Aviation Accident Summaries

Aviation Accident Summary LAX03IA137

Oakland, CA, USA

Aircraft #1

N676FE

Airbus Industrie A300F4-605R

Analysis

During climb out, the fight crew declared an emergency due to smoke in the cockpit and returned to the departure airport for a normal landing, after which the emergency evacuation slides failed to inflate. The flight crew said that they smelled an acrid smoke followed immediately by the illumination of the MAIN DECK CARGO FIRE light and the audio tone (bell). They conducted the emergency procedures, declared an emergency, and turned back for landing. On the downwind leg the MAIN DECK CARGO FIRE light went out; however, on final approach, the MID 2 LOOPS A and B illuminated. After landing the flight crew attempted to evacuate via the 1R emergency slide; however, it did not inflate. The first officer said that he was able to open the door, and that they made several unsuccessful attempts to manually inflate the slide without success. Post incident examination found that the slides' inflation bottle was fully pressurized. Two maintenance personnel noted that the transport-locking pin was with the slide when it was removed from the airplane. The slide was disassembled for inspection at the manufacturer's facility. No discrepancies were found that would have prevented the slide from inflating. Damage was found to the slide's girt bar in the area of the manual inflation handle that was consistent with the transport-locking pin being installed in the inflation bottle's regulator at the time of the slide's deployment. The cause of the smoke was determined to be oil or other fluid contamination of the air-condition packs.

Factual Information

On April 10, 2003, at 1350 Pacific daylight time, an Airbus A300F4-605R, N676FE, declared an emergency due to smoke in the cockpit during the takeoff climb out from the Metropolitan Oakland International Airport (OAK), Oakland, California. Federal Express (FedEx) operated the nonscheduled domestic cargo airplane under the provisions of 14 CFR Part 121. The airplane was not damaged. The two airline transport certificated pilots were not injured. Visual meteorological conditions prevailed for the cross-country flight, and an instrument flight rules (IFR) flight plan had been filed. The flight departed Oakland at 1330, with a scheduled destination of Denver International Airport (DEN), Denver, Colorado. In the captain's written statement he indicated that during climb out he and the first officer smelled an acrid smoke followed immediately by the illumination of the MAIN DECK CARGO FIRE light, as well as the audio tone (bell). They conducted the emergency procedures, declared an emergency, and turned back to land at Oakland. While on the downwind leg, the MAIN DECK CARGO FIRE light went out. However, on final, the MID 2 LOOPS A and B illuminated. The captain stated that after landing, the flight crew accomplished the GROUND EMERGENCY EVACUATION procedures. He indicated that the 1R door slide did not inflate automatically or manually. In the first officer's written statement he indicated that during the evacuation he opened the 1R door. The door opened and the evacuation slide partially deployed; however, it did not inflate. The captain made several unsuccessful attempts to inflate the slide with the manual inflation handle. The first officer further stated that he and maintenance personnel checked the door during the preflight at Oakland. FedEx attributed the smoke to oil and another fluid, possibly glycol, contaminating the air-conditioning packs. Maintenance personnel found the number 1 and 2 water coalescer separator bags covered in a dark fluid. They replaced the APU load compressor, along with the two water coalescer separator bags. They completed a ground run of the airplane with no discrepancies noted. According to a maintenance person who arrived with a pay mover to move the airplane back to the FedEx facility, when he arrived on-scene he saw that the emergency slide had been deployed and was hanging against the fuselage from its girt bar, and was deflated. He went inside the airplane and a crewmember pointed, with a flashlight, where smoke had been. He observed a "white smoke low to the floor three quarters down the fuselage, smoke was minimal and motionless, [he] did not observe any smell of smoke." FedEx employees took several pictures of the incident slide after it had been removed from the airplane and placed into a maintenance vehicle. The pictures indicated that the slide's inflation bottle was still fully pressurized and that internal components from the inflation bottle's regulator had been removed. A Safety Board investigator interviewed numerous maintenance employees who had contact with the slide. Two of the employees recalled seeing the transport-locking pin (with a red streamer) with the incident slide on the back of the maintenance truck. The incident slide was torn down at the manufacturer's facility, and they noted no discrepancies that would have prevented the slide's inflation during the evacuation. According to the manufacturer, damage to the slide's girt in the area of the manual inflation handle was consistent with the transport locking pin being installed in the inflation bottle's regulator at the time of the slide's deployment.

Probable Cause and Findings

the failure of the 1R evacuation slide to inflate because the transport-locking pin had not been removed from the regulator during the slide's installation on the 1R door. The cause of the cabin/cockpit smoke was contamination of the air conditioning packs.

 

Source: NTSB Aviation Accident Database

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