# NTSB CHI93LA043: Boeing 727-232, N401DA, Chicago, IL, November 28, 1992

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: November 27, 1992, 20:39 local (Nov 28, 1992, 02:39 UTC)
- Place: Chicago, IL
- Location: 41.8500° N, 87.6501° W: Placed by OpenAirDocs: center of Chicago, IL, within about 9 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=41.8500&lon=-87.6501&mi=10
- Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping)
- Highest injury: Serious injuries
- Injuries: 1 serious, 5 minor, 118 uninjured
- Status: Completed, report October 15, 1993
- Report: Approved by Office Director
- Safety recommendations: Yes
- NTSB case key (mKey): 15631
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI93LA043
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15631/pdf
- Page: https://openairdocs.org/ntsb/CHI93LA043

## Probable cause

THE CAPTAIN'S INADEQUATE COORDINATION WITH THE GROUND AND FLIGHT CREW.  FACTORS RELATED TO THE ACCIDENT WERE: THE PASSENGER'S PERCEPTION THAT THE APU EXHAUST WAS A FIRE, WHICH RESULTED IN ACTION THAT INITIATED AN EVACUATION.

## Sequence of events

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

- Miscellaneous/other, standing - engine(s) not operating
  - powerplant - switched off
  - generator - inadvertent deactivation, pilot in command (contributing factor)
  - passenger compartment light(s) - disconnected
  - apu - selected, flight engineer
  - visual/aural perception, passenger (contributing factor)
  - evacuation - initiated, passenger (contributing factor)
  - crew/group coordination - inadequate, pilot in command (cause)

## Analysis

THE FLIGHT HAD ARRIVED AT THE JETWAY AND THE PASSENGERS WERE BEGINNING TO DEPLANE. BEFORE EXTERNAL GROUND POWER WAS SUPPLIED TO THE AIRPLANE, THE CAPT PREMATURELY SHUT DOWN THE NUMBER ONE ENGINE WHICH WAS SUPPLYING ELECTRICAL POWER TO THE CABIN. WHEN THE ENGINE WAS SHUT DOWN, THE MAIN CABIN LIGHTS WENT OUT, FOLLOWED IMMEDIATELY BY THE ILLUMINATION OF THE BATTERY-POWERED EMERGENCY FLOOR LIGHTS. THE FLIGHT ENGINEER ANNOUNCED TO THE CAPT THAT HE WAS STARTING THE AUXILIARY POWER UNIT (APU). AS HE STARTED THE APU, AN EXHAUST FLAME MOMENTARILY CAME OUT FROM THE APU EXHAUST PIPE LOCATED NEAR THE TOP OF THE RIGHT WING ROOT. SOME PASSENGERS YELLED 'FIRE' AND BEGAN AN UNCOMMANDED EVACUATION THROUGH THE OVERWING EXITS. CREW MEMBERS WERE ABLE TO STOP THE EVAUCATION, BUT NOT BEFORE SEVERAL PASSENGERS HAD JUMPED OFF THE WINGS AND INCURRED INJURIES.

## Aircraft

- Registration: [N401DA](https://openairdocs.org/deregistered/N401DA-2013-08-15), registration cancelled 2013-08-15, S/N 21145, built 1975 (OpenAirDocs)
- Reported make and model: BOEING 727-232
- Registry model: [Boeing 727-232](https://openairdocs.org/model/boeing-727-232) (registry code 1384082) (OpenAirDocs)
- Registry engine: [Pratt & Whitney JT8D-9 series](https://openairdocs.org/engine/pratt-whitney-jt8d-9-series) (registry code 52048, turbo-jet) (OpenAirDocs)
- Category: Airplane
- Serial number: 21145
- Engines: P&W JT8D 15500 lbs thrust turbo fan
- Damage: No damage
- Flight: Part 121
- Operator: Delta Airlines
- Registered owner: Delta Airlines
- Airworthiness certificate: Standard, Transport
- Last inspection: Continuous airworthiness, January 2, 2000
- Departed: MCO, ORLANDO, FL
- Destination: ORD
- Flight plan: IFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 59; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 19,998 total, 8,860 in this make and model, 106 in the last 90 days, 10 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Night/dark
- Wind: 220° at 7 knots
- Visibility: 8 statute miles
- Lowest ceiling: none
- Temperature: -0 °F, dew point -0 °F

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 19921127055899A](https://openairdocs.org/incident/19921127055899A), Nov 27, 1992: Boeing 727232, Chicago, IL. PIC shut down NR1 engine powering lights prior APU. Passengers saw exhaust flame on APU start. Panicked. Evacuated.

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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