DCA90MA002

NTSB accident investigation · Boeing 727-232 · Salt Lake City, UT · October 14, 1989

Accident · Minor injuriesMajor investigationFinal report
Date
October 14, 1989, 14:19 local (21:19 UTC)
Place
Salt Lake City, UT
Injuries
5 minor, 17 uninjured; on the ground: 3 minor
Damage
Destroyed
Phase of flight
Standing
Aircraft
N530DABoeing 727-232
Weather
Day
Status
Completed · report June 21, 1990
Report
Approved by Office Director
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19891014066559A
Case key
15929

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 fire which started in the passenger oxygen system for undetermined reasons. Contributing to the accident was the failure of delta airlines to recognize, attend to and correct repeated leaks in the oxygen system.

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.

Fire/explosionStanding
Oxygen system,passenger - leakCause
Oxygen system,passenger - undeterminedCause
Maintenance - inadequateCompany maintenance personnelFactor
Insufficient standards/requirements,aircraftCompany/operator mgmtFactor
Emergency procedure - inadequateCompany/operator management
Emergency lights - not possible
Evacuation - delayedCopilot/second pilot

Analysis

The crew heard a muffled explosion & saw flames coming from the vent near seat 3-D while acft was parkked at gate. Location of fire prevented crew from returning to cockpit to notify CFR & illuminate emerg floor lighting. Passengers & crew evacuated acft. Second officer, last to leave, could not reach rear airstairs & exited via emerg window exit after having difficulty in locating an exit because of smoke. A mechanic noted low passenger oxygen supply during preflight & replaced oxygen cylinders. While exiting the electrical equip bay the mechanic saw a white flash engulf the oxygen system flow control unit. He attempted to have CFR notified of the fire using a hand held radio to no avail. The passenger oxygen system had 6 low oxygen quantity maintenance write-ups during previous 30 days but was not 'flagged' by company automated trend analysis program because of the job title of the person entering the write-ups. Inspection of delta's fleet revealed 35 oxygen system leaks on other acft.

Aircraft

Registration
N530DA
Reported as
Boeing 727-232
Category
Airplane
Serial number
21813
Airframe hours
30,173
Engine
P&W JT8D-15A, 15,500 lbs thrust, turbo jet
Damage
Destroyed
Fire
On-Ground
Flight
Part 121
Registered owner
Delta Airlines, Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · September 30, 1989 · 150 hours before
Destination
VEG · Edmonton Canada, OF
Flight plan
IFR
Airport
SLC · Salt Lake City

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
45
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
15,000 total · 5,000 in this make and model · 8,000 as pilot in command · 200 in the last 90 days · 70 in the last 30 days

Weather

Conditions
Day
Visibility
20 statute miles
Temperature
70 °F, dew point -0 °F

FAA reports on this event · 1

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