FLIGHT FINDINGSAVIATION OCCURRENCE MAP
Back to map

Federal Express Boeing 767-300F incident

18 Oct 2023 · Memphis, TN, United States

Boeing 767-300F · Incident: fire/smoke (non-impact) during initial climb

Report a problem

Event

NTSB case
ENG24FA003
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 767-300F

Aircraft type
Boeing 767
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
N287FE
Onboard fatalities
Unknown
Route
From not recordedTo not recorded
Aircraft age
About 1 year (built 2022)
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
Fire/smoke (non-impact)
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
  • Organizational issues › Development
  • Organizational issues › Support/oversight/monitoring

Approximate · Coordinates from the NTSB case API, not marked as estimated; no uncertainty radius is established.

NTSB narrative

The incident engine, a General Electric (GE) CF6-80C2 turbofan, suffered an undercowl fire due to a high-pressure fuel leak originating from a bolted flange interface between a high-pressure fuel crossover tube and the hydromechanical unit (HMU) accessory gearbox adapter pad. The engine’s accessory heat shield surface temperatures and stagnant airflow near the fuel leak location were sufficient to cause ignition.

Two threaded inserts in the adapter pad were found protruding and likely prevented the fuel tube from correctly seating on the adapter pad surface. Threaded inserts were not securely installed into the adapter pad, which allowed the crossover tube bolts to partially pull out. Multiple insert holes had stripped threads, linear scoring, counterclockwise material smearing, missing surface anodization, cross-threading, and concave hole profiles.

Avio Aero, the adapter manufacturer, implemented an automated pre-tap operation that pre-machined threads into the adapter pad to ease installation of self-tapping steel inserts. In early 2023, this pre-tap operation was determined to be a deviation from the part’s drawing requirements.

Neither GE Aerospace nor Avio Aero could find documentation supporting the decision to pre-tap the adapter holes or Avio Aero communicating to GE of their decision to deviate from the print requirement. Avio Aero may have decided to pre-tap the adapter holes because other parts were using this process.

Probable cause

A high-pressure fuel leak from a gap in the bolted flange interface between the main fuel pump’s fuel crossover supply tube and the hydromechanical unit idler adapter pad, which resulted in the crossover tube flange bolts partially pulling out and allowing fuel to escape and ignite on contact with the engine’s heatshield.

Contributing to the fuel leak was Avio Aero's incorrect manufacture of the idler adapter pad bolt holes, which deviated from GE's manufacturing print requirement; Avio Aero's improper installation of threaded inserts into the idler adapter bolt holes; Avio Aero's failure to inform GE about the manufacturing deviation and request approval; and GE's failure to identify the manufacturing deviation during adapter quality and compliance design reviews.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record ENG24FA003
Event ID
20231019193272
Case number
ENG24FA003
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, cause areas. 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: 03716dcda2748f792d1e58a8d4999c76db23606c0f59b1766a2efac22828a25e; retrieved 2026-09-16T18:14:05.462Z.