# NTSB DCA15CA129: Mcdonnell Douglas DC 9 83(MD-83), N869GA, St Petersburg, FL, June 8, 2015 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Data collection · Final report - Date: June 8, 2015, 17:00 local (21:00 UTC) - Place: St Petersburg, FL - Coordinates: 27.909999, -82.6875 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.9100&lon=-82.6875&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Defining event: [Taxi-from runway: Evacuation](https://openairdocs.org/ntsb-events/460) - Highest injury: Serious injuries - Injuries: 1 serious, 7 minor, 137 uninjured - Status: Completed, report April 8, 2016 - Report: Approved by Office Director - NTSB office: Major Investigations Division - NTSB case key (mKey): 91327 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA15CA129 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91327/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91327 - Page: https://openairdocs.org/ntsb/DCA15CA129 ## Probable cause evacuation of the aircraft due to reported, but unverified, aircraft condition and poor communication between Aircraft Rescue and Firefighting personnel and the flight crew. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Flight crew (probable cause); cases with it: [Mcdonnell Douglas DC-9-83(MD-83), 1 case](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=3022083), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Communication (personnel): lack of communication](https://openairdocs.org/ntsb-findings/02063510): Personnel issues › Task performance · Emergency services personnel (probable cause); cases with it: [Mcdonnell Douglas DC-9-83(MD-83), 1 case](https://openairdocs.org/ntsb-findings/02063510/cases.md?model=3022083), [All aircraft, 84 cases](https://openairdocs.org/ntsb-findings/02063510/cases.md) - [Communication (personnel): interpretation/understanding](https://openairdocs.org/ntsb-findings/02063530): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Mcdonnell Douglas DC-9-83(MD-83), 1 case](https://openairdocs.org/ntsb-findings/02063530/cases.md?model=3022083), [All aircraft, 10 cases](https://openairdocs.org/ntsb-findings/02063530/cases.md) - [Communication (personnel): lack of communication](https://openairdocs.org/ntsb-findings/02063510): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Mcdonnell Douglas DC-9-83(MD-83), 1 case](https://openairdocs.org/ntsb-findings/02063510/cases.md?model=3022083), [All aircraft, 84 cases](https://openairdocs.org/ntsb-findings/02063510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150); cases with it: [Mcdonnell Douglas DC-9-83(MD-83), 1 case](https://openairdocs.org/ntsb-events/150/sequence.md?model=3022083), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) - [Taxi-from runway: Evacuation](https://openairdocs.org/ntsb-events/460) (defining event); cases with it: [Mcdonnell Douglas DC-9-83(MD-83), 2 cases](https://openairdocs.org/ntsb-events/460/sequence.md?model=3022083), [All aircraft, 103 cases](https://openairdocs.org/ntsb-events/460/sequence.md) ## Analysis During initial climb after departure from St Pete-Clearwater International Airport (PIE), St. Petersburg, Florida, the flight attendants (FA) notified the flight crew of an odor they described as that of "burning rubber". The flight returned to PIE where two Aircraft Rescue and Firefighting (ARFF) vehicles responded and met the airplane as it stopped on the taxiway after landing. The captain communicated with ARFF personnel over Air Traffic Control (ATC) ground control frequency. According to statements, the ARFF Lieutenant advised that there was smoke coming from the #1 engine and requested that the crew shut down the engine so they could examine the airplane. The firefighter in ARFF vehicle 3 stated that while the Lieutenant was outside the vehicle examining the airplane, the flight crew reported their intent to evacuate the airplane and the firefighter advised the crew to hold off on the evacuation while he contacted the Lieutenant. According to flight crew statements, the crew asked for verification of this request three times without hearing a response. Flight crew statements indicated the flight deck crew did not communicate with the cabin crew during this time to assess the conditions in the cabin. The crew stated that they believed the delay in receiving response to their radio calls indicated ARFF personnel were busy addressing a safety concern and after hearing no further transmissions, the crew completed the evacuation checklist and advised passengers and cabin crew to proceed with evacuation. During the evacuation, one passenger sustained a serious injury (fractured wrist) and six passengers and one cabin crew member received minor injuries. Although ARFF and the flight deck crew established a direct line of communication, they lacked prompt, clear, and concise communication. Following this event, Allegiant Air implemented a Captain Leadership training program and established joint flight deck and cabin crew resource management training. ## Factual narrative During initial climb after departure from St Pete-Clearwater International Airport (PIE), St. Petersburg, Florida, the flight attendants (FA) notified the flight crew of an odor they described as that of "burning rubber". The flight returned to PIE where two Aircraft Rescue and Firefighting (ARFF) vehicles responded and met the airplane as it stopped on the taxiway after landing. The captain communicated with ARFF personnel over Air Traffic Control (ATC) ground control frequency. According to statements, the ARFF Lieutenant advised that there was smoke coming from the #1 engine and requested that the crew shut down the engine so they could examine the airplane. The firefighter in ARFF vehicle 3 stated that while the Lieutenant was outside the vehicle examining the airplane, the flight crew reported their intent to evacuate the airplane and the firefighter advised the crew to hold off on the evacuation while he contacted the Lieutenant. According to flight crew statements, the crew asked for verification of this request three times without hearing a response. Flight crew statements indicated the flight deck crew did not communicate with the cabin crew during this time to assess the conditions in the cabin. The crew stated that they believed the delay in receiving response to their radio calls indicated ARFF personnel were busy addressing a safety concern and after hearing no further transmissions, the crew completed the evacuation checklist and advised passengers and cabin crew to proceed with evacuation. During the evacuation, one passenger sustained a serious injury (fractured wrist) and six passengers and one cabin crew member received minor injuries. Although ARFF and the flight deck crew established a direct line of communication, they lacked prompt, clear, and concise communication. Following this event, Allegiant Air implemented a Captain Leadership training program and established joint flight deck and cabin crew resource management training. ## Aircraft - Registration: [N869GA](https://openairdocs.org/deregistered/N869GA-2018-12-15), registration cancelled 2018-12-15, S/N 53294 (OpenAirDocs) - Reported make and model: MCDONNELL DOUGLAS DC 9 83(MD-83) (83) - Registry model: [Mcdonnell Douglas DC-9-83(MD-83)](https://openairdocs.org/model/mcdonnell-douglas-dc-9-83-md-83) (registry code 3022083) (OpenAirDocs) - Category: Airplane - Serial number: 53294 - Airframe hours: 48214 - Engines: Pratt & Whitney JT8D-219 21000 lbs thrust turbo fan; Pratt & Whitney JT8D-219 21000 lbs thrust turbo fan - Damage: No damage - Flight: Part 121 - Operator: Allegiant Air LLC - Registered owner: Sunrise Asset Management LLC - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, May 5, 2015 - Departed: PIE, St Petersburg, FL - Destination: HGR, Hagerstown, MD - Flight plan: IFR - Airport: PIE, St Pete-Clearwater, runway 36R, 9,730 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 43; injuries: none; airline transport, private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review May 17, 2015; seat: left; restraint: 5-point; flight hours: 7,162 total, 1,199 in this make and model, 463 as pilot in command - Co-pilot; age 29; injuries: none; airline transport, private; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review November 12, 2014; seat: right; restraint: 5-point; flight hours: 7,283 total, 492 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 10° at 4 knots - Visibility: 10 statute miles - Temperature: 91 °F, dew point 66 °F - Altimeter: 29.98 inHg - Observed at: KPIE ## Docket (3 files) The files NTSB released with the investigation on April 8, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91327. 1.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438668&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Company Safety Event Report - Crew Statements (item 2, .PDF, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438669&FileExtension=.PDF&FileName=Company%20Safety%20Event%20Report%20-%20Crew%20Statements-Master.PDF - Airports/ARFF - Statements (item 3, .PDF, 352 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438670&FileExtension=.PDF&FileName=Airports%2FARFF%20-%20Statements-Master.PDF 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.