CHI02LA069

NTSB accident investigation · McDonnell Douglas DC-9-41 · Indianapolis, IN · January 24, 2002

Accident · Serious injuriesLimited investigationFinal report
Date
January 24, 2002, 14:00 local (19:00 UTC)
Place
Indianapolis, IN
Injuries
1 serious, 74 uninjured
Damage
No damage
Phase of flight
Standing
Aircraft
N754NWMcDonnell Douglas DC-9-41
Weather
Visual (VMC) · Day
Status
Completed · report August 28, 2002
Report
Approved by Office Director
Parties
FAA
FAA report
20020124001709A
Case key
54074

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The passenger fell off the side of the slide during the emergency evacuation. Factors were the emergency evacuation and the erratic ignition exciter.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

FireStanding - starting engine(s)
Ignition system,exciter - erraticFactor
Fluid,fuel - excessive flow/outputFactor
Emergency procedure - performedPilot in command
Evacuation - initiatedPilot in command
Miscellaneous/otherStanding - engine(s) not operating
MiscellaneousPassengerCause

Analysis

A passenger suffered a broken wrist when he fell off the side of the slide during an emergency evacuation. The airplane was positioned near the end of the runway with the engines shut down during an air traffic control delay. After approximately 15 minutes, the flightcrew was informed by ground control that they should start their engines, as they would probably be released for takeoff soon. The captain reported they were unable to start the right engine. They performed the "clearing procedure" and then went on to start the left engine with no problem. They then attempted to start the right engine again. Airport Rescue and Firefighting (ARFF) personnel were parked near the airplane reported to air traffic control that there were smoke and flames coming from the right engine. There were no fire warning indications in the cockpit. The flightcrew performed the ENGINE FIRE checklist and subsequently discharged both fire suppressant bottles into the engine. The flightcrew eventually shut down both engines and ARFF requested that the flightcrew begin evacuating the airplane. All of the passengers were directed to the front of the airplane and the evacuation took place using the 1L and 1R doors. A witness reported that the injured passenger stepped out of the airplane onto the slide. The passenger bounced down the slide and went over the side of the slide approximately four to five feet above the ground. The investigation revealed the engine start fuel scheduling for the Fuel Control Unit was high. In addition, the ignition exciter box and igniter plugs were tested. The ignition exciter box was found to operate intermittently on the D.C. circuit which would be used for engine start.

Factual narrative

On January 24, 2002, at 1400 eastern standard time, a McDonnell Douglas DC-9-41, N754NW, operated by Northwest Airlines as flight 1118, experienced a number 2 (right) engine tail pipe fire during engine start while on the ramp near the end of runway 32 at the Indianapolis International Airport, Indianapolis, Indiana. An emergency evacuation was performed during which one passenger received a broken arm. The 2 cockpit crewmembers, 3 flight attendants, and 69 other passengers were not injured. The scheduled domestic flight was operating under 14 CFR Part 121. Visual meteorological conditions prevailed and an IFR flight plan was filed. The scheduled destination for the flight was Detroit, Michigan.

According to the captain, the airplane was pushed back from the gate when they attempted to start the engines. He reported they attempted to start the right engine and they were unable to get it to start. The captain reported they performed the "clearing procedure" then went on to start the left engine, which started successfully. The crew then attempted to start the right engine again, and this time it started successfully. They then proceeded to taxi to runway 32 where they were informed of a 20-minute air traffic control (ATC) delay. The flightcrew shut down the engines during the delay.

After approximately 15 minutes, NW1118 was informed by ground control that they should start their engines, as they would probably be released for takeoff soon.

The captain reported they attempted to start the right engine and again could not get it started. They performed the "clearing procedure" and then went on to start the left engine with no problem. They then attempted to start the right engine again. The captain reported "Ground reported smoke then a few seconds later fire on right engine. We performed the ENGINE FIRE checklist discharging bottle number 2. Soon ground said there was still fire; we discharged number 1 and performed emergency evacuation." The captain reported that they did not receive any fire warning indications in the cockpit.

The investigation revealed Airport Rescue and Firefighting (ARFF) personnel were parked near NW 1118. It was ARFF personnel who first reported the smoke and flames coming from the number 2 engine. ARFF personnel began relaying information to the airplane through ATC. Upon seeing the smoke and fire, ARFF requested that the pilot shut down the engine. The flight crew informed ARFF that they performed the engine fire checklist and discharged one of the fire suppressant bottles. ARFF reported that the smoke was continuing to come from the engine. The flightcrew shut down the left (number 1) engine and ARFF informed the flightcrew that there was a tug coming out to tow the airplane back to the hangar. ARFF then reported that flames were still visible in the number 2 engine and they were going to apply fire-fighting agent to the engine. They requested that the flightcrew begin evacuating the airplane. The flightcrew initiated an evacuation. All of the passengers were directed to the front of the airplane and the evacuation took place using the 1L and 1R doors.

One passenger, who exited the 1R door, received a broken wrist during the evacuation. This passenger reported, "A flight attendant motioned to me to leave by the galley door by pointing with his finger. I crouched down as best I could and sat on the slide. The next memory I had was laying face down on the tarmac, in pain, wondering how I got there. My first instinct was to stand up and walk to the other passengers. A firefighter stopped me and said that I fell from a further distance than I thought I did and that I shouldn't move until I got checked out." At witness reported that the passenger stepped out onto the slide during the evacuation. The passenger bounced down the slide and fell over the side when approximatley four to five feet off the ground.

The investigation revealed the engine start fuel scheduling for the Fuel Control Unit was high. In addition, the ignition exciter box and igniter plugs were tested. The ignition exciter box was found to operate intermittently on the D.C. circuit which would be used for engine start.

Aircraft

Registration
N754NW
Reported as
McDonnell Douglas DC-9-41
Category
Airplane
Serial number
47178-323
Airframe hours
76,188
Engine
Pratt & Whitney JT8D-11, 15,000 lbs thrust, turbo jet
Damage
No damage
Fire
On-Ground
Flight
Part 121
Registered owner
Northwest Airlines, Inc.
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · September 1, 2001
Departed
IND · Indianapolis, IN
Destination
DTW · Detroit, MI
Flight plan
IFR
Airport
IND · Indianapolis International

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
44
Injuries
None
Certificates
Airline transport, Flight engineer
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
12,204 total · 2,417 in this make and model · 3,417 as pilot in command · 52 in the last 30 days · 3 in the last 24 hours
Role
Co-pilot
Age
35
Injuries
None
Certificates
Flight instructor, Flight engineer, Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Right
Flight hours
5,016 total · 2,516 in this make and model · 127 in the last 90 days · 58 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 15 knots
Visibility
10 statute miles
Lowest ceiling
1,900 ft overcast
Temperature
37 °F, dew point 30 °F
Altimeter
30.00 inHg
Observed at
IND

Docket · 6

The files NTSB released with the investigation on August 9, 2002, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.