Southwest B737 near Pensacola on Aug 27th 2016, uncontained engine failure

Last Update: December 10, 2020 / 19:30:46 GMT/Zulu time

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Incident Facts

Date of incident
Aug 27, 2016

Classification
Accident

Airline
Southwest Airlines

Flight number
WN-3472

Departure
New Orleans, United States

Destination
Orlando, United States

Aircraft Registration
N766SW

Aircraft Type
Boeing 737-700

ICAO Type Designator
B737

A Southwest Airlines Boeing 737-700, registration N766SW performing flight WN-3472 from New Orleans,LA to Orlando,FL (USA) with 99 passengers and 5 crew, was climbing through FL310 out of New Orleans, about 80nm west of Pensacola,FL (USA) when the front section of the left hand engine (CFM56) separated, debris impacted and punctured the left side of the fuselage causing a loss of cabin pressure. The crew diverted the aircraft to Pensacola for a safe landing on runway 17, the aircraft vacated the runway and taxied to the apron with emergency services following the aircraft. There were no injuries, the aircraft sustained substantial damage.

The airline reported the captain decided to divert the aircraft to Pensacola due to a mechanical issue with the #1 engine. The NTSB has been informed and opened an investigation.

The NTSB reported: "NTSB investigating incident involving a Southwest Airline fight that experienced uncontained engine failure, diverted to Pensacola Int’l." (editorial note: we believe that is just a typo)

The Southwest Airlines Pilots' Association wrote: "A great job today by our professional SouthwestAir pilots! The best safety device is always a well-trained pilot."

A replacement Boeing 737-700 registration N908WN was dispatched to Pensacola and reached Orlando with a delay of 5 hours.

On Sep 7th 2016 the NTSB wrote that the aircraft experienced an uncontained engine failure and cabin depressurization while climbing through FL310 resulting in substantial damage to the aircraft. The occurrence was rated an accident and is being investigated. (No further information released at this time)

So far the responsible NTSB investigator has not replied to an inquiry (and subsequent reminders) by The Aviation Herald submitted on Aug 28th 2016 with the main question "Is it possible to explain, why the NTSB so far reported an uncontained engine failure?" with reference to comments seen all over aviation industry sources including flight crew and licensed aircraft mechanics doubting the rating as uncontained engine failure as in all photos available so far (offering incomplete evidence however) none of the rotating parts appeared to be missing and a radial (rather than axial) ejection of engine parts thus appeared impossible despite the fuselage damage (more detailed analysis of the photos available, in particular after editing intensity and contrast however seems to suggest, again without firm evidence, that at least one fan blade is missing), industry sources further arguing it appeared only the engine inlet had separated from the aircraft forward of the actual engine and thus also forward of the fan and compressor section. The AVH only received an initial reply identifying the responsible investigator, who was copied in in that reply, and the promise the investigator would provide the answers asked for (the AVH had hoped for a one sentence reply that e.g. one fan blade remains unaccounted for or along those lines making clear the uncontained nature of the engine failure).

About 30 minutes after the parapraph above was posted the investigator in charge advised The Aviation Herald, that the NTSB is going to release a further update later today (Sep 7th 2016) or tomorrow (Sep 8th 2016) which would provide all the facts gathered so far. The Aviation Herald is going to cover as soon as this update becomes available.

Late Sep 12th 2016 (US time) the NTSB reported, that one fan blade separated from the fan disk during the accident flight, the root of the fan blade remained in the fan hub, however, the rest of the fan blade was missing. The fracture surface of the titanium alloy fan blade, root covered by copper-nickel-indium alloy, showed evidence of a fatigue crack, however no surface or material anomalies were found during initial metallurgic analysis. The engine inlet separated from the engine and impacted fuselage, wing and empanage resulting in a 5x16 inch hole above the left wing, the interior cabin compartment was not penetrated, no fan blade or engine inlet material was found in the hole, the aircraft experienced a loss of cabin pressure.

A similiar accident happened almost two years later, see Accident: Southwest B737 near Philadelphia on Apr 17th 2018, uncontained engine failure takes out passenger window.

The NTSB released their final report stating the defining event of the accident was an uncontained engine failure and concluded the probable causes of the accident were:

A low-cycle fatigue crack in the dovetail of fan blade No. 23, which resulted in the fan blade separating in flight and impacting the fan case. This impact caused the fan blade to fracture into fragments that traveled farther than expected into the inlet, which compromised the structural integrity of the inlet and led to the in-flight separation of inlet components. A portion of the inlet struck the fuselage and created a hole, causing the cabin to depressurize.

The NTSB analysed:

The Boeing 737-700 airplane was climbing through flight level 310 when fan blade No. 23 in the left CFM56-7B engine fractured at its root, with the dovetail (part of the blade root) remaining within a slot of the fan disk. The separated fan blade impacted the engine fan case and fractured into multiple fragments. The blade fragments traveled forward into the inlet and caused substantial damage that compromised the structural integrity of the inlet, causing most of the inlet structure to depart from the airplane. A large portion of the inlet contacted and punctured the left side of the fuselage, creating a hole of sufficient size to cause the cabin to depressurize. The flight crew conducted an emergency descent and landed safely at Pensacola International Airport, Pensacola, Florida, about 21 minutes after the fanblade-out (FBO) event occurred.

The fan blade fractured due to a low-cycle fatigue crack that initiated in the blade root dovetail under the blade coating near the outboard edge. Metallurgical examination of the fan blade found that its material composition and microstructure were consistent with the specified titanium alloy and that no surface anomalies or material defects were observed in the fracture origin area. The fracture surface had fatigue cracks that initiated close to the dovetail leading edge convex side area, which is where the greatest stresses from operational loads, and thus the greatest potential for cracking, were predicted to occur.

The fan blades were not certified as life-limited parts. The accident fan blade (as well as the six other cracked fan blades in the accident engine) failed with 38,152 cycles since new. Similarly, the fan blade associated with an April 2018 FBO accident (case number DCA18MA142) failed with 32,636 cycles since new. Further, 19 other cracked fan blades on CFM56-7B engines had been identified as of January 2020, and those fan blades had accumulated an average of about 33,000 cycles since new when the cracks were detected.

After this accident, CFM reevaluated the fan blade dovetail stresses and determined that the fatigue cracks initiated in an area of high stress on the dovetail and that the dovetail was experiencing peak stresses that were higher than originally predicted. CFM found that the higher operational stresses resulted from coating spalling, higher friction levels when operated without lubrication or a shim, variations in coating thickness, higher dovetail edge loading than predicted, and a loss or relaxation of compressive residual stress (the stress that is present in solid material in the absence of external forces).

Before the application of the dovetail coating during manufacturing and before the reapplication of the coating that is stripped during each overhaul, the entire blade, including the dovetail, is shot-peened to provide a compressive residual stress surface layer for the material, which increases the fatigue strength of the material and relieves surface tensile stresses that can lead to cracking. A loss of residual stress could be the result of a fan blade's exposure to high temperatures during the application of the dovetail coating as part of the overhaul of a blade set, but no evidence indicated that the accident fan blade dovetail was subjected to an overheat situation during the coating repair process. However, higher-thanexpected dovetail operational stresses could also lead to the loss/relaxation of residual stress and premature fatigue crack initiation, which occurred during this event.

Residual stress measurements were taken from multiple areas of the dovetail surface on fan blade No. 23 and eight other blades from the accident engine, including three blades with no identified cracks. All nine blades had abnormal residual stress profiles compared with the reference profile data.

One method that CFM recommended to maintain the fan blade loads within the predicted range and reduce the overall stresses on the blade root in the contact areas is repetitive relubrication of the fan blade dovetails. As part of the relubrication procedure, the fan blades were visually inspected for crack indications. The investigation of this accident found fan blade cracks that had initiated and propagated underneath the dovetail coating. Because such cracks might not be detected during a visual inspection, CFM implemented, in March 2017, an on-wing ultrasonic inspection method to detect cracks with the coating still on the dovetail.

A review of the fan blade overhaul process found that a fluorescent penetrant inspection (FPI) was performed (as specified in the CFM engine shop manual) during the fan blade set's last overhaul in August 2007 to detect cracks. As a result of this accident, CFM implemented, in November 2016, an eddy current inspection (ECI) technique for the fan blade dovetail as part of the overhaul process (in addition to the FPI). An ECI has a higher sensitivity than an FPI and can detect cracks at or near the surface (unlike an FPI, which can only detect surface cracks).

The shims for fan blade Nos. 22 through 24 had a newer design configuration that was introduced after the blades and their associated hardware were first installed on the accident disk. Wear patterns on the shims from blade Nos. 23 and 24 showed that a significant area of coating was missing from the blade dovetails at the time that the shims were installed. The location of the missing coating was in the area where overhaul of the blades was required within 50 cycles. The National Transportation Safety Board could not determine, with the available evidence, how long the dovetail coating damage existed and whether the cracks were large enough to be detected by an FPI during an overhaul in response to the coating damage (when the dovetail coating damage first became significant enough during visual inspections conducted at relubrication to trigger the overhaul).

The damage to the accident inlet and fan case showed that there were significant differences between the accident FBO event and the engine FBO containment certification tests. For example, during the accident FBO event, the fan blade fragments that went forward of the fan case and into the inlet had a greater total mass and a different trajectory (a larger exit angle) and traveled beyond the containment shield. Also, the inlet damage caused by these fan blade fragments was significantly greater than the amount of damage that was defined at the time of inlet certification. Given the results of CFM's engine FBO containment certification tests and Boeing's subsequent structural analyses of the effects of an FBO event on the airframe, the post-FBO events that occurred during this accident could not have been predicted.
Aircraft Registration Data
Registration mark
N766SW
Country of Registration
United States
Date of Registration
Pfdqppembbjgl Subscribe to unlock
TCDS Ident. No.
Njqph Subscribe to unlock
Manufacturer
BOEING
Aircraft Model / Type
737-7H4
Number of Seats
Ji Subscribe to unlock
ICAO Aircraft Type
B737
Year of Manufacture
Dlig Subscribe to unlock
Serial Number
Pgidc Subscribe to unlock
Aircraft Address / Mode S Code (HEX)
NA n l Subscribe to unlock
Engine Count
Subscribe to unlock
Engine Manufacturer
Igcb negd Subscribe to unlock
Engine Model
Gilkdpe pfAf Subscribe to unlock
Engine Type
MngllkgAb Subscribe to unlock
Main Owner
Pc pdejpffipeifnAehfeflmqcpAqgbghpflege hp fckjdAdl ngnbeqqnjfbhbegh Subscribe to unlock
Incident Facts

Date of incident
Aug 27, 2016

Classification
Accident

Airline
Southwest Airlines

Flight number
WN-3472

Departure
New Orleans, United States

Destination
Orlando, United States

Aircraft Registration
N766SW

Aircraft Type
Boeing 737-700

ICAO Type Designator
B737

This article is published under license from Avherald.com. © of text by Avherald.com.
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