# NTSB DCA85IA019: Boeing 747-123, N9663, Detroit, MI, April 25, 1985

- Type: NTSB incident investigation
- Classification: Incident · Minor injuries · Incident investigation · Final report
- Date: April 25, 1985, 10:45 local (15:45 UTC)
- Place: Detroit, MI
- Coordinates: 42.200653, -83.479522 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=42.2007&lon=-83.4795&mi=10
- Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping)
- Highest injury: Minor injuries
- Injuries: 42 minor, 439 uninjured
- Status: Completed
- Report: Approved by Office Director
- NTSB office: Major Investigations Division
- NTSB case key (mKey): 15843
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA85IA019
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15843/pdf
- Page: https://openairdocs.org/ntsb/DCA85IA019

## Sequence of events

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

- Airframe/component/system failure/malfunction, standing - pre-flight
  - passenger compartment light(s) - overtemperature (cause)
  - maintenance,service bulletin/letter - not followed, company/operator management (contributing factor)
  - fuselage,cabin - smoke
  - emergency procedure - performed
  - misc eqpt/furnishings,slides - inoperative (contributing factor)
  - maintenance,installation - improper, company maintenance personnel (contributing factor)
  - door,emergency exit - improper (contributing factor)
  - maintenance,installation - improper, company maintenance personnel (contributing factor)
  - door,emergency exit - jammed (contributing factor)

## Analysis

THE FLT CREWMEMBERS OF THE JUMBO JET WERE PREPARING TO START THE ENGS WHEN FLT ATTENDANTS (F/A'S) IN THE FORWARD CABIN DETECTED A FAINT ODOR PRIOR TO CLOSING DOOR 1L. THE SOURCE COULD NOT BE DETERMINED, SO THE DOOR WAS CLOSED IN PREPARATION FOR A PUSHBACK. SHORTLY THEREAFTER, SMOKE WAS DISCOVERED IN THE VICINITY OF THE OVERHEAD BIN AT ROW 16. THE CAPTAIN WAS NOTIFIED & HE ORDERED THAT 'OCCUPANTS EVACUATE, IF THERE IS A FIRE ONBOARD.'  THE JETWAY WAS BROUGHT BACK TO DOOR 1L. THE SMOKE DISSIPATED; THUS, THE F/A'S AT DOORS 1R, 2L & 2R DID NOT OPEN THEIR DOORS. HOWEVER, THE F/A'S AT THE OTHER 6 DOORS WERE UNAWARE OF THE SITUATION & CONTINUED THE EVACUATION. THE RAMPS AT DOORS 3L & 3R DID NOT INFLATE & DOOR 5R JAMMED HALFWAY OPEN. THE RAMP PACKS FOR 3R & 3L WERE IMPROPERLY MOUNTED. THE 5R PACK BOARD WAS MADE FOR A LEFT HAND DOOR & THE LANYARD WAS NOT CONNECTED TO THE BOTTOM PANEL PULLEY. AN EXAM REVEALED A BALLAST FOR AN OVERHEAD FLOURESCENT LIGHT, PN 69-33C, HAD OVERHEATED & MELTED THE PLASTIC CASE.

## Aircraft

- Registration: N9663 (not matched to a registry record)
- Reported make and model: BOEING 747-123
- Category: Airplane
- Serial number: SN20102
- Airframe hours: 38827
- Engines: P&W JT9 14500 lbs thrust turbo fan
- Damage: No damage
- Fire: On-Ground
- Flight: Part 121
- Operator: United Air Carriers, doing business as National Airlines, Inc.
- Registered owner: United Air Carriers
- Airworthiness certificate: Standard, Normal
- Departed: DTW, DETROIT, MI
- Destination: LAS, LAS VEGAS, NV
- Flight plan: IFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 46; airline transport; airplane ratings: single-engine sea, multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 12,000 total, 600 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: 280° at 13 knots
- Visibility: 10 statute miles
- Lowest ceiling: 2,300 ft broken
- Temperature: 52 °F, dew point 48 °F
- Altimeter: 29.00 inHg
- Observed at: DTW, 5 nm away

## 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 19850425077599I](https://openairdocs.org/incident/19850425077599I), Apr 25, 1985: Boeing 747123, Detroit, MI. Smoke from a light fixture was observed before pushback. Three escape slides were improperly installed.

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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