NTSB Identification: MIA02FA075.
The docket is stored in the Docket Management System (DMS). Please contact Records Management Division
Scheduled 14 CFR Delta Air Lines, Inc.
Accident occurred Sunday, March 31, 2002 in Charlotte, NC
Probable Cause Approval Date: 04/28/2004
Aircraft: McDonnell Douglas MD-11, registration: N809DE
Injuries: 5 Serious,11 Minor,229 Uninjured.
NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
The captain stated he was the pilot flying and the takeoff and climb to the cruise altitude of 33,000 feet was conducted within normal parameters. After level off the relief pilot left the cockpit to begin his rest period. Within a few minutes he observed that the number 2 engine master warning light was illuminated, as well as a level 3 alert on the Engine and Alert Display and a red light on the number 2 fire handle and fuel shutoff lever. The fire bell did not activate. He and the first officer performed the memory and initial action items on the hard card checklists for an engine fire and shutdown the No. 2 engine. In addition, the captain discharged an engine fire bottle. The engine fire light continued to illuminate. The captain then fired a second engine fire bottle. The engine fire light continued to be illuminated. The captain requested that the relief pilot return to the cockpit. He then contacted Air Traffic Control (ATC) and told them that their No. 2 engine was on fire and that they intended to land at the nearest suitable field. ATC responded that Charlotte was 35 miles away with a 10,000 foot runway. He asked for radar vectors and an immediate descent into Charlotte. They were given a lower altitude. The first officer initiated fuel dumping. The relief pilot returned to the cockpit and he asked the relief pilot and the first officer to run the checklists. As they descended the aircraft encountered heavy rain, light hail, and moderate turbulence. In addition, they observed a bright flash to the left of the nose, which might have been a lightning strike. As they completed the descent and approach checklists he told the crew to expect an emergency evacuation upon landing and directed the first officer to so inform the flight attendants. The aircraft was configured for an engine out approach and they reviewed the loss of a second engine procedure. The remainder of the approach, touchdown and landing roll occurred within normal parameters. He brought the airplane to a stop on the runway. The engine fire indication remained illuminated. The relief pilot stated they did not terminate fuel dumping prior to landing. They completed the items on the evacuation checklist. He then ordered an evacuation of the airplane. According to Delta Air Lines representatives, examination of the No. 2 engine by company maintenance personnel found one fire loop chafed through an adjacent cable, an integrated drive generator (IDG) feeder cable, inside the No. 2 engine cowling This allowed a direct 115 volt AC connection between the IDG and the fire detection control unit. The result was an electrical short and complete failure of the detection control unit that was indicated in the cockpit as a fire warning. There was no evidence of fire in the No. 2 engine. Boeing Service Bullettin MD11-71-086 was issued on May 21, 1996. The subject of the service bulletin was "Power Plant - Electrical Harness - Replace/Modify Integrated Drive Generator (IDG) Wire Harness Support Brackets". On May 21, 2001, Boeing elevated the service bulletin to the "Alert" level. Boeing recommended that aircraft operators accomplish the service bulletin within 1 year. According to Delta Air Lines personnel, in November 2001, Delta Air Lines Aircraft Engineering issued a Engineering Order to comply with Alert Service Bulletin MD11-71A086. The Engineering Order stated that all engines should be inspected and modified by November 2002. All three engines on the accident aircraft were inspected and modified in accordance with the Engineering Order on March 3, 2002. On March 28, 2002, the No. 2 engine was changed and the engine installed had not been modified by the Engineering Order.The Delta Airlines descent, approach, and before landing checklists dated June 30, 2000, and which were in use at the time of the accident, required the pilots to check the Engine and Alert Display. When fuel dumping is activated, a message is displayed on the Engine and Alert Display.
The National Transportation Safety Board determines the probable cause(s) of this accident to be: The failure of the aircraft operator to comply with, in a timely manner, on the No. 2 engine, Boeing Alert Service Bulletin MD11-71A086, resulting in the integrated drive generator feeder cable chaffing through a fire warning loop and failure of the fire warning system due to electrical damage. This resulted in a continuous indication in the cockpit of a No. 2 engine fire, an emergency descent and landing, and injuries to passengers during the subsequent emergency evacuation of the airplane. Full narrative available
Index for Mar2002 | Index of months