# NTSB CHI93IA124: Aerospatiale ATR-42-300, N426TE, Moline, IL, March 31, 1993

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: March 31, 1993, 13:00 local (19:00 UTC)
- Place: Moline, IL
- Coordinates: 41.479244, -90.480216 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=41.4792&lon=-90.4802&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 21 uninjured
- Status: Completed, report August 26, 1994
- Report: Approved by Office Director
- NTSB case key (mKey): 15596
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI93IA124
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15596/pdf
- Page: https://openairdocs.org/ntsb/CHI93IA124

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Fire, cruise
  - misc eqpt/furnishings,lavatories - fire (cause)
  - procedures/directives - disregarded, passenger (cause)
  - fire warning system,lavatory - inoperative (contributing factor)
  - maintenance,aaip/progressive program - inadequate, manufacturer (contributing factor)
  - inadequate substantiation process,insuff review, faa(organization) (contributing 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 (not matched to a registry record)
- Reported make and model: AEROSPATIALE ATR-42-300 (ATR 42-300)
- Category: Airplane
- Serial number: 228
- Engines: P&W PW-120 1800 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.

- Pilot; age 36; 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

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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