Incident Overview

Date: Sunday 12 September 1999
Aircraft Type: Boeing 737-3T0
Owner/operator: Continental Air Lines
Registration Number: N17356
Location: West Palm Beach International Airport, FL (PBI) – ÿ United States of America
Phase of Flight: En route
Status: Substantial, repaired
Casualties: Fatalities: 0 / Occupants: 89
Component Affected: The No. 1 engine, specifically the forward rotating air seal (HPT) rotor and its associated shaft and seal.The No. 1 engine, specifically the forward rotating air seal (HPT) rotor and its associated shaft and seal.
Investigating Agency: NTSBNTSB
Category: Accident
A Boeing 737-300, operated by Continental Airlines as flight 1933, experienced a near-miss incident following takeoff from West Palm Beach. The pilot reported a sudden and severe engine failure, characterized by a loud bang, violent jolt, and shaking. The No. 1 engine lost thrust, and the pilot successfully maintained control of the aircraft, returning to West Palm Beach International Airport without further incident. Examination of the aircraft revealed significant damage to the left wing, including damage to high lift devices, fuselage, stabilizers, rudder, and tail cone. A critical component ? the No. 1 engine’s forward rotating air seal ? separated, resulting in a catastrophic failure. The separation was attributed to a manufacturing defect in a bolt hole that was not detected during inspection, exacerbated by inadequate inspection techniques employed by the engine manufacturer. The recovery of the HPT rotating air seal debris further supports this conclusion.A Boeing 737-300, operated by Continental Airlines as flight 1933, experienced a near-miss incident following takeoff from West Palm Beach. The pilot reported a sudden and severe engine failure, characterized by a loud bang, violent jolt, and shaking. The No. 1 engine lost thrust, and the pilot successfully maintained control of the aircraft, returning to West Palm Beach International Airport without further incident. Examination of the aircraft revealed significant damage to the left wing, including damage to high lift devices, fuselage, stabilizers, rudder, and tail cone. A critical component ? the No. 1 engine’s forward rotating air seal ? separated, resulting in a catastrophic failure. The separation was attributed to a manufacturing defect in a bolt hole that was not detected during inspection, exacerbated by inadequate inspection techniques employed by the engine manufacturer. The recovery of the HPT rotating air seal debris further supports this conclusion.

Description

A Boeing 737-300, operated by Continental Airlines as flight 1933, had a failure of the No. 1 engine shortly after takeoff from West Palm Beach. The captain stated he was in the right seat and acting as a check airman. The second pilot, who was flying the aircraft from the left seat, was receiving initial operating experience as a captain. Both pilots stated that after takeoff on runway 9 left, as they were climbing through about 1,000 feet, there was the sound of a loud bang, they felt a extremely violent jolt, and felt severe shaking of a short duration. The No. 1 engine gauges went to zero. There was no indication of fire. The second pilot continued to fly the airplane and the captain ensured the No. 2 engine was increased to full power. They entered a left downwind leg for runway 9 left and returned to West Palm Beach International Airport, where they landed without further incident. Examination of the airplane showed there was damage to the left wing high lift devices, fuselage, vertical and horizontal stabilizers, rudder, and tail cone. The No. 1 engine left thrust reverser had separated. Debris from the No.1 engine was located over an eight block long by three block wide city block area. Examination of the No. 1 engine revealed that it had a 360 degree separation in plane with the high pressure turbine (HPT) rotor and that the HPT shaft and the HPT forward rotating air seal had exited the engine. The HPT rotating air seal was recovered in the debris field. PROBABLE CAUSE: “The fatigue fracture and separation of the high pressure turbine forward rotating air seal due to a manufacturing defect in a bolt hole that was not detected by the engine manufacturer due to inadequate and ineffective inspection techniques. Contributing to the accident was the engine manufacturers failure to provide adequate hole making requirements at the time the forward rotating air seal was manufactured and the engine manufacturers failure at the time of last inspection to require eddy current inspections for the high pressure turbine forward rotating air seal bolt holes.”

Primary Cause

Manufacturing defect in a bolt hole that was not detected during the engine manufacturer’s inspection, leading to inadequate hole making requirements and insufficient eddy current inspections for the high pressure turbine forward rotating air seal bolt holes.Manufacturing defect in a bolt hole that was not detected during the engine manufacturer’s inspection, leading to inadequate hole making requirements and insufficient eddy current inspections for the high pressure turbine forward rotating air seal bolt holes.

Share on:

Leave a Reply

Your email address will not be published. Required fields are marked *