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Southwest Airlines Flight 4635

3 Jun 2017 · Washington, DC, United States

Boeing 737 7H4 · Incident: uncontained engine failure en route

From Tampa International Airport (TPA) to Frederick Douglass Greater Rochester International Airport (ROC)

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Event

NTSB case
ENG17IA027
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Incident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
0 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
Airline
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Unknown

Boeing 737 7H4

Aircraft type
Boeing 737
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N765SW
Onboard fatalities
Unknown
Route
From Tampa International Airport (TPA), Tampa, FLTo Frederick Douglass Greater Rochester International Airport (ROC), Rochester, NY
Aircraft age
About 17 years (built 2000)
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 121: Air Carrier
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
En route
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Uncontained engine failure
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Minor

Cause areas

  • Aircraft › Aircraft power plant

Approximate · Coordinates from the NTSB case API, which marks them as estimated or does not say; no uncertainty radius is established.

NTSB narrative

The alternator control gearshaft (L3 gearshaft) failed due to high cycle fatigue intergranular corrosion cracking. High cycle fatigue is normally vibration driven where fatigue striations are hard to resolve (count) and where the number of cycles far exceeds the flight cycles. No indications of any abnormal vibration were noted during the event flight and a review of fan and core vibration diagnostic data from the last shop visit in 2017 (the AGB was overhauled at that time) showed all the vibration levels to be within acceptable limits.

A review of the manufacturing records showed that the failed L3 gearshaft was 1 of 32 initially produced from the same production batch. Due to corrosion issues during the initial manufacturing process, all the gearshafts were subjected to additional manufacturing operations; only 8 were deemed serviceable and put into service, one of which was the event gearshaft.

To understand the impact of the additional manufacturing processing steps performed on the failure L3 gearshaft, a series of chemical etch and black oxide treatments were performed on a sample of the same material. This sample was compared with the failed L3 gearshaft and revealed that the intergranular attack observed on the failed L3 gearshaft could not be replicated; the sample material showed no intergranular attack even after 5 chemical etchings. CFMI concluded that the chemical etching alone could not account for the intergranular attack observed on the event L3 gearshaft; instead it is thought that the additional machining process stress combined with the chemical etching needed to remove the corrosion caused the increase in quantity and density of the microcracks along with the grain boundary consumption. However, this still did not fully account for why the gearshaft failed in high cycle fatigue, which is normally a vibration driven failure mode.

Since the event L3 gearshaft was introduced into service, it had operated almost 20 years; accumulated 63,711 hours time since new and 37,433 cycles since new; and was subjected to in-service inspections at the piece part level on two occasions; once in 2007 and then again in 2017 with no anomalies reported. Had the additional manufacturing processing been the solely cause of the failure, the L3 gearshaft most likely could not have operated as long as it had, and it would most likely not have failed in a vibratory mode. Instead the additional manufacturing operations most likely affected the high cycle fatigue capability of the gearshaft, but it wasn't until a change in the vibratory stress that the part was exposed did it fail. Unfortunately, the engine is not equipped with any vibration sensors on the AGB so detecting any changing vibratory response in the AGB was not possible. The engine is however equipped with a No. 1 bearing sensor and fan frame compressor case vertical sensor. Review of the flight data recorder data showed no aircraft vibration monitoring alerts prior to, or after the engine failure event. Also, a review of fan and core vibration diagnostic data from the last shop visit in 2017, the AGB was overhauled at that time, to the event date showed all the vibration levels to be within acceptable limits.

The transfer shaft locking nut was found loose but was still engaged with the 47 tooth gearshaft and the transfer gearbox. Review of the maintenance records showed locking nut was last torqued in accordance with the approved procedures during the engine's last shop visit. The locking nut threads and mating threads on the L3 gearshaft were in good condition, the lock nut retaining ring was present, properly installed, and in good condition, and the transfer shaft was found fully engaged. CFMI's experience with locking nuts becoming untorqued during operation is that the transfer shaft disengages resulting in a subsequent in-flight shutdown; in this case the transfer shaft remained fully engaged. Therefore, the loose transfer nut did not cause nor a contributing factor to the failure of the L3 gearshaft and was an artifact of the initial failure event.

Probable cause

The failure the control alternator gearshaft, which disconnected the accessory gearbox from the rest of the engine and resulted in an uncommanded in-flight shutdown of the left engine and subsequent flight diversion. The control alternator gearshaft failed because of high cycle fatigue intergranular corrosion cracking. Contributing to the failure of the control alternator gearshaft were additional manufacturing processing steps to address part non-conformances that reduced its high cycle fatigue capability and potential change in vibratory environment since the last shop visit.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record ENG17IA027
Event ID
20170608X90705
Case number
ENG17IA027
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: investigation status, coordinates. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.
  • API snapshot SHA-256: 4b6ae7431780cfe3c9cdca72954e95523233351d7d0ec004e62f67c874cbf16b; retrieved 2026-09-16T05:23:03.909Z.