DCA01MA005

NTSB accident investigation · Douglas DC-9 · Atlanta, GA · November 29, 2000

Accident · Minor injuriesMajor investigationFinal report
Date
November 29, 2000, 13:50 local (18:50 UTC)
Place
Atlanta, GA
Injuries
13 minor, 84 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N826ATDouglas DC-9
Weather
Day
Status
Completed · report May 8, 2003
Report
Approved by Office Director
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
20001129041599A
Case key
50698

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

the leakage of lavatory fluid from the airplane's forward lavatory onto electrical connectors, which caused shorting that led to a fire. Contributing to the accident were the inadequate servicing of the lavatory and the failure of maintenance to ensure reinstallation of the shield over the fuselage station 237 disconnect panel.

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.

Airframe/component/system failure/malfunctionClimb
Electrical system,electric wiring - arcingCause
FireLanding
Electrical system,electric wiring - burned
Fuselage,cabin - burned
Fuselage,cargo compartment - burned

Analysis

Shortly after takeoff, the airplane experienced electrical problems, including numerous tripped circuit breakers. The flight crew requested a return to airport. During the landing rollout, the lead flight attendant and air traffic control personnel reported to the flight crew that smoke was coming from the left side of the airplane; subsequently, the flight crew initiated an emergency evacuation on one of the taxiways. Examination of the airplane revealed fire damage to the left, forward areas of the fuselage, cabin, and forward cargo compartment. The greatest amount of fire damage was found just aft of the electrical disconnect panel located at fuselage station 237. There was no evidence that the drip shield normally installed over the disconnect panel was present at the time of the accident. Bluish stains caused by lavatory rinse fluid were observed on surfaces near the disconnect panel on the accident airplane and in the same areas on another of AirTran's DC-9 airplanes. Examination of one of the connectors from the disconnect panel on the accident airplane revealed light-blue and turquoise-green deposits on its internal surfaces and evidence of shorting between the connector pins. It could not be determined when the drip shield over the disconnect panel was removed; however, this likely contributed to the lavatory fluid contamination of the connectors. Following the accident, AirTran revised its lavatory servicing procedures to emphasize the importance of completely draining the waste tank to avoid overflows. Boeing issued an alert service bulletin recommending that operators of DC-9 airplanes visually inspect the connectors at the FS 237 disconnect panel for evidence of lavatory rinse fluid contamination and that they install a drip shield over the disconnect panel. Boeing also issued a service letter to operators to stress the importance of properly sealing floor panels and adhering to lavatory servicing procedures specified in its DC-9 Maintenance Manual. The Safety Board is aware of two incidents involving the military equivalent of the DC-9 that involved circumstances similar to the accident involving N826AT. Drip shields were installed above the FS 237 disconnect panels on both airplanes.

Factual narrative

History of flight

On November 29, 2000, about 1550 eastern standard time (all times in this brief are eastern standard time based on a 24-hour clock), the flight crew of a McDonnell Douglas (McDonnell Douglas is now known as Boeing, Douglas Product Division) DC-9-32, N826AT, operating as AirTran Airways flight 956, executed an emergency landing at Hartsfield Atlanta International Airport (ATL), Atlanta, Georgia. Shortly after takeoff, the flight crew observed that several circuit breakers had tripped and several annunciator panel lights had illuminated. Subsequently, about 2 minutes after takeoff, the flight crew requested a return to ATL. After the landing, one of the flight attendants reported to the flight crew that smoke could be seen emanating from the left sidewall in the forward cabin; air traffic control (ATC) personnel also notified the flight crew that smoke was coming from the airplane. The flight crew then initiated an emergency evacuation on one of the taxiways. Airport rescue and firefighting (ARFF) personnel assisted in subduing the fire. Of the 2 flight crewmembers, 3 flight attendants, and 92 passengers on board, 13 passengers received minor injuries. The airplane sustained substantial damage. Flight 956 was operating under 14 Code of Federal Regulations Part 121 as a regularly scheduled passenger flight from ATL to Akron-Canton Regional Airport, Akron, Ohio. Visual meteorological conditions prevailed at the time of the accident.

The captain was the pilot flying. About 1541, ATC cleared the flight for takeoff. At 1543:10, as the airplane was climbing through about 3,800 feet, the cockpit voice recorder (CVR) recorded popping sounds consistent with the sound of circuit breakers tripping, which continued for about 34 seconds. During postaccident interviews, both flight crewmembers stated that during this time, they noticed that several circuit breakers had tripped. The flight crew also noted that the MASTER CAUTION light, several annunciator panel lights, the left and right fuel pressure lights, and the radio rack fan OFF annunciator lights had illuminated. At 1543:28, the captain told the first officer to tell ATC that they wanted to level off at 4,000 feet and return to the airport because "right now we have electrical problems." The captain stated that he then glanced over his shoulder to check for smoke but did not observe any smoke at that time.

The ATL north departure controller instructed flight 956 to maintain 4,000 feet and asked whether the flight would need the ARFF equipment available upon landing; the first officer replied that they would need the equipment available. The captain stated that he selected emergency power, took the generators offline, and switched the cabin pressurization to manual to stop the circuit breakers from tripping. The captain stated that during the descent, the left?side attitude directional indicator failed intermittently. He stated that, specifically, the failure flags appeared and the instrument was "jumpy." Further, he stated that the cockpit lights were flickering and that he was afraid that all of the cockpit instruments would fail.

At 1544:47, flight data recorder data ceased, and, at 1544:51, there was an interruption of audio on all CVR channels. Intermittent CVR audio returned several minutes later and continued until 1549:11, at which time, the CVR recording ended (the airplane landed about 1 minute later). Signals from the airplane's radar transponder were also lost around 1544:51 but were regained briefly until they ended around the same time as the CVR recording ended.

At 1549:40, flight 956 was cleared to land on either runway 26L or 26R. The captain stated that there was no visible smoke or smell of smoke in the cockpit before landing. About 1550, the airplane landed on runway 26R. The captain stated that the landing and rollout were normal. During the airplane's exit from the runway onto taxiway B-3, the lead flight attendant opened the cockpit door and announced that there was smoke in the cabin. A short time later, the lead flight attendant again opened the cockpit door and reported that the amount of smoke in the cabin had increased and asked the captain if he wanted to evacuate.

The captain stated that he set the brakes and told the lead flight attendant that they would evacuate and that he would make an announcement to the passengers. However, the public address system had become inoperative, and the emergency evacuation commenced with the flight attendants making announcements to the passengers and directing the evacuation.

The captain stated that the first officer completed the emergency evacuation checklist and exited the airplane. The captain then donned protective breathing equipment and proceeded through the cabin looking for any incapacitated passengers. He reported that the visibility in the first?class cabin was about 1 to 2 feet. He stated that he proceeded to the rear of the airplane to check the lavatories, at which time, he found the No. 3 flight attendant leaving with the last passenger. He reported that after ensuring that everyone had exited the airplane, he exited through the right overwing exit to further assist with the evacuation.

Damage to airplane

Examination of the airplane revealed fire damage to the left forward areas of the fuselage and cargo compartment from fuselage stations (FS) 237 to 313 and damage to the cabin floor and sidewall. Fire damage was concentrated in an area just aft of the electrical disconnect panel located at FS 237, which is a junction panel for seven wire bundles. The fuselage exterior also exhibited heat discoloration in an area beneath the lavatory service panel located between FS 237 and 256 and a soot trail that extended aft from the radio rack vent, located just aft of the lavatory service panel. Soot was also present throughout the forward cargo compartment and on the cabin outflow valve near the rear of the airplane.

The floor structure and carpet of the passenger cabin exhibited fire damage from the left sidewall to the centerline of the airplane from FS 237 to 313. The seat tracks under seats 1A and 1C were buckled from heat exposure, the carpeting in front of seats 2A and 2C was burned and melted, and the floor in the aisle next to row 3 was spongy and buckled.

Further examination of the interior area between the forward cargo compartment and the fuselage revealed bluish stains, similar in color to lavatory rinse fluid (also known as blue water) on sidewall insulation blankets and components near FS 237. No drip shield, which was designed to protect the connectors at FS 237 from overhead fluid leakage, was installed over the FS 237 disconnect panel at the time of the accident, although the support brackets for the drip shield were in place. The drip shield was incorporated into the design of DC-9 series airplanes beginning with fuselage line number 271, which included N826AT. N826AT was delivered with the drip shield installed, but investigators could not determine why the shield was not in place at the time of the accident. Of the first 270 DC-9s manufactured, 80 included a forward lavatory.

The damaged wiring from the area around FS 237 was removed and sent to the Safety Board's materials laboratory for detailed examination. Beading was observed on the ends of many individual wires, which is consistent with heat damage from arcing. Each of the seven electrical connectors from the removed wire bundles was opened to determine the internal condition of the connector pins and grommet material. One connector exhibited more thermal damage than the other six and contained light-blue and turquoise-green crystalline deposits on the mating surfaces of its two sides and around nearly all of its pins. This connector also exhibited evidence of pin-to-pin shorts. Laboratory tests of the grommet material from this connector revealed elevated levels of sulfate (

Aircraft

Registration
N826AT
Reported as
Douglas DC-9
Category
Airplane
Serial number
47359
Airframe hours
78,255
Engine
Pratt & Whitney JT8D, turbo fan
Damage
Substantial damage
Fire
Both
Flight
Part 121
Operator
Airtran Airways Inc
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · November 29, 2000
Destination
Akron/Canton, OH
Flight plan
IFR
Airport
ATL · The William B Hartsfield Atlan, runway 26R

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
38
Injuries
None
Certificate
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
12,000 total · 6,000 in this make and model
Role
Co-pilot
Age
25
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Right
Flight hours
3,100 total · 0 in this make and model

Weather

Conditions
Day
Wind
270° at 7 knots
Visibility
4 statute miles
Lowest ceiling
2,700 ft broken
Temperature
52 °F, dew point 50 °F
Altimeter
30.13 inHg
Observed at
KATL

Docket · 42

The files NTSB released with the investigation on January 29, 2002, on NTSB’s docket system: statements, records, photos and specialists’ reports. 56.8 MB in all.

Operations 2 - Factual Report of Group ChairmanItem 1 · .PDF · 670 KBOperations 2 - Attachment 2A - Crew Pairing Print ReportItem 2 · .PDF · 78 KBOperations 2 - Attachment 2B - Excerpts from AirTran DC-9 Aircraft Operations ManualItem 3 · .PDF · 307 KBOperations 2 - Attachment 2C - Excerpts from AirTran DC-9-30 Quick Reference HandbookItem 4 · .PDF · 855 KBOperations 2 - Attachment 2D - Copy of AirTran DC-9 Normal ChecklistItem 5 · .PDF · 151 KBOperations 2 - Attachment 2E - Copies of Pilot Training RecordsItem 6 · .PDF · 186 KBOperations 2 - Attachment 2F - Control Column ChecklistItem 7 · .PDF · 43 KBOperations 2 - Attachment 2G - Copies of Flight Departure PapersItem 8 · .PDF · 691 KBOperations 2 - Attachment 2H - Copies of Weight, Balance and Performance InformationItem 9 · .PDF · 713 KBOperations 2 - Attachment 2I - Copies of Air Traffic Control TranscriptsItem 10 · .PDF · 646 KBSurvival Factors 6 - Factual Report of Group ChairmanItem 11 · .PDF · 503 KBSurvival Factors 6 - Attachment 1 - Written Flight Attendant StatementsItem 12 · .PDF · 549 KBSurvival Factors 6 - Attachment 2 - Passenger QuestionnairesItem 13 · .PDF · 30.9 MBSurvival Factors 6 - Attachment 3 - Passenger Safety Briefing CardItem 14 · .PDF · 409 KBSurvival Factors 6 - Attachment 4 - PhotographsItem 15 · .PDF · 177 KBSurvival Factors 6 - Attachment 5 - Injury ChartItem 16 · .PDF · 67 KBSurvival Factors 6 - Attachment 6 - The William B. Hartsfield Atlanta International Airport - Airport DiagramItem 17 · .PDF · 194 KBSurvival Factors 6 - Attachment 7 - City of Atlanta Fire Department Final Incident ReportItem 18 · .PDF · 526 KBSurvival Factors 6 - Attachment 8 - City of Atlanta Fire Department Critique of the Bid Bird 2000 (Operational Readiness Drill)Item 19 · .PDF · 259 KBSurvival Factors 6 - Attachment 9 - Airport Operations Division Incident Form and Daily Events Log for November 29, 2000Item 20 · .PDF · 484 KBSystems 9 - Systems and Fire Group Chairman Factual ReportItem 21 · .PDF · 3.2 MBFlight Data Recorder 10 - Factual Report of Group ChairmanItem 22 · .PDF · 425 KBMaintenance Records 11 - Group Chairman Factual ReportItem 23 · .PDF · 248 KBMaintenance Records 11 - Appendix A - DC-9-30 Fuselage Stations and Cabin Floor Panel DiagramItem 24 · .PDF · 93 KBMaintenance Records 11 - Appendix B - "C" Check Cards, Non-Routines, and Corrective ActionsItem 25 · .PDF · 3.1 MBMaintenance Records 11 - Appendix C - Relevant Log PagesItem 26 · .PDF · 463 KBMaintenance Records 11 - Addendum to Group Chairman's Factual Report Regarding Lavatory Servicing ProceduresItem 27 · .PDF · 58 KBMaintenance Records 11 - Addendum to Group Chairman's Factual Report Regarding Lavatory Servicing Procedures - Appendix A - Douglas Aircraft Company DC-9 Maintenance Manual Lavatory Servicing (Dated 7/15/66; 6/1/82; and 8/1/85)Item 28 · .PDF · 469 KBMaintenance Records 11 - Addendum to Group Chairman's Factual Report Regarding Lavatory Servicing Procedures - Appendix B - AirTran Airways Standard Practice Manual DC-9 Lavatory Servicing (In effect on November 29, 2000)Item 29 · .PDF · 481 KBMaintenance Records 11 - Addendum to Group Chairman's Factual Report Regarding Lavatory Servicing Procedures - Appendix C - AirTran Airways Standard Practice Manual Lavatory Servicing for all aircraft. (Revision Date June 1, 2001)Item 30 · .PDF · 1.1 MBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 31 · .PDF · 841 KBHazardous Material 17 - Factual Report of Group ChairmanItem 32 · .PDF · 247 KBHazardous Material 17 - Appendix A - Information from AirTranItem 33 · .PDF · 3.6 MBHazardous Material 17 - Appendix B - Information from the Federal Aviation AdministrationItem 34 · .PDF · 1.9 MBHazardous Material 17 - Appendix C - Information on the ASAP ShipmentItem 35 · .PDF · 203 KBHazardous Material 17 - Appendix D - Miscellaneous InterviewsItem 36 · .PDF · 216 KBHazardous Material 17 - Appendix E - Baggage Inspection RecordItem 37 · .PDF · 286 KBHazardous Material 17 - Appendix F - PhotographsItem 38 · .PDF · 796 KBFAA ATC TranscriptsItem 39 · .PDF · 416 KBChemical Testing of Grommet MaterialItem 40 · .PDF · 59 KBSubmission from Association of Flight AttendantsItem 41 · .PDF · 120 KBSubmission from BoeingItem 42 · .PDF · 252 KB

FAA reports on this event · 1

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