Date: July 19, 1989 Type: McDonnell-Douglas DC-10-10 Registration: N1819U Operator: United Airlines Where: Sioux Gateway Airport, Iowa Report No. NTSB-AAR-90-06 Report Date: November 1, 1990 Pages: 126 Executive Summary: On July 19, 1989, at 1516, a DC-10-10, N1819U, operated by United Airlines as flight 232, experienced a catastrophic failure of the #2 tail-mounted engine during cruise flight. The separation, fragmentation, and forceful discharge of stage 1 fan rotor assembly parts from the #2 engine led to the loss of the three hydraulic systems that powered the airplane's flight controls. The flightcrew experienced severe difficulties controlling the airplane, which subsequently crashed during an attempted landing at Sioux Gateway Airport, Iowa. There were 285 passengers and 11 crewmembers onboard. One flight attendant and 110 passengers were fatally wounded. The National Transportation Safety Board determines that the probable cause of this accident was the inadequate consideration given to human factors limitations in the inspection and quality control procedures used by United Airlines' engine overhaul facility, which resulted in the failure to detect a fatigue crack originating from a previously undetected metallurgical defect located in a critical area of the stage 1 fan disk that was manufactured by General Electric Aircraft Engines. The subsequent catastrophic disintegration of the disk resulted in the liberation of debris in a pattern of distribution and with energy levels that exceeded the level of protection provided by design features of the hydraulic systems that operate the DC-10's flight controls. The safety issues raised in this report include: 1. General Electric Aircraft Engines' (GEAE) CF6-6 fan rotor assembly design, certification, manufacturing, and inspection. 2. United Airlines' maintenance and inspection of CF6-6 engine fan rotor assemblies. 3. DC-10 hydraulic flight control system design, certification and protection from uncontained engine debris. 4. Cabin safety, including infant restraint systems, and airport rescue and firefighting facilities. Recommendations concerning these issues were addressed to the Federal Aviation Administration, the Secretary of the Air Force, the Air Transport Association and the Aerospace Industries Association.