CHI93IA124

NTSB incident investigation · Aerospatiale ATR-42-300 · Moline, IL · March 31, 1993

Incident · No injuriesIncident investigationFinal report
Date
March 31, 1993, 13:00 local (19:00 UTC)
Place
Moline, IL
Injuries
21 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N426TEAerospatiale ATR-42-300
Weather
Visual (VMC) · Day
Status
Completed · report August 26, 1994
Report
Approved by Office Director
Case key
15596

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

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Probable cause

The passenger's failure to extinguish a cigarette before placing it into the lavatory waste bin. Factors related to the incident were: an inoperative smoke detector in the lavatory, the manufacturer's inadequate maintenance program, and inadequate review of the maintenance program by the federal aviation administration.

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.

FireCruise
Misc eqpt/furnishings,lavatories - fireCause
Procedures/directives - disregardedPassengerCause
Fire warning system,lavatory - inoperativeFactor
Maintenance,aaip/progressive program - inadequateManufacturerFactor
Inadequate substantiation process,insuff reviewFaa(organization)Factor

Analysis

A passenger had discarded a cigarette before leaving the lavatory. The flight attendant found smoke issuing from the waste bin and extinguished the fire. There was no indication in the cockpit of smoke or fire. A later check of the smoke detector showed it did not activate when smoke was generated in the lavatory. The operator adhered to the aircraft manufacturer's recommended maintenance program; the program contained no procedure or interval for cleaning smoke detectors or ducting. There was no operational test which demostrated a detector could sense smoke.

Aircraft

Registration
N426TE
Reported as
Aerospatiale ATR-42-300 (ATR 42-300)
Category
Airplane
Serial number
228
Engine
P&W PW-120, 1,800 horsepower, turbo prop
Damage
No damage
Fire
In-Flight
Flight
Part 121
Operator
Trans States Airlines, doing business as Trans World Express
Registered owner
Mcdonnell -Douglas Finance Cor
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · April 3, 1993 · 21 hours before
Departed
STL · St. Louis, MO
Flight plan
IFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
36
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
9,500 total · 2,700 in this make and model · 7,800 as pilot in command · 242 in the last 90 days · 100 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 7 knots
Visibility
2 statute miles
Lowest ceiling
1,650 ft overcast
Temperature
59 °F, dew point 55 °F
Altimeter
29.00 inHg
Observed at
MLI, 70 nm away