TECHNICAL REVIEW OF FLUORESCENT

PENETRANT INSPECTION PROCESS

CONDUCTED BY THE FEDERAL AVIATION ADMINISTRATION
The Airport and Aircraft Safety Research and Development Division (AAR-400)
JULY 14, 2000
This is a publicly available report extracted from the Summary Report,
Technical Review of Penetrant Inspection Process, dated March 28, 1998.

TABLE OF CONTENTS
I. Executive Summary
II. Background Summary
III. Discussion
A. Qualification of Personnel
B. Cleaning and Handling
C. Fluorescent Penetrant Inspection (FPI) Process
IV. Conclusions
V. Recommendations

I. EXECUTIVE SUMMARY
The Manager, Engine & Propeller Directorate, formed a Fluorescent Penetrant
Inspection (FPI) Process Technical Review Team on August 6, 1996, to review
the FPI process and operations at Delta Air Lines, Inc. Subsequent to that
review, the Manager, Engine & Propeller Directorate, reformed the Team on
September 12, 1996, to examine six additional facilities which perform FPI of
high energy rotating engine components. This Team was chartered to review,
evaluate, and provide recommendations to the Engine & Propeller Directorate.
This Team was tasked with evaluating the six FPI facilities to determine whether
systemic problems exist in the available FPI guidance material or its
implementation, and recommend corrective actions as necessary. The Team
utilized the same procedures and perspectives developed and implemented
during the review of Delta Air Lines, Inc.
The on-site facility review core Team generally consisted of the Chief Scientist
& Technical Advisor, Nondestructive Evaluation, an Aerospace Engineer from
the Engine Certification Office, Aircraft Certification Service, and an Aviation
Safety Inspector from the Boston Aircraft Evaluation Group, Flight Standards
Service. Additionally, each on-site visit was enhanced through the addition of
Aviation Safety Inspectors from the Flight Standards Service with specific
facility oversight responsibility.
The Team concentrated on the following three major areas during all on-site
visits:
1. Qualification of Personnel
2. Cleaning and Handling
3. FPI Process
This report summarizes the results of the seven FPI reviews.

The facilities responded positively to the observations and recommendations

made by the Review Team and implemented the necessary changes. Each
cognizant Flight Standards Office through its own follow-on action has provided
a report documenting the final corrective actions taken by the facilities.

II. BACKGROUND SUMMARY

On July 6, 1996, Delta Air Lines, Inc., Flight No. 1288, a McDonnell Douglas
MD-88 Aircraft experienced an uncontained failure of the No. 1 engine front
compressor front hub (fan hub) during takeoff at the Pensacola Regional Airport,
Pensacola, Florida. The aircraft was equipped with two Pratt & Whitney JT8D219 engines.
An investigation revealed that during the takeoff the fan hub separated into two
sections approximately 120 and 240 degrees of the circumference with fan
and/or engine debris penetrating the aft cabin area, resulting in two fatalities and
one serious injury. The fractured fan hub, Part Number 5000501-01, Serial
Number R32971, was last inspected in December 1995, after accumulating
12,693 flight cycles. The fan hub failed at 13,835 cycles (1,142 cycles since last
inspection). The published life limit of this fan hub is currently 20,000 cycles.
The investigation also revealed the fan hub failure resulted from a fatigue crack
that originated in a tie bolt hole. The fatigue crack initiated from mechanical
surface damage produced during the machining of the tie bolt holes at
manufacture, and propagated in a low cycle fatigue mode due to normal engine
start-stop cycles. The manufacturing records indicated that a surface anomaly
was observed in a tie bolt hole during a Blue Etch Anodize inspection. The
anomaly was dispositioned to be acceptable by the inspection standards in effect
at that time.
The National Transportation Safety Board (NTSB) performed a metallurgical
examination. Results suggest a 1.36 inch crack in total surface length was
present at the last Fluorescent Penetrant Inspection (FPI). The crack extended
0.46 inches on the aft end face of the hub and continued along the wall of a tie
bolt hole approximately 0.9 inches. Published reliability data from the
Nondestructive Testing Information Analysis Center indicates that a crack of this
size should be detectable with a probability of detection and confidence level
both exceeding 95 percent.
On July 29, 1996, the NTSB issued Safety Recommendation A-96-77 which
recommended the Federal Aviation Administration (FAA) review and revise, in
conjunction with the engine manufacturer and air carriers, the procedures,
training that includes the syllabi and visual aids, and supervision provided to
inspectors for performing FPI and other nondestructive testing of high energy
rotating engine components, with particular emphasis on the JT8D-200 series tie
rod and stress redistribution holes.
The Manager, Engine & Propeller Directorate, formed a FPI Process Technical
Review Team on August 6, 1996, to review the FPI process and operations at
Delta Air Lines, Inc., in support of the failure investigation.

In an effort to determine whether systemic problems exist in the available FPI

guidance material or its implementation, and to develop corrective actions as
necessary, the Manager, Engine & Propeller Directorate, reformed the FPI
Process Technical Review Team on September 12, 1996, to examine six
additional facilities which perform FPI of high energy rotating engine
components and to provide their observations and recommendations to the
Engine & Propeller Directorate.

III. DISCUSSION
The Fluorescent Penetrant Inspection Technical Review Team (for the purpose
of this report, the term "Team" will be used) concentrated on the following three
major areas during each FPI facility review:
1. Qualification of Personnel
2. Cleaning and Handling
3. FPI Process
The Team completed a total of seven individual FPI reports based on these
reviews, which contain the observations and recommendations in the three major
areas noted above. This report is a compilation of all seven reports, providing
the Teams' overall conclusions and recommendations to the Manager, Engine &
Propeller Directorate. The Team was not specifically tasked to document
positive observations, therefore, the reports address observed deficiencies only.
The FAA's intent was to sample FPI facilities that process a large quantity of
critical rotating engine components. The types of facilities sampled included
major air carrier maintenance, engine manufacturer repair, and independent
repair facilities. The distribution for the seven facilities sampled is shown in
Figure 1.

Fig 1: Distribution of FPI Facilities

A total of 157 observations were documented by Team members during the

seven FPI on-site facility reviews. Figure 2 provides the distribution of the
Teams' observations for the three major review areas.

Fig 2: Major Review Areas

This report addresses the three major review areas in Figure 2, and cites the
Team's objective and the outcome of the reviews. All observations in each major
review area have been condensed into sub-elements to promote a clearer
understanding of the observed deficiencies.
A. Qualification of Personnel
Objective: Inspections are performed by qualified personnel.
A total of 44 Team observations were made in the area of inspector qualification.
The Qualification of Personnel review focused on a comparison between the
guidance material used by the facility and the industry guidance. The Team
determined whether the facility was following their own guidance. Those
observations have been condensed into the following four generic areas:
Documentation/Manuals, Certification/Recurrent Training, Tracking Systems,
and an area called Other, as shown in Figure 3.
The FPI inspectors overall, appeared to be responsible individuals who are
motivated to do a good job. At some of facilities this was evident in spite of poor
organizational oversight of the inspection operation. In most of the facilities,
formal recurrent training did not exist. This was evident by non-compliance to
procedures, poor documentation and in some cases not having the appropriate
qualification requirements to accomplish work assignments.
Documentation/Manuals: In parallel with training and certification, is the need
to document the results for historical purposes and provide evidence of
compliance to the procedures. Several observations were made where the
procedures or manuals were not revised to the latest standards, or were in need
of revision to clarify the intent of the instructions provided.

Fig 3: Qualification of Personnel

Certification/Recurrent Training: These observations ranged from nonperformance of required certifications or recurrent training of inspection
personnel, to the facility not having the appropriate certification requirements.
Several instances of non-compliance to the recurrent visual testing was of
particular concern to the Team.
Tracking Systems: The observations made in this category clearly indicated a
need to revise or implement tracking systems. This would provide proper
monitoring of inspector qualifications and provide a mechanism for identifying
when recurrent training is required.
Other: This category captures all remaining observations, and has the third
largest number of observations. These observations range from the need to
establish and perform audits of training systems, to revising the forms used for
record keeping.
The inspector's practical experience is to find numerous indications in the items
he/she inspects. In some cases, indication finds are daily. However, the bulk of
those indications found are not on critical rotating components. Indication finds
on critical rotating components are very rare. Since FPI lines do not discriminate
between critical and non-critical components, the inspection practices
established by inspectors will not either. Less than optimal inspection techniques
may be adequate in finding indications on non-critical components, but will give
the inspector a false sense of expectation in finding indications on critical
rotating components. The importance of training, certification and currency
through recurrent training in a timely manner can only be emphasized. A general
response by inspector's when it's pointed out that he/she is using less than
optimal techniques is "I'm still finding cracks". The concern is, are we missing
any cracks?
B. Cleaning and Handling
Objective: Components have been properly handled and cleaned for inspection.
A total of 59 observations were made in the area of Cleaning and Handling. The
cleaning review focused on a comparison between the guidance material used by
the facility and the industry guidance. The Team determined whether the facility

was following its own guidance material. The facility was also evaluated on
what was considered to be good practice. The cleaning observations have been
condensed into the following five generic areas: Process/Procedure, Calibration,
Oils, Media Blast and Other as shown in Figure 4.

Fig 4: Cleaning

Process/Procedure: These observations ranged from non-compliance with

requirements, to the need for revising and updating manuals and processes to
ensure that cleaning methods have been substantiated by approved data. Several
observations of current cleaning practices led to the Team's recommendation to
discontinue the practice until the process could adequately be accomplished.
Calibration: The Team noted several observations where the review of standard
practices was required to ensure that the operating pressures and temperatures
were correct, and the need to revise the manuals to include specific operation
procedures for gauges. The Team recommended the use of electric timers as a
reasonable expected practice in place of personal wrist watches or wall clocks.
Oils: Several observations on the inappropriate use of penetrating oils for engine
disassembly were noted. In some cases, penetrating oils were used which were
not on an approved list. Penetrating oils should be used sparingly to prevent the
possibility of residual oil remaining in a crack if not cleaned properly.
Media Blast: The majority of Team observations were on the use of media blast
cleaning processes. The facilities were required to review the recommended
media blast guidance material to ensure the use of proper types of media, and to
set operating pressures to the recommended levels. Other: These observations
were applicable to the implementation of qualified personnel to perform
cleaning processes, and the use of placards on tanks for identification of
temperature ranges and contents.
C. Fluorescent Penetrant Inspection (FPI) Process

Objective: Perform inspections that detect cracks.

A total of 54 observations were made in the area of FPI Process. The FPI
Process review focused on a comparison between the guidance material used by
the facility and the industry guidance. The Team determined whether the facility
was following its own guidance material. The facility was also evaluated on
what was considered good practice. The FPI Process observations have been
condensed into the following four generic areas: Procedures, Handling, TAM
Panels (an FPI verification tool), and Other as shown in Figure 5.

Fig 5: Fluorescent Penetrant Inspection Process

Procedures: These observations ranged from non-compliance with requirements,

to the need for revising and updating manuals and processes. In some cases,
improvement and clarification of guidance material was needed to bring the
guidance material up to their most current versions. Of particular concern was
the guidance material for the use and maintenance of TAM panels.
Handling: The noted observations were to review shop practices, and to revise
and implement shop practices to preclude metal-to-metal contact between the
part and handling fixtures.
TAM Panels: Several observations were relative to the improper use of TAM
panels. The Team recommended FPI personnel receive refresher training in the
use of TAM panels. Of concern was the disconnect in the cleaning, storage, and
the overall process for the use of TAM panels.
Other: These observations were relative to training in the handling, processing,
and process control parameters of the FPI process. This included the use of
timers, labeling of tanks, and use of fixtures.

IV. CONCLUSIONS
Based on the review and evaluation of the observations documented in the
individual facility reports, the following conclusions concerning Qualification of
Personnel, Cleaning and Handling, and the FPI Process are applicable to more
than one of the facilities, if not most. They should not be interpreted as
comments directed solely at one individual facility.

General:
The observations documented in this report indicate poor quality assurance
practices at most of the reviewed FPI facilities. Extensive changes in the areas
addressed by the Team have occurred at a number of the facilities following the
Team's review.
Qualification of Personnel
The certification and recurrent training of inspection personnel were either
poorly structured or practically non-existent. The documentation and tracking of
inspector qualification and training was incomplete. Tracking systems lacked the
capability of providing notification when inspector recurrent training was
required. Procedures and manuals were not revised to the latest standards, or
were in need of revision to clarify the intent of the instructions. Missing from the
qualification of FPI personnel was experience and validation of performance on
actual engine hardware with real indications.
Cleaning and Handling
There seemed to be a pervasive lack of concern on the part of Level III's and
managers of FPI organizations that items, before reaching the inspection area,
had been properly prepared for an inspection. The high rate of return of items
going back for cleaning was treated as a conflict issue between shops rather than
an indication of deficiencies in the cleaning process.
There was little sensitivity of the cleaning organizations as to the next
destination of the parts. The cleaners simply "cleaned". Parts going to the FPI
line were not treated any differently from those going to other destinations.
There was a lack of sensitivity to the issue that parts had to be clean enough for
inspection.
Unapproved penetrating oils were present, and utilized for engine disassembly in
most of the facilities. There was little concern on the part of FPI personnel
regarding penetrating oils and the negative impact they may have on the
adequacy of pre-cleaning.
FPI Process
There are acceptable procedures and guidance in place for qualified inspectors to
perform the FPI process. There was no single guidance document that was
utilized by the facilities visited. Each of the engine Original Equipment
Manufacturer's (OEM's) guidance is different. OEM guidance also differs from
the current guidance in place at some of the facilities. There was some relabeling of the procedure steps at the facilities. There were some facilities that
generated their own generic procedures because they processed more than one
OEM's engines. Improvements in the guidance materials should be made to
improve and clarify requirements, and bring procedures up to their latest
revision. A single, complete, easy to follow, stand-alone guidance document is

needed to ensure that proper utilization, consistent and uniform procedures, and
easily auditable instructions are achieved.
An observation applicable to most of the facilities was the improper use of TAM
panels in the areas of: interpretation of guidance material, maintenance and
cleaning procedures, and overall utilization.

V. RECOMMENDATIONS
The following recommendations are provided to the Engine & Propeller
Directorate, Aircraft Certification Service, for improvements in the FPI process.
Support the adoption of a single document for FPI process guidance and work
with the Engine Manufacturers, end users, and providers of FPI materials to
disseminate guidance information to all entities. A reasonable candidate for an
industry standard is SAE 2647A, soon to be superseded by SAE 2647B,
"Fluorescent Penetrant Inspection, Aircraft and Engine Component
Maintenance".
Conduct Research and Development Programs to:
1. Assist in the implementation and maintenance of best practices
for FPI for use by the aviation industry. Includes the performance
of engineering studies to evaluate the critical parameters in the
pre-cleaning and drying steps before the FPI process.
2. Generate and assist in the implementation of a generic
performance verification sample kit so that the air carriers and
repair stations can assess their capability relative to that
performance verification kit.
3. Evaluate the need for an universal FPI kit that would aid in
inspecting difficult areas (i.e., cavities in hardware), and develop
common tooling.
4. In cooperation with OEM's, provide FPI training materials for use
by the airlines and overhaul and repair organizations.
Conduct an FPI workshop for FPI inspectors and FAA Aviation Safety
Inspectors as a forum to discuss the observations and recommendations of this
review.
Communicate to the Flight Standards Service the need to assure that only
qualified personnel are engaged in the performance of FPI.
Support the implementation of documented training for cleaning personnel in
the practices and procedures they employ. Especially for those items which will
subsequently be inspected by FPI. For the performance of FPI, a number of
acceptable consensus industry/military guidance documents exist for the
qualification of personnel. Similar guidance for cleaning personnel does not
appear to be available. The Engine & Propeller Directorate should also support
the establishment of a guidance standard by an industry group such as ATA.

The Engine & Propeller Directorate should request from the OEM's, data that
supports their guidance on cleaning, plastic media blast, and drying of parts
prior to the FPI process; and the impact, if any, the above guidance material may
have on the adequate detectability of cracks in critical rotating components.