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United Air Lines Flight 1768

21 Feb 2019 · Orlando, FL, United States

Boeing 737 924 · Incident: powerplant system/component malfunction/failure during initial climb

From Orlando International Airport (MCO) to George Bush Intercontinental Airport (IAH)

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Event

NTSB case
ENG19IA013
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 737 924

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
N30401
Onboard fatalities
Unknown
Route
From Orlando International Airport (MCO), Orlando, FLTo George Bush Intercontinental Airport (IAH), Houston, TX
Aircraft age
About 18 years (built 2001)
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
Initial climb
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
Powerplant system/component malfunction/failure
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
None

Cause areas

  • Aircraft › Aircraft power plant

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

The No. 2 engine high pressure compressor (HPC) failure was caused by a stage 2 blade separation. A HPC stage 1 variable stator vane (VSV) trunnion stem, identified as VSV #33, was missing a washer and retaining nut that allowed VSV #33 to rotate independent of the other vanes in the stage. The out-of-schedule VSV created a 1 per revolution pulse on the HPC stage 2 rotor that eventually created fatigue cracks on the HPC stage 2 blade posts that secure the rotor blades in the disk spool. When one of the fatigue cracks transitioned to overload, a section of a blade post separated and allowed a blade to enter the gas path. Titanium fragments created by secondary impact damage as a result of the separated blade were caught between the rotating blade tips of the stage 1 blades and the steel HPC cases. The contact created a brief but intense titanium fire that melted the HPC case material around the HPC stage 1 rotor plane of rotation. The damage observed both immediately upstream of the separated HPC stage 2 blade and through all remaining stages aft was secondary impact damage.

The GE Aviation Materials Laboratory performed a binocular analysis on the HPC VSV #33 trunnion stem and D-head and found wear patterns and witness marks that confirmed that a washer and retaining nut were present at some point. According to engine maintenance records, the last time the HPC VSVs were removed was during an engine overhaul at the GE Aviation- Celma maintenance, repair, and overhaul (MRO) facility, Petrópolis, Brazil in July 2014. When the HPC was assembled during the engine overhaul, the VSV #33 washer and retaining nut were likely either omitted or improperly torqued, which may have allowed the retention nut to back off during engine operation.

Probable cause

A No. 1 (left) engine high pressure compressor stage 2 blade separation. The blade separated due to a mixed-mode fatigue crack that originated on a blade disk post and was initiated by a misaligned (out-of-schedule) high pressure compressor stage 1 variable stator vane that was missing a washer and retaining nut on the vane trunnion stem.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record ENG19IA013
Event ID
20190222X84313
Case number
ENG19IA013
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, damage. 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: 836979c25a629b137a20bebd8c2f60d094cb34a29a55f46b73742d85d35b3ea5; retrieved 2026-09-16T08:36:43.843Z.