Boeing 737 incident near Orlando, Florida, February 21, 2019
On February 21, 2019 at about 12:27 pm local time, a 2001 Boeing 737, registered N30401, was involved in an incident during initial climb near Orlando, Florida. It was flown under scheduled airline rules (Part 121). No one was hurt; 181 people were on board or involved. The weather was conditions the NTSB did not record.
The NTSB's probable cause their words, unchanged
A No. 1 (left) engine high pressure compressor stage 2 blade separation. The blade separated due to a mixed-mode fatigue crack that originated on a blade disk post and was initiated by a misaligned (out-of-schedule) high pressure compressor stage 1 variable stator vane that was missing a washer and retaining nut on the vane trunnion stem.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- February 21, 2019 · about 12:27 pm local time
- Place
- Orlando, Florida · map
- Type
- Incident
- Injuries
- No one was hurt; 181 people were on board or involved.
- Weather
- conditions the NTSB did not record
- Aircraft
- Boeing 737 924, built 2001 · all 737s on the register
- Registration
- N30401 · registry record · serial 30118
- Damage
- Not recorded
- Flight
- Flight · scheduled airline rules (Part 121)
The NTSB's narrative final · quoted from the NTSB record
The No. 2 engine high pressure compressor (HPC) failure was caused by a stage 2 blade separation. A HPC stage 1 variable stator vane (VSV) trunnion stem, identified as VSV #33, was missing a washer and retaining nut that allowed VSV #33 to rotate independent of the other vanes in the stage. The out-of-schedule VSV created a 1 per revolution pulse on the HPC stage 2 rotor that eventually created fatigue cracks on the HPC stage 2 blade posts that secure the rotor blades in the disk spool. When one of the fatigue cracks transitioned to overload, a section of a blade post separated and allowed a blade to enter the gas path. Titanium fragments created by secondary impact damage as a result of the separated blade were caught between the rotating blade tips of the stage 1 blades and the steel HPC cases. The contact created a brief but intense titanium fire that melted the HPC case material around the HPC stage 1 rotor plane of rotation. The damage observed both immediately upstream of the separated HPC stage 2 blade and through all remaining stages aft was secondary impact damage. The GE Aviation Materials Laboratory performed a binocular analysis on the HPC VSV #33 trunnion stem and D-head and found wear patterns and witness marks that confirmed that a washer and retaining nut were present at some point. According to engine maintenance records, the last time the HPC VSVs were removed was during an engine overhaul at the GE Aviation- Celma maintenance, repair, and overhaul (MRO) facility, Petrópolis, Brazil in July 2014. When the HPC was assembled during the engine overhaul, the VSV #33 washer and retaining nut were likely either omitted or improperly torqued, which may have allowed the retention nut to back off during engine operation.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record from the NTSB's investigation tables, in plain English
What happened, in order
- Powerplant sys/comp malf/fail during initial climb defining event
- Engine shutdown during initial climb
The NTSB's findings
- cause Aircraft › Aircraft power plant › Engine (turbine/turboprop) › Compressor section › Failure
- factor Aircraft › Aircraft power plant › Engine (turbine/turboprop) › Compressor section › Incorrect service/maintenance
The aircraft
- Maximum gross weight: 174,198 lb
- Landing gear: retractable
- Engine 1: Cfm Intl. CFM56 SERIES (turbofan); 0 hours total
- Engine 2: Cfm Intl. CFM56 SERIES (turbofan); 59,395 hours total
- Operator: United Air Lines INC
The flight
- Departed from: MCO Orlando FL
- Destination: IAH Houston TX
- Flight plan: IFR
- A second pilot was aboard
Weather at the time
- Light: dawn
- Temperature: 0°F (-18°C), dew point 0°F (-18°C)
- Observation at 12:27 pm from KMCO, 1 miles away
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Cabi | 4 | |||
| Flight crew | 2 | |||
| Passengers | 175 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
2 documents, released by the NTSB on April 15, 2020. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.
| # | Document | What it is | |
|---|---|---|---|
| 1 | Powerplants Group Chairman's Factual Report | PDF, 21 pages | View Download |
| 2 | Metallurgical Investigation Report- Ge Aviation | PDF, 136 pages | View Download |
The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.