NTSB CAROL · Event
Event DCA17FA021
Aircraft involved
Probable cause & findings
The failure of the high-pressure turbine (HPT) stage 2 disk, which severed the main engine fuel feed line and breached the right main wing fuel tank, releasing fuel that resulted in a fire on the right side of the airplane during the takeoff roll. The HPT stage 2 disk failed because of low-cycle fatigue cracks that initiated from an internal subsurface manufacturing anomaly that was most likely not detectable during production inspections and subsequent in service inspections using the procedures in place. Contributing to the serious passenger injury was (1) the delay in shutting down the left engine and (2) a flight attendant's deviation from company procedures, which resulted in passengers evacuating from the left overwing exit while the left engine was still operating. Contributing to the delay in shutting down the left engine was (1) the lack of a separate checklist procedure for Boeing 767 airplanes that specifically addressed engine fires on the ground and (2) the lack of communication between the flight and cabin crews after the airplane came to a stop.
Factual narrative
The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/01. On October 28, 2016, about 1432 central daylight time, American Airlines flight 383, a Boeing 767-323, N345AN, had started its takeoff ground roll at Chicago O'Hare International Airport, Chicago, Illinois, when an uncontained engine failure in the right engine and subsequent fire occurred. The flight crew aborted the takeoff and stopped the airplane on the runway, and the flight attendants initiated an emergency evacuation. Of the 2 flight crewmembers, 7 flight attendants, and 161 passengers on board, 1 passenger received a serious injury and 1 flight attendant and 19 passengers received minor injuries during the evacuation. The airplane was substantially damaged from the fire. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed at the time of the accident. NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-18/01. On October 28, 2016, about 1432 central daylight time, American Airlines flight 383, a Boeing 767-323, N345AN, had started its takeoff ground roll at Chicago O'Hare International Airport, Chicago, Illinois, when an uncontained engine failure in the right engine and subsequent fire occurred. The flight crew aborted the takeoff and stopped the airplane on the runway, and the flight attendants initiated an emergency evacuation. Of the 2 flight crewmembers, 7 flight attendants, and 161 passengers on board, 1 passenger received a serious injury and 1 flight attendant and 19 passengers received minor injuries during the evacuation. The airplane was substantially damaged from the fire. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121. Visual meteorological conditions prevailed at the time of the accident. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- C Aircraft-Aircraft power plant-Engine (turbine/turboprop)-Turbine section-Failure
- — Aircraft-Aircraft systems-Fuel system-(general)-Damaged/degraded
- F Personnel issues-Task performance-Use of equip/info-Use of policy/procedure-Cabin crew
- F Personnel issues-Action/decision-Action-Delayed action-Flight crew
- F Personnel issues-Task performance-Communication (personnel)-Lack of communication-Flight crew
- F Personnel issues-Task performance-Communication (personnel)-Lack of communication-Cabin crew
- C Organizational issues-Development-Manufacture/production-Equipment manufacture-Manufacturer
- F Organizational issues-Development-Design-Task design-Manufacturer
- — Organizational issues-Management-Resources-Adequacy of documents/info-FAA/Regulator
- — Organizational issues-Support/oversight/monitoring-Training-Emergency proc training-FAA/Regulator
Verbatim from NTSB's published report. Source file
NTSB_2016_DCA17FA021.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (engine failure). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- NTSB Aircraft Accident Reports 2018 · Accident report
Atlas Air Flight 3591 Boeing 767 Loss of Control (preliminary)
Atlas Air 3591 / Boeing 767-300 / Trinity Bay TX (Feb 23 2019) — preliminary. Preliminary investigation findings; superseded by the AAR-21/01 final report.
- NTSB Aircraft Accident Reports 2021 · Accident report
Crash of Atlas Air Flight 3591, Boeing 767-300 (N1217A)
Atlas Air 3591 crashed into Trinity Bay, Texas, February 23, 2019. Investigation of the in-flight loss-of-control crash of Atlas Air 3591 into Trinity Bay, Texas.
- arXiv 2022 · arXiv preprint
Multi-level Adaptation for Automatic Landing with Engine Failure under Turbulent Weather
This paper addresses efficient feasibility evaluation of possible emergency landing sites, online navigation, and path following for automatic landing under engine-out failure subject to turbulent wea…
- NASA NTRS 2019 · Conference Paper
Simulation of Liquid Rocket Engine Failure Propagation Using Self-Evolving Scenarios
Traditional probabilistic risk assessment approaches often require failure scenarios to be explicitly defined through event sequences that are then quantified as part of the integrated analysis.
- NASA NTRS 2019 · Conference Paper
Rocket engine failure detection using system identification techiques
The theoretical foundation and application of two univariate failure detection algorithms to Space Shuttle Main Engine (SSME) test firing data is presented.
- NASA NTRS 2019 · Conference Paper
Rocket engine failure detection using system identification techniques
The theoretical foundation and application of two univariate failure detection algorithms to Space Shuttle Main Engine (SSME) test firing data is presented.
Browse the full corpus — academia portal ↗