Accident · 1989-07-19

What the record says

Event date

1989-07-19

Event type

Accident

Highest injury level

Fatal injury

Aircraft

MCDONNELL DOUGLAS DC-10-10 (N1819U)

Operating rule

Part 121

Operator

UNITED AIRLINES, INC. Operator named in NTSB report

Operated by (per NTSB report)

UNITED AIRLINES

Probable cause

THE INADEQUATE CONSIDERATION GIVEN TO HUMAN FACTORS LIMITATIONS IN THE INSPECTION AND QUALITY CONTROL PROCEDURES USED BY UNITED AIRLINES' ENGINE OVERHAUL FACILITY WHICH RESULTED IN THE FAILURE TO DETECT A FATIGUE CRACK ORIGINATING FROM A PREVIOUSLY UNDECTECTED METALLURGICAL DEFECT LOCATED IN A CRITICAL AREA OF THE STAGE 1 FAN DISK THAT WAS MANUFACTURED BY GENERAL ELECTRIC AIRCRAFT ENGINES. THE SUBSEQUENT CATASTROPHIC DISINTEGRATION OF THE DISK RESULTED IN THE LIBERATION OF DEBRIS IN A PATTERN OF DISTRIBUTION AND WITH ENERGY LEVELS THAT EXCEEDED THE LEVEL OF PROTECTION PROVIDED BY DESIGN FEATURES OF THE HYDRAULIC SYSTEMS THAT OPERATED THE DC-10'S FLIGHT CONTROLS.

Flight crew

Flight-crew details for this event aren't in the NTSB database extract we hold (its coverage starts with 2008 events) — a gap in our data, not an absence of crew.