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NTSB · Safety Recommendation

Safety Recommendation A-19-017

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Require Boeing to determine the critical fan blade impact location(s) on the CFM56-7B engine fan case and redesign the fan cowl structure on all Boeing 737 next-generation-series airplanes to ensure the structural integrity of the fan cowl after a fan-blade-out event.

Safety Issue and Context

This report discusses the April 17, 2018, accident involving a Boeing 737-7H4, N772SW, operated by Southwest Airlines as flight 1380, that experienced a failure of its left CFM International CFM56-7B turbofan engine while climbing through flight level 320 en route to the flight’s assigned cruise altitude (the flight had departed from LaGuardia Airport, Queens, New York, about 30 minutes earlier). Portions of the left engine inlet and fan cowl separated from the airplane; one fan cowl fragment impacted the left-side fuselage near a cabin window, and the window departed the airplane, which resulted in a rapid depressurization.

As a result of the engine failure, the flight crew conducted an emergency descent and diverted to Philadelphia International Airport (PHL), Philadelphia, Pennsylvania. The airplane landed safely at PHL about 17 minutes after the engine failure occurred. Of the 144 passengers and 5 crewmembers aboard the airplane, 1 passenger received fatal injuries, and 8 passengers received minor injuries.

Safety issues identified in this report include the need to ensure the structural integrity of the fan cowl on Boeing 737 next-generation-series airplanes after a fan-blade-out event involving CFM56 7B engines, the need to determine whether other airframe/engine combinations have any critical fan blade impact locations and how an impact at those locations could affect nacelle components, the need to emphasize the importance of having flight attendants secured in a jumpseat during emergency landings, and the need to mitigate hazards to passengers affected by an in-flight loss of seating capacity.

As a result of this investigation, the National Transportation Safety Board makes five new safety recommendations to the Federal Aviation Administration and one new recommendation each to Southwest Airlines and the European Aviation Safety Agency.

Response History

May 2, 2025 · NTSB Correspondence · FAA

We understand that Boeing has determined the critical fan blade impact locations and developed modifications for these and the additional surrounding structure of 737NG airplanes. Further, in 2023, Boeing published three service bulletins (SBs) detailing these modifications (737-71-1937, 737-71-1938, and 737-78-1106). We believe these SBs and your work to approve those modifications satisfy the intent of this recommendation. Accordingly, the Board has classified Safety Recommendation A-19-17 CLOSED-- ACCEPTABLE ACTION.

September 20, 2024 · Recipient Response · FAA

-From Micheal G. Whitaker, Administrator: The Federal Aviation Administration (FAA) previously informed the Board that Boeing submitted their service bulletins (SBs) containing redesigns and modifications for the critical fan blade impact locations and additional surrounding structure of 737NG airplanes. However, the FAA asked Boeing to resubmit the SBs after it had demonstrated compliance with all applicable regulations.

Boeing has determined the critical fan blade impact locations and defined the required redesigns for the critical locations and additional surrounding structures. These modifications have been approved by the FAA, and the SBs to accomplish each modification have been published for operators to begin installing them.

The three Boeing SBs are available at the following websites: https://www.regulations.gov/document/FAA-2023-2234-0002 https://www.regulations.gov/document/FAA-2023-2235-0002 https://www.regulations.gov/document/FAA-2023-2236-002

Read Recommendation

Recommendation Facts

Status
Closed - Acceptable Action
Issued
December 12, 2019
Priority
CLASS II
Recipient
FAA
Adopted
November 19, 2019
Closed
May 2, 2025
Related Investigation
DCA18MA142
Related Report
AAR-19-03

We currently plan to mandate modifications of the inlet, fan cowl, and exhaust nozzle by issuing three separate airworthiness directives (ADs). On December 12, 2023, the FAA published the Notices of Proposed Rulemaking (NPRMs) (Dockets No. FAA-2023-2236, FAA-2023-2234, and FAA-2023-2235) to propose mandating the accomplishment of each modification SB for the inlet, fan cowl, and exhaust nozzle, respectively, prior to July 31, 2028. The NPRMs comment phase concluded on January 26, 2024, and we are currently dispositioning those comments prior to issuing the final rule AD.

Moreover, the FAA has mandated additional engine fan blade inspections through AD 2018-26- 01, CFM International S.A. Turbofan Engines: Amendment 39-19531, which has reduced the risk of fan blade failures.

I will keep the Board informed of the FAA’s progress on Safety Recommendations A-19-17 through -19 and anticipate providing an update by July 31, 2025.

September 18, 2023 · NTSB Correspondence · FAA

We note that Boeing submitted, for FAA review and approval, service bulletins (SBs) containing redesigns and modifications for the critical fan blade impact locations and additional surrounding structure of 737NG airplanes. However, you have asked Boeing to resubmit the SBs after it has demonstrated compliance with all applicable regulations. We also note that, after the SBs have been published, you are still planning to issue three separate airworthiness directives (ADs) to require the redesigns and modifications contained in the SBs.

Pending our review of Boeing’s published SBs and the notice of proposed rulemaking ADs, Safety Recommendations A-19-17 through -19 remain classified Open—Acceptable Response.

May 2, 2023 · Recipient Response · FAA

-Billy Nolen, Acting Administrator: The Federal Aviation Administration (FAA) continues to work jointly with Boeing as it defines the needed redesign and retrofit efforts for the fan cowl structures on the Boeing 737 next-generation-series airplanes.

Boeing has determined the critical fan blade impact locations and shared with the FAA the redesigns and modifications for the critical locations and additional surrounding structure. We have identified additional requirements, and Boeing must demonstrate compliance to the applicable regulations and requirements before obtaining FAA approval.

Boeing expects to resubmit these service bulletins (SBs) for FAA approval by June 30, 2023. Following FAA approval, Boeing can publish the SBs for fan cowl, inlet, and nozzle modifications. As each SB is published, the FAA will then publish a notice of proposed rulemaking airworthiness directive (AD) for each corrective action to require their accomplishment.

As noted in the Board’s aircraft accident report, Left Engine Failure and Subsequent Depressurization, Southwest Airlines Flight 1380, Boeing 737-7H4, N772SW, Philadelphia, Pennsylvania, April 17, 2018 (NTSB/AAR-19/03), the FAA has taken interim action on this matter through AD 2018-26-01, CFM International S.A. Turbofan Engines, effective on January 10, 2019. The AD mandates additional fan blade inspections and decreases the compliance time for the initial inspection from 20,000 to 17,000 cycles since new, reducing the risk of fan blade failures.

I will keep the Board informed of the FAA’s progress on Safety Recommendations A-19-17 through -19, and provide an update by May 31, 2024.

December 5, 2022 · NTSB Correspondence · FAA

We note that Boeing has determined the critical fan blade impact locations on 737 NG-series airplanes and is working with you to ensure that the recommended redesign and retrofit meet regulatory requirements and safety assurance principles. We also note that you are still planning to issue three separate airworthiness directives (ADs) to require the modifications contained in Boeing’s service bulletins (SBs), which will include instructions for modifying the inlet, fan cowl, and exhaust nozzle on Boeing 737 NG-series airplanes.

In addition, because ADs do not apply to military variants, you plan to require that Boeing install the modified structure on new production baseline airplanes that will be later modified into the P-8 military variant. Pending our review of Boeing’s published SBs and the notice of proposed rulemaking ADs, Safety Recommendations A-19-17 through -19 remain classified OPEN--ACCEPTABLE RESPONSE.

May 23, 2022 · Recipient Response · FAA

-From Billy Nolen, Acting Administrator: The Federal Aviation Administration (FAA) continues to work jointly with Boeing as it defines the needed redesign and retrofit efforts for the critical locations and additional surrounding structures necessary to meet regulatory requirements and safety assurance principles. This joint work follows Boeing’s determination of the critical fan blade impact locations on Boeing 737 next-generation-series (NG) airplanes. We will continue to update the Board on this work as the various phases progress towards completion.

As previously mentioned, the FAA plans to issue airworthiness directives (ADs) to mandate modifications of the fan cowl, inlet, and exhaust nozzle of the 737NG airplanes. Boeing is expected to submit a series of service bulletins (SBs) throughout 2022 to include fan cowl, inlet, and nozzle modifications. The FAA plans to issue a separate notice of proposed rulemaking ADs upon publication of the SBs for each corrective action to require their accomplishment.

Boeing has identified the corrective actions applicable to the P-8 military variant, and they will be addressed in the same way as the mandated actions on the 737NG airplanes. Since military variants are not FAA-certified configurations and cannot be included in the AD’s effectivity, the FAA will require that Boeing install the modified structure on new production baseline airplanes that will be later modified into military variants. Boeing will be implementing a production change to incorporate the design updates in future production and will be issuing separate P-8 specific SBs to accomplish the same modifications.

September 10, 2021 · NTSB Correspondence · FAA

We note that Boeing is developing the recommended design changes and plans to release three separate service bulletins (SBs) with instructions for modifying the inlet, fan cowl, and exhaust nozzle on Boeing 737 NG-series airplanes, which the FAA has determined is the only affected fleet. We also note that you plan to issue three separate airworthiness directives (ADs) to require the modifications contained in the SBs.

You reported that the 737 NG-series airplane is no longer in production for commercial operations; however, because it is still produced as the baseline airplane for modification into the P-8 Poseidon for military operations, you are working with Boeing to determine if the redesigned fan cowl structure is appropriate for these baseline airplanes. Pending our review of your determination and the notice of proposed rulemaking ADs, Safety Recommendations A-19-17 through -19 remain classified OPEN-- ACCEPTABLE RESPONSE.

April 2, 2021 · Recipient Response · FAA

-From Steve Dickson, Administrator: The Federal Aviation Administration (FAA) will issue three separate airworthiness directives (AD) to address mandating corrective actions for the modifications of the inlet, fan cowl, and exhaust nozzle. Safety Recommendations A-19-17 through A-19-19 are specific to the redesign and retrofit of the fan cowl structure for the Boeing 737 next-generation series (NG) airplanes.

The FAA is working with Boeing to ensure that the design changes will address the most critical fan blade impact locations for each area of structure. Boeing will release three service bulletins (SB) with modification instructions for each area. The SBs for the inlet and fan cowl have an anticipated release date of July 2021. We are working with Boeing on a schedule for the SB on the exhaust nozzle. As they publish the SBs, the FAA will release a notice of proposed rulemaking AD to mandate each corrective action.

The FAA worked with Boeing on a cross model qualitative safety assessment that included all Boeing commercial airplanes with a similar design. Based on the assessment, the 737NG is the only affected fleet.

The 737NG is no longer in production for commercial operations, but Boeing still produces it as the baseline airplane for modification into the P-8 Poseidon for military operations. We are working with Boeing to determine if the redesigned fan cowl structure is appropriate for installation in production on baseline airplanes that will be modified into P-8 airplanes.

July 6, 2020 · NTSB Correspondence · FAA

We note that you are working with Boeing to develop a design change that will address the most critical fan blade impact locations on 737 NG-series airplanes. We also note that you intend to require that all in-service and new production 737 NG-series airplanes incorporate the new design once it is available. Pending the completion of Boeing’s redesigned fan cowl structure, and issuance of requirements for the new design to be installed on new-production and in-service 737 NG-series airplanes, Safety Recommendations A-19-17 through -19 are classified OPEN--ACCEPTABLE RESPONSE.

March 9, 2020 · Recipient Response · FAA

-From Steve Dickson, Administrator: The Federal Aviation Administration (FAA) is working with Boeing to determine the best course of action to mitigate the risk associated with this accident for the Boeing 737NG fleet. The FAA conducted an assessment of the risk associated with fan blade failures on Model 737 Next Generation (NG) airplanes using Transport Airplane Risk Assessment Methodology and determined that the fleet risk met FAA guidelines to issue an airworthiness directive (AD) to mandate corrective action in the form of a design change. The AD will apply to in-service Model 737 NG airplanes.

We are working with Boeing to ensure that the corrective action, in the form of a design change, will address the most critical fan blade impact locations. Upon completion, the design change will be incorporated into production of new aircraft.

December 12, 2019 · NTSB Correspondence · FAA

The attached letter from the NTSB Chairman provides information about the NTSB’s [Click HERE then type the report date.], report [Click HERE then type the Title of Report (in italics), City, State, Date of Accident, Report Number.]. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov.

The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, A-19-17 through -21). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response.

This letter provides information about the National Transportation Safety Board’s (NTSB) November 19, 2019, report Left Engine Failure and Subsequent Depressurization, Southwest Airlines Flight 1380, Boeing 737-7H4, N772SW, Philadelphia, Pennsylvania, April 17, 2018, NTSB/AAR-19/03. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov.

As a result of this investigation, we identified the following safety issues:

• Need to ensure the structural integrity of the fan cowl on Boeing 737 next generation series airplanes after a fan-blade-out event involving CFM56 7B engines. • Need to determine whether other airframe/engine combinations have any critical fan blade impact locations and how an impact at those locations could affect nacelle components. • Need to emphasize the importance of having flight attendants secured in a jumpseat during emergency landings. • Need to mitigate hazards to passengers affected by an in-flight loss of seating capacity.

Accordingly, the NTSB makes the following safety recommendations to the Federal Aviation Administration. Additional information regarding these recommendations can be found in the noted sections of the report.

• Require Boeing to determine the critical fan blade impact location(s) on the CFM56 7B engine fan case and redesign the fan cowl structure on all Boeing 737 next generation series airplanes to ensure the structural integrity of the fan cowl after a fan-blade-out event. (A-19-17) (See section 2.2.3.)

• Once the actions requested in Safety Recommendation A-19-17 are completed, require Boeing to install the redesigned fan cowl structure on new-production 737 next generation series airplanes. (A-19-18) (See section 2.2.3.)

• Once the actions requested in Safety Recommendation A-19-17 are completed, require operators of Boeing 737 next-generation-series airplanes to retrofit their airplanes with the redesigned fan cowl structure. (A-19-19) (See section 2.2.3)

• Expand the Title 14 Code of Federal Regulations Part 25 and 33 certification requirements to mandate that airplane and engine manufacturers work collaboratively to (1) analyze all critical fan blade impact locations for all engine operating conditions, the resulting fan blade fragmentation, and the effects of the fan-blade-out-generated loads on the nacelle structure and (2) develop a method to ensure that the analysis findings are fully accounted for in the design of the nacelle structure and its components. (A-19-20) (See section 2.2.3.)

• Develop and issue guidance on ways that air carriers can mitigate hazards to passengers affected by an in-flight loss of seating capacity. (A-19-21) (See section 2.5.)

The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, please e mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.