On July 19, 1989, at 1516, a DC-10-10, N1819U, operated by United Airlines as flight 232, experienced a catastrophic failure of the No. 2 tail-mounted engine during cruise flight. The separation, fragmentation and forceful discharge of stage 1 fan rotor assembly parts from the No. 2 engine led to the loss of the three hydraulic systems that powered the airplane's flight controls. The flight crew experienced severe difficulties controlling the airplane, which subsequently crashed during an attempted landing at Sioux Gateway Airport, Iowa. There were 285 passengers and 11 crewmembers onboard. One flight attendant and 110 passengers were fatally injured.
We determined that the probable cause of this accident was 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 fatique crack originating from a previously undetected metallurgical defect locationed in a critical area of the stage 1 fan disk that was manufacutured 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 operate the DC-10's flight controls.
Recommendations concerning these issues were addressed to:
- The Federal Aviation Administration,
- The Secretary of the Airforce,
- The Air Transport Association, and
- The Aerospace Industries Association
