Aviation Crash Map

Boeing 747-132 N709CK

21 October 2004 · Lake Michigan, United States · No injuries

Summary

On 21 October 2004 at about 01:29 local time, a Boeing 747-132 registered N709CK was involved in an accident near Lake Michigan, United States. 5 people were on board and nobody was injured. The aircraft was substantially damaged. The NTSB has published a probable cause for this accident; it is quoted in full below.

The record

Date
at 01:29
Classification
Accident
Location
Lake Michigan, United States
Coordinates
42.0756, -86.8672
Aircraft
Boeing 747-132
Registration
N709CK
Category
Airplane
Engines
4
Operator
Not recorded
Operating rule
Part 121: Air Carrier
Phase of flight
Not recorded
Route
Chicago → New York
Aircraft damage
Substantial
Weather
VMC
Light
Night
NTSB number
CHI05MA011

People

Nobody was injured.

On board Died Serious Minor Uninjured
5 0 0 0 5

Probable cause

The number one engine separated from the airplane during climb due to the uncontained separation of a portion of the second stage turbine disk rim after the second stage turbine vanes contacted the disk. The second stage turbine vanes contacted the second stage turbine disk due to the operator's inadequate inspection of the high pressure turbine module and the improper repair of the module by unknown maintenance personnel.

Quoted verbatim from the NTSB record. This site does not paraphrase or interpret it.

Read the full NTSB narrative

The Boeing 747-132, operated as an unscheduled domestic cargo flight under 14 CFR Part 121, was climbing through 15,000 feet mean sea level when the number one engine separated from its forward and aft engine mounts resulting in substantial damage to the airplane. The flight diverted to an alternate airport where it landed without further incident. Examination of the engine revealed an uncontained separation of an approximately 180-degree arc of the second stage turbine disk rim. The missing section of the rim coincided with circumferential rub marks on the second stage turbine disk that corresponded to rub marks on the rear inner rails of the second stage turbine vanes. The rubbed areas of the disk and vanes did not exhibit heat cracking consistent with a relatively long time period of rubbing relative to a sudden disk-to-vane contact. The fan rotor bearing did not exhibit rotational distress. The engine did not exhibit any evidence of a blade separation, case rupture, or any other uncontainment. The second stage retaining bolts are coated with a baked-on antiseize compound, FelPro C-200, during manufacture. Metallurgical exam of the second stage turbine bolts revealed cracking in the head-to-shank fillet radius and the presence of silver consistent with Silver Goop. Silver Goop is an anti-seize compound not authorized by the engine manufacturer for use in the high-pressure turbine area but is authorized in the low-pressure compressor area due to the catalytic properties of silver with wet FelPro C-200 resulting in a corrosive mixture that can contribute to bolt fractures. The induced loads from the second stage disk rim separation were estimated to have been 3.6 - 6.6 times greater than to those induced by a fan blade separation. The accident operator purchased an engine as-is and that according to maintenance records was not preserved when it was removed from an airplane belonging to another operator about 5 years prior to the accident. The high-pressure turbine (HPT) module was removed from this engine and installed on one of the accident operator's other engines prior to it being removed and then installed on the accident airplane engine. The accident operator's examination of the HPT was limited to a visual inspection that would not have detected a vane shift or ascertained the integrity second stage turbine vane assembly.

Quoted verbatim from the NTSB record.

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