|Title:||Contained engine failure, Douglas DC-9-51, February 9, 1998|
|Micro summary:||This Douglas DC-9-51 experienced an engine failure of the #2 engine on takeoff.|
|Event Time:||1998-02-09 at 947 HST|
|Publishing Agency:||National Transportation Safety Board (NTSB)|
|Site of event:||Honolulu, HI|
|Departure:||Honolulu International Airport, Honolulu, Hawaii|
|Destination:||Kona International Airport, Kailua-Kona, Hawaii|
|Airplane Type(s):||Douglas DC-9-14|
|Type of flight:||Revenue|
NTSB short summary:
the disintegration of the No. 6 bearing in the No. 2 engine which resulted in an aborted takeoff. In addition, the malfunction of the slide in the right forward service door was the result of a faulty seal in the inflation system. The inflation gauge had not been checked that day due to confusion resulting from a change in the operations manual. The change in the language made it unclear as to whose responsibility it was to check the inflation gauge. The operator did not verify that the change was being properly implemented after it had been made effective.
During takeoff the crew heard a loud oscillating sound and aborted takeoff. The tower reported fire was visible from their right engine. The aircraft stopped and the crew initiated the engine fire and emergency evacuation check lists. The forward right service door was opened but the slide did not inflate. The airstairs were then deployed and the occupants deplaned. An inspection revealed an engine bearing cage had disintegrated. The evacuation slide was tested and functioned properly; however, its inflation bottle was found to be empty. While required, the bottle had not been checked that day because of a change in the operations manual that had resulted in confusion as to whose responsibility it was to perform the daily pressure checks. The manual states that it is the captain's responsibility to ensure that the bottle is pressurized but it is not an item on the preflight checklist. The flight crew thought maintenance personnel were performing the checks while maintenance personnel thought the crews were checking the bottles. The bottles have a history of sometimes losing pressure over time.
NTSB factual narrative text:
On February 9, 1998, at 0947 hours Hawaii standard time, Hawaiian Airlines flight 158, a McDonnell Douglas DC-9-51, N601AP, aborted takeoff from Honolulu International Airport, Honolulu, Oahu, Hawaii, following a contained engine failure. The aircraft sustained minor damage; however, none of the 139 passengers nor the crew of 5 were injured. The aircraft was operated by Hawaiian Airlines, Inc., under 14 CFR Part 121 when the incident occurred. The operation was originating at the time of the incident as a scheduled domestic passenger flight to Kona, Hawaii. Visual meteorological conditions prevailed at the time and an IFR flight plan was filed.
During the takeoff roll, about 90 knots, the crew heard a loud oscillating sound. In response, the captain initiated an aborted takeoff. The first officer called the tower operator and asked if they saw anything unusual. The operator responded by saying that he did not. As the aircraft continued to decelerate, the tower operator informed the flight crew that a fire was now visible in the area of the No. 2 engine. The captain was able to bring the aircraft to a stop on a high speed taxiway then initiated the engine fire and emergency evacuation checklists.
The No. 4 main landing gear tires deflated during the incident. An inspection revealed the associated thermal fuse plugs had melted.
A flight attendant opened the forward right service door; however, the emergency evacuation slide did not inflate. The captain then directed the forward left cabin door and airstairs be deployed. The passengers and crew all deplaned through the left cabin door without further incident.
An inspection of the No. 2 engine by Federal Aviation Administration (FAA) inspectors revealed the separation of the No. 6 roller bearing cage. After the incident, 19 of the 26 roller bearings were recovered. The bearing cage was found on the runway in two pieces. The No. 3 & 4 turbine blades and bearing support housing rods exhibited scarring and deformation.
An FAA cabin safety specialist inspected the forward right service door after the incident. He found the door fully open with the girt bar in place. The slide had come out of the bustle, but it did not come out of the packing. The slide was uninflated, hanging outside the doorway. The flight attendant reported that she had heard a "hiss" at the time she opened the service door.
The specialist noted that the pressure gauge on the inflation bottle for the slide read 0 pounds. He then directed that the slide be removed and taken to the airline slide shop where it was tested with a fully charged bottle. The slide inflated fully with no leaks or tears observed.
The bottle (Part No. 300117-100) was last checked and found to be within pressure limits during a 125-hour service check on January 22, 1998. According to the aircraft records, the last overhaul on the bottle was performed on September 22, 1995. The bottles are scheduled to be overhauled every 3 years. The next overhaul for the bottle in the forward right door was scheduled for September 6, 1998.
Historically, some bottles have been known to experience loss of pressure over time. This has been attributed to misalignment of the poppet valve "O" ring seal (Part No. 1A2313-3). According to the operator, the bottle was pressure checked and overhauled after the incident.
According to the operations manual, daily pressure checks of the inflation bottles are required. During the investigation, the operator discovered that a change to the operations manual had resulted in confusion as to whose responsibility it was to perform those daily checks. The manual stated that it is the captain's responsibility to insure that the bottle is pressurized but there is no corresponding item on the preflight inspection checklist. Consequently, the flight crew believed that maintenance personnel had incorporated the checks in their daily inspection. Conversely, maintenance personnel reported that they believed the flight crews were performing the checks. Until the incident, the operator was unaware that the inspections were not being accomplished.
The last major inspection of the aircraft was completed in October, 1996.
|Learning Keywords:||Operations - Bang, pop, crack, sizzle!|
|Operations - Checklists/Procedures|
|Operations - Evacuation|
|Operations - Maintenance|
|Systems - Engine - Contained Engine Failure|
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