1 WASHINGTON, D.C z AIRCRAFT ACCl ENT REPQRT AMERNAN AIRLIWES, INC., E DC-10-10, NllOAA CHICAGO-B'HARE INTERNATIONIIL AIRPORT CHICAGO. 1ltfMftS. I $1 UNITED STATES GGVERNMENT i,.
2 TECHNICAL REPORT WCUMKNTATION PAGE. Report No. 2.Government Accession No. ).Recipient's Catalog No. msb-aar Title and Subtitle Aircraft Accrdent Report- 5.Report Date Ameriean Airlines, Inc. DC-10-10, December NllOAA. Chicarro-O'llare International Airoort 6.Peiforming ~. Organization Chicago; IUinoik Mav I Code. Authorts) I 8.Performing Organization Report NO.. Performing Organization Name and Address IO.Uork Unit No E National Tnmsportation Safety Board II.Contract or Grant NO. Bureau of Accident Investigation Washington, D.C Type of Report and Period Covered 2.Sponroring Agency Name and Address Aircraft Accident Report May 25, 1979 NATIClNAL TRANSPORTATION SAFETY BOARD Washington, D. C Sponsoring Agency Code 15.Supplementary g'otes i6.abstract About 1504 c.d.t., Nlny 25, 1979, American Airlines, Inc., Flight 191. a McDonnell-Douglas DC aircraft, crashed into an open field just short,of a troiler park about 4,600 ft northwest of the departure end of runway 32R at Chicago-O'Haru International Airport, Illinois. Flight 191 was taking cff from runway 32R. The weather was clear and the visibility was 15 miles. i takeoff rotation. the left assemb!v an- 2 ft o w i n n left wi ne separated huathc w n d fell to the runway. Flight 191 continued to climb to about 325fft above the ground and then began to roll to the left. The aircraft continued to ro to the left until the wings were past the vertical position, and during the roll, the aircraft's nose pitched down below the hcrizon. Flight 191 crashed into the open field and the wreckage scattered into an adjscent trailer park. The aircraft was destroyed in the crash and subsequent fire. T w n e d and seventv-on? oersons on board Flight 191 were killed; two persons on the ground were killed. and two others were injured. An old aircraft hangar, several automobiles, and a mcbile home were destroyed. The National Transportation Safety Board determines that the probable cause of this accident was the asymmetrical stall and the ensuing roll of the aircraft I7,,. Y..- ou, YnrAc DC-10; loss of control; asymmetrical stad; stal! warning system; slat disagreement warning light; structural separation; No. 1 engine and Pylon;.. design criteria: maintenance Drocedureg FAA regulations; industry communications procedures. I. z Ii8.0istribution Statement his document is available to he public through the ational Technical Informa- bonservk?:?pringfield, vlrglnla ZZI~I 1 9. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ i 20.Security i~ f~ i C:assification ~ ~ t i ~ 21.No. ~ of Pages 22.Price (of this report) (of this page) UNCLASSIFIED UNCLASSIFIED 103 NTSB Form (Rev. 9/74)
3 because of the uncommanded retraction of the!eft wing outboard leading edge slats and the loss of stall warning and slat disagreement indication systems psu'txfrom maintenance-induced damage leadina to the scparation of the No. 1 tin2 takeoff. The separation rehed frogdemage by hproper mainteiance procedures which led to failure of the pylon'structure. Contributing to the cause of the accident were the vulnerability of the design of the pylon attach points to maintenance damage; the vulnerability of the design. of the leading edge slat system to the damage which produced asymmetry; deficiencies in Federal Aviation Administration surveillance. and reporting systems which failed to detect and prevent the use of improper maintenance procedures; deficiencies in the practices and communications among the operators, the manufacturer, and the FAA which failed to determine and disseminele the particulars regarding previous maintenance damage incidents; and the intolerance. of prescribed operational procedures to this unique emergency. z
4 ~~ CONTENTS 1 Synopsis History of the Flight... 2 s to Persons... 3 Y.3 Damage to Aircraft... Other Damage Fersonnel Information... 3 k. 6 Aircraft Information hleteorological Information... 3, ' 1.8 Aids to Navigation... unications Aerodrome Information... 4 'S Wreckage and Impact Information Medical and Pathological Information Fire Survival AspecLs n Stress Tgsting of the Pylon Aft Bulkhead Wind 'runnel and Simulator Tests... ;' 22 Information Air Carrier Maintenance Procedures... L FAA Reporting & Surveillance Procedures... " Msnufaciurer's Production kina Procedures...., DC-10 Electrical & Hydraulic Systems Flightcrew Procedures...! Analysis Conclusioris Findings Probable Cause Safety Recommendations Appendixes Appendix C. Aircraft Information Appendix D. ISreckage Diagram Appendix E.. Pertinent Airworthiness Regulations... Appendix F. Applicable Airworthiness Directives Appendix G. Suspension and Kestoratioll of DC-10 Type Certificate Appendix H.DFDR Readout... 98
5 NATIONAL TRANSPORTATION SA.FETY BOARD WASHINGTON, D.C Adopted: December 21,1979 AI3CRAFT ACCIDENT KEPORT AMERICAN AIRLINES, INC. DC-10-10, NIIOAA CHICAGO-O'HARE 1NTEKNATIONAL AIRPORT CHICAGO, ILLINOIS MAY 25, 1979 SYNOPSIS About 1504 c.d.t., May 25, 1979, American Airlines, Inc., Flight 191, a McDonneU-Douglas DC aircraft, crashed into an open field just short of a trailer park about 4,600 It northwest of the departure end of runway 32R at Chicago-O'Hare International Airport, Illinois. ', Flight 191 was taking off from runway 32H. The weqher was clear and the visibility was 15 miles. During the takeoff rotation, Me left engine and pylon assembly and about 3 ft of the Icading edge of the left wing separated from the aircraft and fell to the runway. Fhght 191 continued to climb to about 325 ft above the ground and then began to roll to the left. The aircraft continued to roll to the left until the wings were past the vertical position, and during the roll, the ~., aircraft's nose pitched down below the horizon. Flight 191 crashed into the open field and the wreckage scattered into an adjacent trailer park. The airet'aft was destroyed in the crash and subsequent fire. Two hundred and seventy-one persons on board Flight 191 were killea two persons on the ground were killed, and two others were injured. An old aircraft '* hangar, several automobiles, and a mobile home were destroyed. The National Transportation Safety Board determines that the probable. cause of this accident was the asymmetrical stall and the ensuing roll of the aircraft because of the uncommanded retraction of the left wing outboard leading edge slats and the loss of stall warning and slat disagreement indication systems resultingfrom mnintenance-induced damage leading to the separation of the No. 1 engine and pylon assembly at a critical point during takeoff. The separation resulted from damage by improper maintenance procedures which led to failure of the pylon structure. Contributing to the-cause of the accident were the vulnerability of the design of the pylon attach points to maintenance damage; the vulnerability of the design of the leading edge slat system to the damage which produced asymmetry; deficiencies in Federal Aviation Administration surveillance and reporting systems which failed to detect and prevent the use of improper maintenance procedures; deficiencies in the practices and communications among the operators, the manufacturer, and the FAA which failed to determine and disseminate the particulars regarding previous maintenance damage incidents; and the intolerance of prescribed operational procedures to this unique emergency.
6 -2-1. FACTUAL INFORMATION 1.1 History of the Flight At 1459 c.d.t.,- 11 May 25, 1979, American Airlines, Inc., Flight 191, a McDonnell-Douglas DC-10 series 10 aircraft (DC-10-10) (NLIOAA), taxied from the gate at ChicagwO'llare International Airport, Illinois. Flight 191, M regulnrly scheduled passeoiger flight, was en route to Los Angeles, Californie, with 258 passengers and 13 crewmembers on board. Rlaintenance personncl who monitored the flight's engine start, push-beck, and start of taxi did not observe anything out of the ordinary. I The weather at the time of departure was clear, and the reported surface wind was 020"at 22 kns. Flight 191 was cleared to taxi to runway 32 right (32K) for takeoff. The company's Takeoff Data Card showed that the stabilizer trim setting was So aircraft noseup, the takeoff Gap setting was loo, (ind the takeoff gross weight was-379,000 lbs. The target low-pressure compressor (N ) rpm setting was 99.4 percent, critical engine failure speed. (V ) was 139 ',k& indicated airspeed (KIAS), rotation speed (VK) was 145 KIM, and takeoff safety speed (V,) was 153 KIAS. %. Flight 191 was cleared to taxi i.nto position on runway 32R and hold. At 1502:38, the flight was cleared for takeoff. nnd at 1502:46 the captain ncknowled: ged, "American one nitiety-one under way." Company personnel fnmilinr with the flightcrew's voices identified the captain as the person making this cnll end the ensuing V1 and VR speed callouts on the cockpit voice recorder (CVH). The takeoff roll was normal until just"before rotation at which time sections of the left, or No. 1, engine pylon structure came off the hircrnf't...witnesses saw white smoke or vapor coming from the vicini$p.g! thc No. I, engine *; pylon. DuF& rotati,ge- 1 engine a_n~~y~-~etd.-frpm_lhe a- over-che top of the wme%dlell to the runway. Flight 191 lifted off about 6,000 ft down runway 32K, climbed out in a wings-level attitude, and reached an altitude of about 300 It above the ground (a.g.1.) with its wings still level. Shortly thereafter, the aircraft began to turn and roll to the left, the nose pitched down, and the aircraft began to descend. As it descended, it continued to roll left until the wings were past the verticnl position. Flight 191 crashed in an open field and trailer park about 4,680 ft northwest of the departure end of runway 32K. The aircraft was demolished during the impact, explosion, and ground fire. Two hundred and seventy-one persons on board Flight 191 were killed, two persons on the g-ound were killed, md two persons on the ground sustained second- ana third-degree bwns. The aircraft crashed about 1504, during daylight hours; the COOrdinHteS of the crnsh site were 42%0'35"N, 8755'45"W. - l! All times herein are central daylight time, based on the 24-hour clock.
7 Injuries to Persons llljuries -- Crew Passengers Others Fatal Seriom MinorlNone Damage to Aircraft The aircraft was destroyed. 1.4 Other Damage An old aircraft hangar, several automobiles, and a mobile home were destroyed Personnel lnformation * All flight and cabin personnel were qualified. (See appendix B.) 1.6 Aircraft Information Flight 191, a McDonnell-Douglas DC-10-10, NllOAA, was owned and operated by American Airlines, Inc., and was powered by three General Electric CF6-6D engines (See appendix C.) According to the manufacturer, e-hed 11,512 :bj,f~~.i.l..855 lbj,.&r,. a With the loss of the engine pylon structure, the.+ircraft's center of gravity (c.g.) moved aft 2 percent to about 22 percent mean aerodynamic eherd (MAC). The resultant c.g. was within the forward (16.4 percent MAC) and aft (30.8 percent MAC) c.g. limits. The lateral c.g. shift was 11.9 inches to the right. 1.7 Meteorological Information At the time of the accident, the weather at the airport was clear. The surface observations at O'Hare International were as follows: 1451, surface aviation: Clear, visibility-15 mi, weather-none, temperature--63"f, dewpoint--299, winds020'at 22 kns, altimeter inhg , local: Clear, visibility--15 mi, weather--none, temperat~re--63~ F, dewpoint--29' F, winds--020 at 19 kns gusting to 28 kns, altimeter inhg., remarks--aircraft mishap Aids to Navigation Not applicable. *,
8 1.9 Communications There were no known communications malfunctions Aerodrome Information ChicagcrO'Hare International Airport is located 16 mi northwest of downtown Chicago, Illinois, and is served by seven runways. Runway 32R is 10,003 ft long and 150 ft wide, and has a concrete surface.' The runway elevation is 649 ft mean sea level (m.s.1.) at its southeast end and ti52 It m.s.1. at its northwest end Flight Recorders The aircraft was equipped with a Fairchild Model A-100 CVR, serial No The CVK was recovered and brought to the Safety Board's laboratory where a transcript of the recording wns prepared. The recording was Incomplete because of the loss of electrical power to the recorder during aircraft rotation. However, the aircraft's gross weight, stabilizer trim setting, V1, end VR cailouts ' were recorded. z The aircraft was equipped with a Sundstrand digital flight data recorder (DFDR), serial no The recorder had been damaged structurally, but there was no fire or heat damage. The recording tape' was broken; upon removal from the recorder the tape was spliced together and a readout was made. Two 6-sec areas of data were damaged because of the breaks in the tapes; however, most of these data was recovered. 8 The DFDR recorded 50 sec of data during the takeoff roll and 31 sec of airborne data before the recording ended. (See appendix ti.) The DFDR readout showed that the stabilizer trim setting for takeoff was 6.5O aircraft noseup. The DFDK's tolerance for this parameter is + lo. Because of unusual aircraft attitudes' during the last few seconds of the fligtit, the recorded altitude and airspeed data were not correct. Therefore, the DFUR altitude and indicated airspeed values cited hereaiter have been corrected for the position errors resulting from the aircraft's attitudes during the last few seconds of the descending flight. Correlation of the DFDR and CVR recordings. disclosed that the.. flightcrew had set the flaps and stabilizer trim at loo and about 5' aircraft noseup, respectively, for takeoff. A rolling takeoff was made, takeoff thrust was stabilized at EO KIAS, and left rudder and right aileron were used to compensate for the right crosswind. The V and V callouts were made about 2 sec after these speeds were recorded by the DhDR. &e elevator began to deflect up at VR. The aircraft began to rotate upward immediately and continued upward at a rate of 1.5' per sec. Flight 191 accelerated through V speed during rotation and before it lifted off the ranway. The last stable tat?eoff thrust on the No. 1 'engine was recorded 2 sec before liftoff. One second later, the word "damn" was recoraed on the CVR, and then the CVR ceased operating. Onr second before llftoff and simultaneous with the loss of the CVR and the No. 1 engine's parameters, the DFDR ceased recording the positions of the left inboard ailero,:.: left inboard elevator, lower rudder, and Nos. 2 and 4 left wing leading edge slats. The DFDK continued to record ali other parameters b
9 -5- including the position of the upper rudder, the outboard aileron, the outboard elevator, and the No. 4 leading edge slats on the right side of the aircraft. The electrical power for the CVK and the sensors for the lost DFDH functions were all derived from the aircraft's No. 1 e.c. generator bus. Flight 101 became airborne about 6,000 ft from the start of the takeoff roll and remained airborne for 31 sec. It lifted off at V2 + 6 KIAS and at 10" pitch attitude. Twoseconds after liftoff, the UFDR reading for the No. 1 engine's N1 was zero, the No. 2 engine's N speed was increasing through 101 percent, and the No. 3 engine's N1 was essentidy at the takeoff setting. The flight lifted off in a slight left wing-down attitude. Application of right wing-down aileron and right rudder restored the flight to a wings-level attitude and the headlng was stabilized between 325' and 327'. The flight maintained a steady climb about 1,150 feet per minute (fpm) at a 14' noseup.p~tch attitude--the target pitch'attitude displayed by the Ilight director for a twoengine climb. During the climb, the No. 2 engine N speed increased graduallj from 101 percent to a final value of 107 percent; the do. 3 engine N speed did not cllangf appreciably from the takeoff setting. During the initid par#ibf the climb, the aircraft accelerated to 8 maximum speed of 172 KIAS; it reached this value about 9 sec after liftoff and about 140 ft a.g.1. Flight 191 continued to climb about 1,100 fpm. The pitch attitude and heading were relatively stable. Right wing-down aileron and right rudder were used lo control and maintain the heading and the roll altitude during the climb in... the gusty right crosswind. During the climb, the aircraft began to decelerate from 172 KIAS at an average rate 01 about 1 kn per second. At 20 sec after liftoff, at 325 ft a.g.1. and 159 KIAS, the flight began to roll to the left and passed through 5O left wing down. The left roll was accompanied by incqeasing right-wing-down aileron deflection. At this point, the previoudy stabilized right rudder deflected suddenly to zero, remainec' at zero for I sect and then moved toward its previous deflection. The flight began to turn to the left, and the left roll incrpsed even though increasing right rudder and right-wing-down aileroc deflections were being applied. At 325 ft a.g.1. the flight had turricd through the runway heading and was rolling to the left at 4' per second. The right rudder deflection increased during the turn. The previously stable pitch attitur'c began to decrease from 14O even though the elevator was being increased to the full aircraft noseup deflection. The maximum pitch rate of about 12'pCr second was reached just before the crash. rudder and right-wing-down aileron deflections. Three seconds before the end of Flight 191 continued lo roll and turn to the left despite increasing right the DFDK tape, the aircraft was in a YOo left bank and at a O'pitch attitcde. The DFUR recording ended with the eircraft in '1eft roll and M 21'nosedown pitch attitude with full counter aileron and rudder controls $nd nearly full up elevator being applied. 1
10 DFDR longitudinal and vertical acceleration data were integrated to determine the headwind components at points where the aircraft attained certain speeds and where it lifted ofl; to establish an altitude profile; and to determine the location where the DFDK stopped. These data showed that the DFDK ceased operation 14,370 ft from the southeast end of runway 32R and 820 ft left of tke runwny's extended centerline. Examination of the crash site showed that the first point of impact was 14,450 ft beyond the southeest end of runway 32R and 1,100 It left of its extended centerline. Based on these data and the corrected altitudes, the DFDK ceased operating at impact. The flight reached a maximum altitude of 350 ft a.g Wreckage and Impact Information Flight 191 struck the ground in a left wing-down and posedown attitude. The left wingtip hit first, anc! the aircraft exploded, broke apart, and was scattered into an open ficld and n trailer park. The disintegration of the aircraft structure was so cxtcnsivc that little useful data were obtainetl from postimpact examination of the wreckage with the cxccption of the No. 1 pylon, which 'vas found off the right side of runway 32K. (See figure 1.) Investigators located and documented identifiablc aircraft components. Except for the No. 1 enginc nnd pylon, portions of the enginc cowling, and a part of the leading edge of the wing directly nbove the pylon, the aircraft wreckage came to rest in the open field and trailer park. (See appendix D.) The first marks made by engine contact of the No. 1 engine an3 pylon with. the runway began about IY It to the right of the ccnterline lights tind about 6,953 ft beyond the southeast end jf rtinhay Other parts of cngine and pylon structure were located in this aren; however, no spoiler artuators or hydraulic lines were found. The pylor is attached to lhc wing using Spherical ball joints in three different structural elements. Two of the spherical joints are aligned vertically in a forward bulkhead which is ettnched to structure in the wing forward of the front spar. Another spherical joint behind the forward bulkhead transmits thrust loads from pylon structure into a thrust link which in turn is connected through another spherical joint to structure on the lower surface of the wing. The third atbachment point is a spherical joint in the pylon aft oulkhcad which attaches,'to a clevis mounted on the underside of the wing. The pylon forward bulkhead and portions Gf the flange irom the pylon oft bulkhe3d either remained with the separated No. 1 pylon or wcre scr'tercd along the runwny. (See figures 2 and 3.) The No. 1 pylon's aft clevis attach assembly and portions of the pylon aft bulkhead, wing thrust angle assembly nnd thrust link, and pylon forwnra bulkhead attach assembly remained with the wing. The pylon forward bulkhead was bent forward about 30'and most of the bolts which held the bullillcad upper plates were m.issing. Thc upper 12 inches of the forward plate were bent forward an additional 10' to 15'. The aft plate Was broken below the thrust fitting connection, and a iarge piece of the upper left corner was missing.. &
14 -10- The wing's forward support fitting, which attached the pylon forward bulkhead to the wing at the upper and lower plugs and spherical bearings, was found at the main wrechage site. The upper and lower plugs and their attaching hardware were intact, and the upper and lower spherical bearings were attached to the fitting. The pylon thrust fitting remained attached to. the forward portion of the pylon's aft upper spar web. The pylon thrust link, which attached the pylon thrust fitting to the wing thrust angles, was found at the main wreckage site attached to a portion of the wing thrust angles. Its forward spherical bearing was cocked to the exlreme left, and a segment of the bearing which had broken away WBS found on the runway. The thrust bushing bolt had broken in two parts, both of which wzre found in the grass adjacent to the runway. The bolt nut was attached to one of the broken pieces, and the faces of the nut were gouged severely. Except for one lubrication rstainer washer, which was not found, thc remniqing portions of the thrust bushing bolt assembly were found along the runway. ' One shim spacer fro,,, the assembly was crushed severely while the other was relativqly undrhlaged. The upper two-thirds of the pylon aft bulkhead separated from the flanges around its periphery and wcs found in the wrerkage. The top two pieces of its attach lugs had separated from the bulkhead, and the eft skie of the bulkhead was gouged heavily near the lower edge of the wing clevis lug, which attache0 the aft bulkhead to the wing. The WIAL clevis was attached to the wing. The aft bulkhead's spherical bearing was attachcd to the clevis, tad thc separated pieces of 4 the aft bulkhead's attach lugs were found on top of the spherical bearing. The Nos. 2 and 3 engines were located in the main wreckage., The damage to the engines indicated that they were operating at high rpm at impact. AU three engines were taken to the American Airline's Maintenance Facility at Tulsa, Oklahoma, where they were torn down and examined. There was no evidence of any preimpect malfunctions. The examinations of the main and nose landing gears and actuators indicated thnt the gear was down and locked at impact. The left and right stabilizer jackscrews were recovered and the distance between the upper surfaces of the jackscrews' drive nuts and the lower surfaces of the actuators' upper stops was measured. These measurements indicated that the stabilizer was positioned at 5.71'aircraft noseup: Examination of the hydraulic system components did not reveal any evidence of internal operating distress. Thc control valvc of the 2-1 nonreversible motor pump was in the open position, indicating that the No. 2 hydraulic system was driving the No. 1 hydraulic system's pump. All eight flap actuators were recovered, and.investigators attempted to verify the position of the trailing edge flaps by measurin'ethe extension of the flap actuator pistons. The piston extensions were compared to those of another aircraft with flaps extended to 10'. Based on this comparison, some degree of B
15 -11- flap extension was probable, but the actual position could not be established. However, the DFDR data showed that the flaps were set at 109 A 3-ft section of the left wing's leading edge, just forward of the point where the forward part of the pylon joined the wing, whs torn away when the engine pylon assembly separated from the aircraft. The No. 1 and No. 3 hydraulic system's extension and retraction lines and the followup cables for the left wing's outboard slat drive actuators were severed. Thirty-five of the 36 leading edge slat tracks were examined. The examination disclosed that at impact the left wing's outboard slats were retracted, while the left wing's inboard slats and the right wing's inboard and outboard slats were extended to the takeoff position. The examination of the cockpit instruments did not disclose any usable informa'.ion Medical and Pathological Information A review of the autopsies and toxicological examinations of the fl,ghtcrew disclosed no ev~idence of preexisting physiological prpblemswhich could have affected their performance Fire The aircraft was subjected to severe ground fire Survival Aspects This accident w8s no? surviveble bcceusc impact forces exceeded human tolerances Tests and Research Study of Photographs FiOe'motographs taken of Flight 191's departure by two cameras--one in the terminal and one onboard a DC-10 on final approach to runway 9R-were sent to Lockheed's Palo Alto Research Laboratories for a Photo-Image Enhancement Study to determine the position of the flight controls. The process produced black and white images containing expanded variations of gray shading which, in the absence of the enhnncement process, would be too subtle for the eye to distinguish. Based on the study of 'these photo-images, the following observations were made: (1) The tail assembly was not damage& (2) the nose gear was down during the initial climbout and before the onset of roll; (3) spoilers Nos. I, 3, and 5 were extended on the right wing; and (41 the trailing edge of the right wing inboard aileron was up. Although the position cf the slats was difficult to determine, the left wing inboard slats appeared to be extended, and'the position of all other control surfaces appenred to be thc snme as recorded by the DFDR. The pitch and roll attitudes of the aircraft were extrapolated from the photographs, and extrapolations agreed closely with those recorded by the DFDR.
16 NlIOAA's pylon aft bulkhead was examined at the Safety Ijoard's 1 - : in the inbotra-oulo- 3.; ne Iraeture characteristi lond separation. Chevron and tear marks Qn the fracture indicated thnt lh~ ruplure progressed downward at the center of the flange, then in inbourd tmd oulbonrd directions on the flange. The bottom portion of the fracture exhibilcd snlwril~g consistcnt with the compression portion of a bending fracture. The sinrar WIIS IIIOW prevnlcnt-about 6 inches long-in the thinner center portion of llw upper I'langv struclurc, but became less prevalent at the outer ends of the. to he rcl;llivcly frci. of oxidation and dirt. z Fntiguc mt&ing was evident a* hth.iendl of tha.,traeture: At the ~nhn~~rd (!IN:. 11~' ifil!gw progressed inboard trnd aft; then, it progressed downward md 1nbomi 10 lhc tt;)orr inboard fustener that attached the forward section of the hulkl~okil lo llw r~ll srction. 'The fatigue progressed past the fastener R short dis111:1w bclorc r,stiibiting rnpid overstress characteristics in the downward d!rrelloll niil proccrdrd illong the inboerd side of the side flange radius of the forwnrd fl:mgc sivlton. A1 (he outboard end of the fracture, the fatigue propr~p~lcd io?i%:~rcl I I I I ~ sllghtly outboard toward the mmt forward outboard hole in lhc upper ~I~IEICV. 'I!w tot111 lcngtli of the overstress fracture and fatigue cracks was 111m1l 13 IIICI~CS. I'lw remuindcr of the fractures on the bulkhead und within lhc pylon 5lrurlurv rvwlted from ovcrload. ' 1 I IIC cs:~:~~inntion nlso discloscd that three shims were instalkd on the uppcr surfarc of llir I'orward upper flange. Two shims (Part No. AUB ) were m~t:illml, onc of! the inboard top shoulder of the upper flange and one on the ou'ttward lop sho~~idcr. lhcse shims are about 2 inches long, 1 inch wide, and.06j inch thick. A Ill-iwli-long..OSO-inch-thick shim was installed during production to fill :I p p bctwwn lhc upper flnngc and upper spar web. (See figure 6.) The ni~~~~uf,~rlurc.r's (iruw!nm specify that the AUB shim may be required dong the side 01 1Iw b.llkllcnrl: however, they do not indicate that shims may be required on Ihc uppcr surf:trr of the flange. 'The fatigue propagation on the inboard and outlmard cntk 01 t!w ovcrslress fracture began in the aiea underneath We.tlti3-lncll-tl~l<.k\111111<;. Thr ~ f fr~~crt~rc-st~rface t of thc upper flange contained a crescentr'orrmuon Wnch ~n~lohed tbe.shape of the lower end of the wing ctesis. nintton WHS in line '.with the vetiant, centeetina of the..af.t.. t)mcheud d-nlenf hole ws tndicnted by MNOW "d*' in figure?. A deformation WLS noted in the lowcr surfnre of the 1111 wing support fitting's forward clevis lug in the area atcd by tllc hr;rrkct.; 111 ftg skalbw gage was sppht in tlce :A?he tlrro+\: in :!.gure 10, s in a position which w& EORcQFm ',&#&.&$ne,,+lm&n. On-'t sf9alnblv. o f the..u- twwam&k*
18 Figure 5. View of the aft bulkhead pieceindicated as Item 1 in Figure 4.
20 ~~ Figure 7. Closer vi& of fracture on. upper flange in the Fig1 ire 8. Detail of deformation denoted by arrows "d" in Figu~ re 5 and 7.
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