06/08/95 ValuJet Airlines

133 Pages·2005·2.46 MB·English

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06/08/95 ValuJet Airlines
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Official Accident Report Index Page
UNCONTAINED ENGINE FAILURE/FIRE VALUJET
Report Title
AIRLINES FLIGHT 597 DOUGLAS DC-9-32, N908VJ
ATLANTA, GEORGIA JUNE 8, 1995
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Facts of the Accident
96-03
Accident NTSB ID
Airline ValuJet Airlines
Model aircraft DC-9-32, N908VJ
Aircraft manufacturer Douglas
Engine type JT8D-9A
Engine manuafacturer Pratt & Whitney
Date 06/08/95
Time 1855
Location Atlanta, GA
Country USA
IFR or VFR? VFR
Injuries 7
Fire during flight? -
Fire on the ground? Y
Probable cause The failure of Turk Hava Yollari maintenance and
inspection personnel to perform a proper inspection on a
7th stage high compressor disk, thus allowing the
detectable crack to grow to a length at which the disk
ruptured, under normal operating conditions, propelling
engine fragments into the fuselage; the fragments severed
the right engine main fuel line, which resulted in a fire
that rapidly engulfed the cabin area.
Contributing causes The lack of an adequate record keeping system and the
failure to use "process sheets" to document the step-by-
step overhaul/inspection procedures contributed to the
failure to detect the crack and, thus, to the accident.
Weather conditions scattered clouds, visibility 12 miles
Total crew size 5
Cockpit crew size 2
Cabin crew size 3
Passengers 57
Report ID NTSB/AAR-96/03
Pages 131
Day or night? Dusk
Flight number 597
Flight origin Atlanta, GA
Flight destination Miami, FL
Description As the aircraft began its takeoff roll, a "loud bang" was
heard by the airplane occupants and air traffic control
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personnel. The right engine fire warning light
illuminated, the flightcrew of the following airplane
reported to the ValuJet crew that the right engine was on
fire, and the takeoff was rejected. Shrapnel from the right
engine penetrated the fuselage and the right engine main
fuel line, and a cabin fire erupted. The airplane was
stopped on the runway and evacuated. The fuselage was
destroyed.

This report explains the uncontained engine failure/fire on ValuJet Airlines flight 597, a Douglas DC-9-32, N908VJ, at
Atlanta, Georgia, on June 8, 1995. The safety issues discussed in the report include the clarity of operations
specifications for repair stations, recordkeeping requirements for foreign repair stations, regulatory guidance concerning
maintenance documentation, intent of "serviceable tags," independently powered public address systems on all transport-
category airplanes, flight attendant training programs and manuals, enforcement of occupant restraint requirements,
notification of flightcrew of cabin fire, cabin material/fire safety standards, flight attendant attire, and quality of cockpit
voice recordings. Safety recommendations concerning these issues were made to the Federal Aviation Administration
(FAA).
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Executive Summary
On June 8, 1995, a Douglas DC-9-32, N908VJ, was being operated by ValuJet Airlines as a scheduled, domestic
passenger flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121. Flight 597, destined for
Miami, Florida, departed gate C25 at the William B. Hartsfield Atlanta International Airport, Atlanta, Georgia, at 1855,
and was cleared for takeoff on runway 27R at 1908. Five crewmembers and 57 passengers were on board.
As flight 597 began its takeoff roll, a "loud bang" was heard by the airplane occupants and air traffic control personnel.
The right engine fire warning light illuminated, the flightcrew of a following airplane reported to the ValuJet crew that
the right engine was on fire, and the takeoff was rejected. Shrapnel from the right engine penetrated the fuselage and the
right engine main fuel line, and a cabin fire erupted. The airplane was stopped on the runway, and the captain ordered
the evacuation of the airplane.
The flight attendant seated in the aft flight attendant jumpseat received serious puncture wounds from shrapnel and
thermal injuries. Another flight attendant and five passengers received minor injuries. The pilots, the third flight
attendant, and 52 passengers were not injured. The airplane's fuselage was destroyed.
The National Transportation Safety Board determines that the probable cause of this accident was the failure of Turk
Hava Yollari maintenance and inspection personnel to perform a proper inspection of a 7th stage high compressor disk,
thus allowing the detectable crack to grow to a length at which the disk ruptured, under normal operating conditions,
propelling engine fragments into the fuselage; the fragments severed the right engine main fuel line, which resulted in a
fire that rapidly engulfed the cabin area. The lack of an adequate recordkeeping system and the failure to use "process
sheets" to document the step-by-step overhaul/inspection procedures contributed to the failure to detect the crack and,
thus, to the accident.
The safety issues in this report include the clarity of operations specifications for repair stations, recordkeeping
requirements for foreign repair stations, regulatory guidance concerning maintenance documentation, intent of
"serviceable tags," independently powered public address systems on all transport-category airplanes, flight attendant
training programs and manuals, enforcement of occupant restraint requirements, and cabin material/fire safety standards.
Safety recommendations concerning these issues were addressed to the Federal Aviation Administration.
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1. Factual Information
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1.1 History of the Flight
On June 8, 1995, a Douglas DC-9-32, N908VJ, was being operated by ValuJet Airlines as a scheduled, domestic
passenger flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121. Flight 597, destined for
Miami, Florida, departed gate C25 at the William B. Hartsfield Atlanta International Airport, Atlanta, Georgia, at 1855,1
and was cleared for takeoff on runway 27R at 1908. Five crewmembers and 57 passengers were on board.
As flight 597 began its takeoff roll, a "loud bang" was heard by the airplane occupants and air traffic control personnel.
The right engine fire warning light illuminated, the flightcrew of a following airplane reported to the ValuJet crew that
the right engine was on fire, and the takeoff was rejected. Shrapnel from the right engine penetrated the fuselage and the
right engine main fuel line, and a cabin fire erupted. The airplane was stopped on the runway, and the captain ordered
the evacuation of the airplane.
After the airplane came to a stop, the forward flight attendants opened the forward passenger boarding door and the
service door exits, and the airplane was evacuated. The flight attendant at the service door exit stated that when the door
was opened, the cabin filled with smoke from about waist level up to the ceiling.
The flight attendant seated in the aft flight attendant jumpseat received serious puncture wounds from shrapnel and
thermal injuries and evacuated herself from the airplane through an overwing exit. Another flight attendant and five
passengers received minor injuries. The pilots, the third flight attendant, and 52 passengers were not injured. The
airplane's fuselage was destroyed.
The accident occurred at dusk. The airplane came to a stop about 1,500 feet down runway 27R, before taxiway M18,
approximately 33° 38'04" North latitude and 84° 24'50" West longitude(see figure 1)

Figure 1—Location of flight 597 at Hartsfield Atlanta
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1.2 Injuries to Persons
Cockpit Flight attendants Passengers Other Total
Injuries
crew
Fatal
0 0 0 0 0
Serious
0 1 0 0 1
Minor
0 1 5 0 6
None
2 1 52 0 55
Total
2 3 57 0 62
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1.3 Damage to Aircraft
The fuselage was destroyed by fire, which gutted the interior, burned through the roof of the forward cabin area of the
airplane, and consumed most of the cabin overhead. There was substantial exterior damage with circumferential outward
tearing of the right engine cowl and engine case in the plane of rotation of the right engine 7th stage high pressure
compressor (HPC) disk. There was also shrapnel damage to the fuselage and left engine cowl.
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1.4 Other Damage
No other property damage resulted from this accident.
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