance
were performing a high-power engine run-up in response to a flight crew defect
report entered after the previous flight that the left engine lagged behind the right
engine by about 2 percent during the climb from FL360 to FL380. The technicians
who had been on board reported that they had performed a series of
troubleshooting procedures, including deselecting the EEC and then making two
rapid movements of the thrust levers from idle to maximum thrust and back to
idle. They reported that after the left engine had reached maximum thrust for the
second time and was decelerating through 95 percent N1, they had heard a loud
explosion that was quickly followed by a fire under the left wing and in the fuselage
aft of the wing. They stated that they had immediately shut down both engines,
discharged fire shot 1 into the left engine and evacuated the aircraft. The fire
continued until it was extinguished by the attending RFFS personnel.

Examination of the No. 1 engine showed that the HPT stage 1 disc had ruptured and
completely split the engine with the fan, booster, high pressure compressor, and
combustor hanging from the forward-engine mount and the low pressure turbine
and exhaust hanging from the rear-engine mount. The HPT stage 1 disc was found
to have separated from the shaft at the conical section of the shaft and was
completely missing from the engine. The recovery of the pieces of the ruptured disc
showed that it had broken into three approximately equally sized pieces, a fourth
triangular-shaped piece and several smaller fragments. One piece of the disc, which
had initially bounced off of the ground before penetrating the aircraft fuselage had
completely severed the aircraft left-hand keel beam and partially severed the right-
hand keel beam before exiting the fuselage to become lodged in the No. 2 engine
exhaust duct. Another piece of the disc was found in the airplane embedded in an
air duct. A third piece of the disc was found nearly 800 metres away from the
aircraft against an airport perimeter fence after crossing over two active runways,
25R/07L and 25L/07R, as well as taxiways. It was noted that an Air New Zealand
Boeing 747-400 had just landed on Runway 25L. The fourth triangular-shaped piece
of the disc was found embedded in the engine pylon.

Examination of the No. 2 engine showed that the left side of the nacelle was
peppered with holes and impact marks made by debris from the No. 1 engine in
addition to a piece of the HPT stage 1 disc that had gone through the exhaust duct
and was protruding from the right side of the engine. The examination of the
aircraft generally found numerous holes in the left and right wing fuel tanks where
fuel had leaked out and fed the ground fire that burned the left wing and the
fuselage aft of it.

Examination of the failed disc showed that the primary fracture which had
originated the rupture was a small dent at a blade slot at the bottom aft corner and
that it had led to a rim-to-bore radial fracture.

The Investigation formed the view that had the failure occurred during flight rather
than on the ground during maintenance, the aircraft may not have been able to
maintain safe flight. It noted a previously investigated uncontained failure of an HPT
stage 1 disc on the same engine type six years earlier during engine ground runs
and the Safety Recommendations issued as a result if it and also an in-flight
uncontained HPT stage 1 disc rupture that had occurred to an Air New Zealand
Boeing 767-200 with the same engine type in 2002.

It was considered that although all four of the previous NTSB Recommendations
were closed in either an acceptable or acceptable alternate status following FAA
action, the fact that an uncontained failure of an HPT stage 1 disc had recurred was
considered to indicate that further action was necessary.

The Investigation also noted that the CVR (/index.php/CVR) had been intentionally
disabled prior to the ground running, and that this action had removed the
opportunity to access useful data for investigative purposes. The Investigators were
told that that disabling the CVR prior to ground running was normal practice.

The Probable Cause of the event was determined as:

“The HPT stage 1 disk failed from an intergranular fatigue crack because of GE's
inadequate design of the CF6-80 series HPT stage 1 disk. The inadequate design of
the disk resulted in a high stress area in the blade slot bottom aft corner that was
at or nearly at the material's capability so that there was no damage tolerance such
that a small dent could cause a crack to initiate and propagate to failure.”

It was also considered that:

“Contributing to the disk's failure was the FAA's failure to mandate an accelerated
inspection schedule after a previous CF6-80A uncontained HPT stage 1 disk failure
had occurred and after other CF6-80A HPT disks had been found during routine
overhaul to have cracks in the blade slot bottom aft corners.”

On 26 August 2006, during the course of the Investigation, five Safety

Recommendations were made as follows:

that the FAA require that all CF6-80A and -80C2 high pressure turbine (HPT)
stage 1 disks and applicable -80E1 HPT stage 1 disks that have more than
3,000 cycles since new (CSN) and have not been reworked in accordance with
General Electric Service Bulletins (SB) 72-0788 or 72-1089 or have not yet
been inspected in accordance with SB 72-0779 or Alert Service Bulletin 72-
A1026 be immediately removed from service for inspection and rework in
accordance with these SBs. Those CF6-80A and -80C2 HPT stage 1 disks and
applicable -80E1 HPT stage 1 disks that have fewer than 3,000 CSN and have
not been reworked or inspected in accordance with these SBs can remain in
service until reaching the 3,000 CSN threshold, at which time they should also
be removed from service for inspection and rework.

(A-06-60)

that the FAA require that all CF6-80A and -80C2 high pressure turbine (HPT)
stage 1 disks and applicable -80E1 HPT stage 1 disks that have not been
reworked in accordance with General Electric Service Bulletins (SB) 72-0788
or 72-1089 but have been inspected in accordance with SB 72-0779 or Alert
Service Bulletin (ASB) 72-A1026 and have more than 3,000 cycles since the
inspection be immediately removed from service for re-inspection and rework
in accordance with these SBs. Those CF6-80A and -80C2 HPT stage 1 disks
 and applicable -80E1 HPT stage 1 disks that have not been reworked in
accordance with SBs 72-0788 or 72-1089 but have been inspected in
accordance with SB 72-0779 or ASB 72-A1026 and have fewer than 3,000
cycles since the inspection can remain in service until reaching the 3,000
cycles-since-inspection threshold, at which time they should also be removed
from service for re-inspection and rework.

(A-06-61)

that the FAA revise the engine-related airworthiness directive process to

ensure that the compliance timelines are appropriately established.

(A-06-62)

that the FAA require a design review of CF6-80 series high pressure turbine
(HPT) stage 1 disks that incorporate chamfered blade slot bottom aft corners
that includes a stress analysis and finite element model emphasizing the
blade slot bottom aft corner to determine whether sufficient material property
margin exists to ensure that cracks do not occur. If the design review of
chamfered HPT stage 1 disks finds that this design does not provide sufficient
material property margin, then a redesign or material change should be
implemented.

(A-06-63)

that the FAA require that maintenance personnel ensure that an aircraft’s
cockpit voice recorder (CVR) is operating before conducting any engine ground
tests. If an airplane has been involved in a reportable event, the incident CVR
should be removed to preserve the event data and any subsequent ground
test should be delayed until a suitable replacement CVR can be installed in
the aircraft.

(A-06-64)

The Final Report of the Investigation

(http://www.skybrary.aero/bookshelf/books/1373.pdf) was published on 31 January
2008. A separate Letter to the FAA details the Safety Recommendations
(http://www.skybrary.aero/bookshelf/books/1374.pdf) Safety Recommendations and
the reasons for issuing them.
Further Reading
Uncontained Engine Failure (/index.php/Uncontained_Engine_Failure)
Aircraft Ground Running (/index.php/Aircraft_Ground_Running)
Ground Accident Prevention Program
(/index.php/Ground_Accident_Prevention_Program)
Ageing Aircraft - Structural Failure (/index.php/Ageing_Aircraft_-
_Structural_Failure)
Damage Tolerance (/index.php/Damage_Tolerance)

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