FORT LAUDERDALE, FL, USA
N404KW
BOEING 737-400
DURING INITIAL TAKEOFF CLIMB THE FLIGHT CREW ENCOUNTERED SMOKE IN THE COCKPIT AND PASSENGER COMPARTMENT. THE PILOT-IN-COMMAND DECLARED AN EMERGENCY, RETURNED TO THE DEPARTURE AIRPORT, AND COMMANDED AN EMERGENCY EVACUATION OF PASSENGERS AND FLIGHT CREW. TWO AFT EMERGENCY SLIDES DID NOT DEPLOY. EXAMINATION OF THE AIRPLANE REVEALED THE SMOKE/FUMES ENTERED THE AIRPLANE THROUGH THE AIR CONDITIONING SYSTEM AS A RESULT OF A WASH SOLUTION REMAINING IN THE LEFT ENGINE LONGER THAN REQUIRED DURING AN ENGINE WASH. WHILE THE ENGINE WAS BEING WASHED ON THE DAY BEFORE THE ACCIDENT, THE STARTER FAILED AND THE SOLUTION REMAINED IN THE ENGINE MORE THAN THE REQUIRED 20 MINUTES WHILE THE STARTER WAS BEING CHANGED. EXAMINATION OF THE AFT EMERGENCY SLIDES REVEALED THE INSTALLATION SAFETY PINS WERE STILL INSTALLED.
On September 26, 1995, about 1648 eastern daylight time, a Boeing 737-400, N404KW, registered to International Lease, operated by Carnival Airlines, as a 14 CFR Part 121 scheduled domestic passenger flight, experienced smoke in the cockpit and passenger cabin area on initial takeoff climb from Fort Lauderdale-Hollywood International Airport. Visual meteorological conditions prevailed and an IFR flight plan was filed. The pilot- in-command declared an emergency and landed at the Fort Lauderdale-Hollywood Airport. An emergency evacuation was conducted down the forward emergency slides. The two rear emergency slides did not deploy. The airline transport pilot-in-command, first officer, 4 cabin attendants and 156 passengers were not injured. Three passengers reported minor injuries. The flight was originating at the time of the incident. Carnival Airlines Director of Quality Control, stated the airplane had an engine wash on September 25, 1995. During the engine wash on the No. 1 engine the starter failed. The wash solution remained in the engine longer than the required 20 minutes; waiting for the starter to be changed. Carnival Airlines engine wash procedures do not address component failure procedures during an engine wash. The fumes entered the cockpit and cabin area through the airplane air conditioning system. Review of the airplane records indicate the emergency slides were installed in Coopesa, Costa Rica on May 18, 1995, during a "C" phase inspection. Visual inspection of the emergency evacuation slides by Carnival Airlines maintenance personnel after the incident revealed the installation safety pins were still installed.
INADEQUATE WRITTEN MAINTENANCE PROCEDURES ADDRESSING STEPS TO BE FOLLOWED IN THE EVENT OF A COMPONENT FAILURE DURING AN ENGINE WASH. THE EMERGENCY SLIDES FAILED TO DEPLOY DUE TO IMPROPER INSTALLATION BY COMPANY MAINTENANCE PERSONNEL.
Source: NTSB Aviation Accident Database
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