On January 30, 2018, the NTSB held a probable cause hearing concerning the October 2016 uncontained engine failure and fire on the Boeing 767 operated by American Airlines as Flight 383. The NTSB board was presented with the findings of the investigation and adopted numerous probable causes and safety recommendations.
First, the NTSB board was presented with findings that the fracture of the Stage 2 disc in the high-pressure turbine system of the GE CF6-80 engine originated from a small, dirty white spot on the disc. The white spot was dust that became included in the material during the manufacturing process. The second stage of the manufacturing melting process is meant to rid the material of inclusions, like the spot of dust, which can lead to cracks. However, the spot remained. The spot went undetected throughout the entire manufacturing process. The ultrasonic inspection that the disc was subjected to during the manufacturing process only reveals small cracks but would not have revealed the inclusion flaw as the flaw did not cause any cracking during the manufacturing process. The in-service inspection which GE requires operators to perform once the engine is in service does not utilize the ultrasonic method. American Airlines was not able to see the cracking in the disc using the inspection protocol GE mandated. Had the disc been inspected using the ultrasonic method utilized during the manufacturing process, the cracking would have been revealed. The NTSB recommended that the FAA lead an industry group to evaluate the inspection process to enhance inspection during both the manufacturing phase and the in-service phase.
Second, the NTSB board as presented with evidence as to the lack of communication between the flight attendants in the cabin and the flight crew in the cockpit. The accident docket previously released confirmed that the pilot was unaware that the engine had caught fire prior to the flight being evacuated. Two flight attendants had attempted to notify the flight crew using the interphone on board but were unable to dial through to the flight crew. It was determined that American Airlines training procedures did not include hands-on training on the particular model interphone that was on board the flight. The NTSB recommended that training for flight attendants include a hands-on operation of the various models of interphones that the flight attendants may encounter.
Third, the NTSB was presented with evidence as to why the left engine of the aircraft was not shut down following the uncontained engine failure and fire in the left engine. The pilot was unaware that the left engine had caught fire and that the flight attendants were beginning to evacuate the aircraft. The captain followed the Boeing checklist for uncontained engine failure but the checklist did not include powering down the other engine. It was determined that the engine failure checklist only considered in-flight engine failure and did not consider engine failure occurring on the ground. If an engine failure occurs in flight, the other engine cannot be turned off as it is the only engine maintaining flight. On the other hand, maintaining power of the other engine after an uncontained engine failure on the ground can hinder evacuation procedures. The flight attendants had to block the emergency exit nearest to the left engine because the slide could not properly engage when the engine was on and the engine posed a danger to evacuating passengers. The NTSB recommended that the uncontained engine failure checklist differentiates between in-flight failures and on-the-ground failures.
Alexandra Wisner of Wisner Law Firm represents 48 of the passengers from AA383 in a lawsuit pending in the Circuit Court of Cook County, Illinois against Boeing, GE, and American Airlines. According to Ms. Wisner, “The findings of the NTSB support plaintiffs’ allegations of liability against all defendants. The NTSB clearly laid out the deficiencies in the GE manufacturing process, in the American Airlines training procedures, and the Boeing checklist protocol. We are hopeful that these findings will lead to real changes being implemented by these entities to prevent this sort of disaster in the future.”
Wisner Law Firm represented over 100 passengers and crew of British Air Flight 2276 in obtaining compensation for their physical and psychological injuries resulting from uncontained engine failure and fire at McCarron International airport in Las Vegas in the GE 90 engine on the Boeing 777 aircraft.