# NTSB DCA03IA058: McDonnell Douglas MD-80, N462AA, Dfw, TX, September 25, 2003 - Type: NTSB incident investigation - Classification: Incident · Minor injuries · Incident investigation · Final report - Date: September 25, 2003, 06:50 local (11:50 UTC) - Place: Dfw, TX - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 8 minor, 86 uninjured - Status: Completed, report January 31, 2008 - Report: Approved by Office Director - NTSB office: Major Investigations Division - Safety recommendations: Yes - NTSB case key (mKey): 58009 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA03IA058 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58009/pdf - Page: https://openairdocs.org/ntsb/DCA03IA058 ## Probable cause The improper maintenance of the tailcone evacuation system, which prevented the evacuation slide from inflating during an evacuation due to smoke/fumes in the cabin. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, taxi - hydraulic system,line - leak - evacuation - performed, flightcrew - fuselage,cabin - smoke - emergency equipment - not deployed - maintenance,installation - improper, company maintenance personnel (cause) ## Analysis The airliner experienced fumes and smoke in the cabin after powering back from the gate. The airplane was about 200 feet from the jetway when the captain initiated an emergency evacuation. The airplane was not damaged, and 8 of the 89 passengers sustained minor injuries during the evacuation. During the emergency evacuation, the tailcone slide deployed but did not automatically inflate. An off-duty flight attendant reported that she attempted to manually inflate the slide but that she could not locate the red manual inflation handle on the slide's girt. She observed a small metal ring near where the red manual inflation handle should have been located and tried unsuccessfully to inflate the slide numerous times by pulling on that ring. The off-duty flight attendant then blocked the tailcone exit and directed passengers to other exits. The investigation revealed an improperly rigged cable assembly due to improper maintenance of the tailcone evacuation system by the airline. Additionally, other slides were found with similar problems. The slide manufacturer, Air Cruisers, had issued a service bulletin (SB) to address the problem. On May 10, 2004, the Safety Board issued two recommendations (A-04-42 and -43) to the FAA to expeditiously issue an airworthiness directive to require operators to implement the SB on an accelerated schedule and not wait for the slides' next regularly scheduled maintenance interval, and to require operators that are operating airplanes with the affected slides inflation cables that have been improperly modified to include a manual inflation cable handle with a key ring, to reinstall new, unmodified inflation cables at the next scheduled maintenance opportunity. ## Factual narrative On September 25, 2003, at approximately 0650 Central Daylight Time (CDT), a McDonnell-Douglas (Boeing) MD-80, N462AA, operated by American Airlines as flight 1128 from Dallas-Ft. Worth, TX to Tampa, FL, experienced an emergency evacuation after powering back from gate C17. Smoke and/or fumes entered the cockpit and cabin and the captain initiated an emergency evacuation after attempting to return to the jetway. During the evacuation the tailcone slide deployed but did not inflate. The flight was operated as a scheduled domestic passenger airplane under the provisions of 14 CFR 121 and an instrument flight rules (IFR) flight plan had been filed. The airplane was not damaged and there were no injuries to the 5 crewmembers or 81 passengers. Eight passengers sustained minor injuries during the evacuation. ## Aircraft - Registration: [N462AA](https://openairdocs.org/deregistered/N462AA-2012-04-26), registration cancelled 2012-04-26, S/N 49592, built 1988 (OpenAirDocs) - Reported make and model: McDonnell Douglas MD-80 - Registry model: [Mcdonnell Douglas DC-9-82(MD-82)](https://openairdocs.org/model/mcdonnell-douglas-dc-9-82-md-82) (registry code 3022082) (OpenAirDocs) - Registry engine: [Pratt & Whitney JT8D series](https://openairdocs.org/engine/pratt-whitney-jt8d-series) (registry code 52053, turbo-jet) (OpenAirDocs) - Category: Airplane - Damage: No damage - Flight: Part 121 - Operator: American Airlines Inc ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; injuries: none - Co-pilot; injuries: none ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20030925031499I](https://openairdocs.org/incident/20030925031499I), Sep 25, 2003: Doug DC982, Dallas-Ft Worth, TX. (-23) On sep 25, 2003, at approximately 0651 aircraft performed uneventful power back from gate C-17 at dfw airport. Upon initiating taxi, smoke and acrid… 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.