- Date
- November 18, 1996, 20:49 local (Nov 19, 1996, 01:49 UTC)
- Place
- Grand Rapids, MI
- Injuries
- 1 serious, 2 minor, 84 uninjured
- Damage
- No damage
- Phase of flight
- Enroute
- Aircraft
- N9038UBoeing 737-222
- Weather
- Visual (VMC) · Night/dark
- Status
- Completed · report April 15, 1999
- Report
- Approved by Office Director
- FAA report
- 19961118042169I
- Case key
- 10413
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
Probable cause
a passenger sustained a fractured ankle during an emergency evacuation for undetermined reasons.
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.
Analysis
The flight crew received a engine fire warning during an approach to land. The crew performed engine fire emergency procedures and a single engine landing was accomplished. After landing, it was reported that the smoke was coming out of the #2 engine and the Captain ordered an evacuation of the airplane. The exit door 1R slide deployed automatically when the door was opened. The slides for exit doors 1L and 2R did not automatically inflate. Both slides were inflated manually. A passenger exited out of the 1L door and fractured her ankle. According to one of the flight attendants, the passenger did not jump out the exit as directed, but rather sat down, and slid out. Another flight attendant could not rotate door handle on exit door 2L. With assistance from a passenger the door was opened at which time the escape slide inflated into the airplane blocking both of the aft exists. Investigation revealed the operator received approval for an alternate mean of compliance for AD 85-25-04 addressing 737-100, 200, and 300 escape slide modifications, testing and inspections.
Factual narrative
On November 18, 1996, at 2049 eastern standard time (est), a Boeing 737-222, N9038U, registered to United Air Lines, Inc., operated as flight 422, sustained no damage after the captain reported a fire warning on the number two engine and gave the order to evacuate the airplane at the Kent County International Airport, Grand Rapids, Michigan. There were no injuries to four crewmembers. One flight attendant (F/A) received a minor injury. A 79 year old passenger received a fractured ankle and another passenger twisted a knee. The remaining 80 passengers reported no injuries. Visual meteorological conditions prevailed at the time and an IFR flight plan was filed. The flight was a domestic passenger flight, operating under 14 CFR Part 121, from Chicago, Illinois, to Grand Rapids, Michigan.
The glareshield fire-warning light illuminated intermittently with an intermittent aural warning during descent into the Kent County International Airport. The Captain directed the First Officer to troubleshoot the fire warning system. The First Officer was able to stop the warning by pulling the number two fire-warning circuit breaker. The circuit breaker was then reset. The Captain subsequently requested priority handling by air traffic control and was assigned number two for the visual approach. While turning onto final approach, at approximately 1,500 feet, the number two engine fire warning illuminated. The Captain reported that all engine parameters appeared normal, and he directed the First Officer to accomplish the engine fire emergency procedure which included firing both fire bottles. The fire warning light remained illuminated throughout the approach and landing.
The Captain used the interphone to advise the F/A's that they would be making a single engine landing, that there was a possible fire in the number two engine, and they should standby for further instructions. Following the landing, the Captain cleared the runway, stopped the airplane on taxiway A4, and selected 40 degrees of flaps. The Captain contacted the air traffic control tower and asked if they could see smoke or flames coming from the number two engine. He was informed that they could not see anything unusual with the engine. The Captain then used the public address (PA) system and told everyone to "remain seated." Shortly thereafter, the Captain was advised that fire/rescue personnel reported smoke coming from the number two engine cowling. The Captain then used the PA system to issued the command to evacuate the airplane.
Upon hearing the command to "release seatbelts and get out", the F/A's initiated their evacuation procedures. F/A No.1 who was stationed in the front of the airplane opened the 1L door (front left side) and observed that the slide failed to inflate. She reported she then grabbed the manual inflation handle, but was unable to pull it hard enough for the slide to inflate. F/A No.1 stated she then went to the 1R door (front right side) and checked to make sure there was no fire on the right side of the airplane. Not seeing any fire, she opened the 1R door. The slide deployed normally and passengers proceeded to evacuate the airplane through the 1R door. After the First Officer completed the evacuation checklist and proceeded into the cabin, he observed the slide at door 1L was not deployed. He pulled the manual inflation handle twice in order to get the slide to deploy. He stated it felt as if it required approximately 80 pounds of force to activate the slide. F/A No.1 then began directing passengers out of both the 1L and 1R doors. She stated that the passenger who fractured her ankle exited the airplane out of the 1L door. She stated this passenger did not jump out the exit as directed, but rather sat down and slid out.
F/A No.2 was stationed near the 2L (left side rear) door. She stated that during the approach she picked up the interphone and heard the Captain state, "Prepare to evacuate, fire in engine number 2." She stated that both she and F/A No.3 jumped up from their seats and looked out their respective sides of the airplane for fire. They did not see any fire so they strapped back in their seats. She reported hearing the command to stay seated followed by the command to evacuate. F/A No.2 stated that upon hearing the evacuation command she turned on the emergency lights, and looked out her door (2L) to see if it was safe to evacuate out that door. She stated she was unable to move the door handle. She enlisted the assistance of a male passenger and with his help she was able to "crack" the door. She stated the door was opened approximately 45 degrees when she heard a "hissing" noise at which time she saw the slide inflating toward her. She instructed the assisting passenger to move forward and she stood behind the last row of seats as the slide inflated into the galley/cabin. She stated that with the slide inflated in the airplane, access to door 2R was blocked. She then instructed the passengers who were remaining in the airplane to go forward to evacuate. F/A No.2 stated she then went out the left overwing exit and not having anyone there to help her down, she went back into the airplane and exited through the 1R door.
F/A No.3 was located in the back of the airplane near door 2R (right side rear). She reported that during the approach, after they received the interphone call, both she and F/A No.2 both looked out their respective sides of the airplane because they were unsure which engine was the number two. She stated that after receiving the command to evacuate she rotated the handle on the 2R door and had to push hard about seven times on the door to get it to fully open. She said the slide did not automatically inflate after a couple of seconds so she pulled the manual inflation handle and the slide immediately inflated. She stated that about 5 to 8 passengers exited through the 2R door when she heard F/A No.2 shout "Slide! Slide!." She stated she turned around and saw the 2L slide coming at her at which time she exited out the 2R door. F/A No. 3 then went around to the left side of the airplane where she helped passengers off the left wing.
In addition to the door, both overwing exits were opened and utilized by passengers without Flight Attendant direction. The right hatch was found inside the airplane on the cabin floor in the exit aisle and the left hatch was found out on the left wing.
Aircraft information
The airplane was a Boeing 737-222, serial number 19076, N9038U. The airplane had accumulated 54,614 hours time in service at the time of the accident. The left engine had 53,613 hours total with 5,164 hours since its last overhaul. The right engine had 52,078 hours total with 318 hours since its last overhaul. The most recent inspection was conducted on May 24, 1996, 1,053 hours prior to the accident.
Flight recorders
United Airlines did not remove the cockpit voice recorder nor the flight data recorder after the accident. The slides were removed and replaced and the airplane was returned to service.
Tests and research
Inspection of the number 2 engine after the accident revealed a failed element in the lower fire warning detection loop. There was no evidence of a fire in the engine.
Inspection of the evacuation slides was accomplished on December 12th and 13th, 1997, at the United Airlines maintenance facility in San Francisco, California. The results of this inspection were as follows:
1L Evacuation Slide
The slide was equipped with the original style girt which contained stitched nylon webbing reinforcements. The force required to pull the uncharged regulator was about 25 pounds. The bottle cable (firing line) part number was marked on yellow heat shrink tape which was able to slide along the firing line. The tape was found against the cable ball at the regulator valve end. The tape appeared as if it had been scrunched up and a portion of
Aircraft
- Registration
- N9038U
- Reported as
- Boeing 737-222
- Category
- Airplane
- Serial number
- 19076
- Airframe hours
- 54,614
- Engine
- P&W JT8D-7B, 14,000 lbs thrust, turbo jet
- Damage
- No damage
- Flight
- Part 121
- Registered owner
- United Air Lines, Inc.
- Airworthiness certificate
- Standard, Transport
- Last inspection
- Continuous airworthiness · May 24, 1996 · 1,053 hours before
- Departed
- ORD · Chicago, IL
- Destination
- GRR · MI
- Flight plan
- IFR
- Airport
- GRR · Kent County International, runway 26L, 10,000 × 150 ft, asphalt
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
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 43
- Certificates
- Flight engineer, Airline transport
- Airplane ratings
- Single-engine land, Multi-engine land
- Instrument ratings
- Airplane
- Medical
- Class 1, Valid Medical--no waivers/lim.
- Seat
- Left
- Flight hours
- 7,473 total
Weather
- Conditions
- Visual (VMC) · Night/dark
- Wind
- Calm
- Visibility
- 10 statute miles
- Lowest ceiling
- None
- Temperature
- 32 °F, dew point 27 °F
- Altimeter
- 30.00 inHg
- Observed at
- GRR
FAA reports on this event · 1
The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.