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| Title: | Spurious engine fire warning, Boeing 727-276, XA-SIJ, April 3, 1995 |
| Micro summary: | Following a a spurious engine fire warning on climb, this Boeing 727 returned to the origin for an evacuation. |
| Event Time: | 1995-04-03 at 0949 CDT |
| File Name: | 1995-04-03-US.pdf |
| Publishing Agency: | National Transportation Safety Board (NTSB) |
| Publishing Country: | USA |
| Report number: | FTW95IA156 |
| Pages: | 6 |
| Site of event: | DFW |
| Departure: | Dallas-Fort Worth International Airport, Dallas & Fort Worth, Texas, USA |
| Destination: | Cozumel International Airport, Cozumel, Mexico |
| Airplane Type(s): | Boeing 727-276 |
| Flight Phase: | Climb |
| Registration(s): | XA-SIJ |
| Operator(s): | Aeromexico |
| Type of flight: | Revenue |
| Occupants: | 160 |
| Fatalities: | 0 |
| Serious Injuries: | 2 |
| Minor/Non-Injured: | 158 |
| Other Injuries: | 0 |
| Executive Summary: | On April 3, 1995, at 0949 central daylight time, a Boeing 727-276, Mexican Registration XA-SIJ, sustained minor damage and one passenger and one flight attendant received minor injuries during an emergency evacuation at Dallas/Fort Worth Airport (DFW), Texas. Seven crew members and 151passengers were not injured. The airplane, owned and operated by Aeroejecutivo, S.A. de C.V. as Aeroexo flight 749, departed DFW for Cozumel, Mexico, at 0920 CDT, on a Title 14 CFR Part 129 non-scheduled international flight. Visual meteorological conditions prevailed and an IFR flight plan was filed and in effect. During personal interviews, and on the enclosed statements, the crew reported the following information. After a normal takeoff from DFW, the aural and visual fire warnings for the number 1 (left) engine activated during climb through 17,100 feet MSL. Emergency checklist procedures, which included shutting down the number 1 engine, were completed. The fire warning light remained on, an emergency was declared, and the airplane returned to DFW for a one-engine-out landing. At the captain's command, the flight attendants prepared for an emergency evacuation and briefed the passengers. After landing on runway 31R, the captain stopped the airplane on high speed taxiway R1 and issued the evacuation command. During the investigation, the injured passenger was interviewed and requests for statements were made to a random selection of other passengers. A total of eight statements, including one from the injured passenger, were received. Seven of these eight passengers reported problems understanding the flight attendants. One passenger stated: "There were some communication problems because the English speaking ability of the crew was somewhat limited and essentially the entire passenger list were non-Spanish speaking Americans." Five of the eight passengers also reported being unaware of why the airplane was returning to DFW and the possibility of an emergency evacuation. None of the passengers reported encountering any difficulties during the evacuation. The one passenger who received injury reported "no problem getting to the exit" and that she "caught" her right leg "behind" her while going down the aft right (R2) slide. According to the crew, the estimated total time involved in the evacuation was less than 90 seconds. In accordance with the captain's instructions, the aft left (L2) exit was not used because of proximity to the suspected number 1 engine fire. Exits used in the evacuation were the forward left (L1), the aft right (R2), and the four overwing exits. One automatic (R2) and three manual slides were installed in the airplane. The forward right (R1) manual evacuation slide did not fully deploy, and this exit was unusable. The flight attendant stationed at the R1 door reported that she opened the door, and when the slide "did not activate", she "activated" it manually. She further reported that "half of the slide remained on board" inflating into the galley and "hurting" her, after which she pushed the slide out the door. A Federal Aviation Administration (FAA) inspector examined the airplane before it was moved from the site of the evacuation and reported the following information. Three of the overwing exit doors were found outside the aircraft, one on the right wing and two on the ground. All three were scratched and dented. The R1 slide "was found hanging out of the door in a folded position with the tear strips still attached." The slide girt bar was installed in the floor brackets. The slide compartment cover had separated from the backing pan and was found on the floor of the forward galley. Scratches were found on the right forward inner door handle and a corresponding dent was found in the slide compartment cover. The R1 slide, Aircrusier part number D29835-105, serial number 2238290, was examined at the Delta Airlines maintenance facility at DFW on April 4, 1995. The cover latch bracket had separated from the slide compartment cover and was found attached to the latch assembly. The latch assembly is designed to release the slide compartment cover at 15 degrees of door travel. The latch assembly was operated several times and released each time without any difficulty. The slide and the pressure cylinder valve were tested and no discrepancies which would have affected operation of the slide were found. Delta had overhauled the slide on March 31, 1995. Examination of the number 1 engine, a Pratt & Whitney JT8D-15, serial number 700545, revealed no physical evidence of fire. Fire detection system troubleshooting indicated a short in the engine sensing unit, Boeing part number 65-62404-6. According to Aeroejecutivo's Director of Operations, all crew members had received hands on emergency evacuation procedures training in November 1994. The written training records provided by the company (copies attached) show that, in November 1994, each flight attendant received initial B-727-100/200 flight attendant training consisting of 26 hours 30 minutes of classroom instruction and 3 hours 30 minutes of practical instruction. The topics in which practical instruction was provided were fire extinguishing and first aid. Examination of airplane documentation revealed the following discrepancies: 1. Company maintenance status reports indicated numerous AD notes and A, B, and C checks overdue. 2. Data in the weight and balance manual on board the airplane was not current. 3. The company produced several documents regarding their approved maintenance program, each of which contained different time periods for maintenance checks. 4. Passenger briefing cards were not consistent with airplane configuration. 5. Minimum Equipment List showed 4 life rafts "required for dispatch", and none were aboard the airplane. A complete discussion of the maintenance record review is contained in the attached maintenance records group chairman's report. The airplane was released to the operator. |
| Learning Keywords: | Operations - Evacuation |
| Operations - Language | |
| Systems - Engine Fire | |
| Other - Post-Crash Survivability | |
| Consequence - Flight Attendant Fatality - Injury |
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