Pilot Debrief

BOEING 787 near Singapore, OF — 2024-05-14

Final reportENG24LA014
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Date
2024-05-14
Location
Singapore, OF, SG
Aircraft
BOEING 787
Registration
N27957
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Climb

Probable cause

The uncontained left engine failure was caused by the failure and liberation of the HPT stage 1 aft blade retainer as a result of a fatigue crack in the upper collet radius that originated from a surface connected cluster of Oxide/Carbonitride/Nitride/Carbide (OCNC) particles. Contributing to the failure of the HPT stage 1 aft blade retainer was an unknown material behavior unique to OCNC clusters in Rene 65 material that are surface connected in highly stressed material that may result in a localized reduction of material fatigue life capability.

Contributing factors

Contributing to the failure of the HPT stage 1 aft blade retainer was an unknown material behavior unique to OCNC clusters in Rene 65 material that are surface connected in highly stressed material that may result in a localized reduction of material fatigue life capability.

NTSB narrative

The No. 1 (left) engine high pressure turbine (HPT) stage 1 aft blade retainer developed a fatigue crack that initiated and propagated through thickness and circumferentially until final overload failure that was not contained by the turbine case. Fractography of the HPT stage 1 aft blade retainer revealed the crack initiated in the upper collet radius at a single point of origin which corresponded to a surface connected material anomaly that measured 0.005 inches by 0.015 inches by 0.0005 inches. The fracture surface contained an area of intergranular fracture morphology with visible beach marks, consistent with hold-time fatigue growth and the remaining fracture surface was consistent with overload fracture. Further examination of the material anomaly was determined to be a cluster of particles enriched with Titanium, Aluminum, Zirconium, Magnesium, and Oxygen, which is consistent with Oxide/Carbonitride/Nitride/Carbide (OCNC) particles. Analysis of the HPT stage 1 aft blade retainer material found all dimensional and material characteristics to be conforming to GE Aerospace drawings and material specifications. The presence of OCNC particles and clusters of particles is inherent to Rene 65 material with quantity and size distributions accounted for within GE’s philosophy for material life limit calculations. The calculated stress conditions for the GEnx HPT stage 1 aft blade retainer collet feature were found to be uniquely high when compared to the stress conditions of other rotating hardware. This higher stress environment was determined to be the result of the assembly interference fits between the HPT stage 1 disk, the HPT stage 1 aft blade retainer, and the HPT mid seal in combination with the engine’s operational loads. Analysis of material test data suggests that surface connected OCNCs have a reduced crack incubation/nucleation life at high stress conditions, and that surface connected OCNCs do not behave according to traditional crack growth threshold behavior. Activation of surface connected OCNCs can in fact reduce material fatigue life capability but not every OCNC will initiate a crack, suggesting an unknown bimodal behavior.

Analysis

Primary failure mode
Mechanical failure

NTSB coding

Evidence available

  • FDR / data
  • 4 docket documents
View NTSB final reportView NTSB docket

Docket documents4