Lessons Learned

Technical Related Lessons:

Airports with identified bird hazards should effectively use the procedures in their bird hazard control programs in order to confirm that a runway is safe to begin operations. A runway that has been inactive for a substantial period of time must be determined to be clear of birds, prior to directing airplanes to use that runway. (Threat Category: Bird Hazards)

  • ONA Flight 032 was taking-off from runway 13R, a nonconforming runway, at the time of the accident. A nonconforming runway is one that is not being used as an active runway because of wind and noise considerations. The captain had requested runway 13R because of weight considerations. During the take-off roll, the captain saw a flock of birds that rose from the runway, separated, and then regrouped in front of the aircraft.

  • Prior to the accident, JFK International Airport had an existing bird reduction program that included carbide cannons, vehicles capable of transmitting tape recorded stress cries of birds, bird patrols with shotguns, and removal of bird attractants such as water ponds, vegetation, and rodent life. The NTSB concluded that at the time of the ONA Flight 032 accident, JFK airport did not effectively control the bird hazard at the airport with the established program, and had failed to conduct a "bird sweep" of the runway with an airport vehicle prior to permitting the ONA DC-10 to depart.

Foreseeable engine failures which result in significant engine imbalance should not result in uncontained engine failure. (Threat Category: Uncontained Engine Failure)

  • ONA Flight 032 had a massive uncontained engine failure as a result of foreign object ingestion. GEAE engine CF6-50 was certified to 14 CFR 33.13, which prohibited a design feature that would be hazardous or unreliable to the engine. Compliance was based on similarity with data from previous tests on the CF6-6. Testing for the CF6-6 included ingestion of birds per AC 33-1A and consideration of the engine's critical areas. Since this accident, the engine certification standards have been revised to incorporate additional requirements on foreign object ingestion and expected engine behavior. Expected fan damage, and resulting imbalance should not result in engine case rupture, and uncontained engine failure.

An uncontained engine failure during ground operation, which results in a rejected take-off and a fuel tank breech, poses an extreme fire hazard. (Threat Category: Uncontained Engine Failure)

  • As a root cause of this accident, the number 3 engine failed and caught fire. The uncontained engine failure combined with unrestricted fuel leakage from multiple sources, including the main fuel tank of the DC-10, led to post-accident ground fire and destruction of the airplane.

Common Theme Related Lessons:

Individual details of comprehensive safety programs need to be continuously reviewed, and shortcomings identified to mitigate potential vulnerabilities. (Common Theme: Flawed Assumptions)

  • The FAA was monitoring the bird problem at JFK and noticed that there were more bird strikes in early 1975 than in the same period in 1974. A series of meetings were held to discuss solutions. Even with the continuous evolution of the bird hazard control program at JFK, certain deficiencies allowed runway 13R to be declared active without proper bird clearing procedures being conducted.

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