# NTSB DCA90MA002: Boeing 727-232, N530DA, Salt Lake City, UT, October 14, 1989

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Major investigation · Final report
- Date: October 14, 1989, 14:19 local (21:19 UTC)
- Place: Salt Lake City, UT
- Coordinates: 40.809989, -111.939323 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=40.8100&lon=-111.9393&mi=10
- Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping)
- Highest injury: Minor injuries
- Injuries: 5 minor, 17 uninjured; on the ground: 3 minor
- Status: Completed, report June 21, 1990
- Report: Approved by Office Director
- NTSB office: Major Investigations Division
- Safety recommendations: Yes
- NTSB case key (mKey): 15929
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA90MA002
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15929/pdf
- Page: https://openairdocs.org/ntsb/DCA90MA002

## 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

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

- Fire/explosion, standing
  - oxygen system,passenger - leak (cause)
  - oxygen system,passenger - undetermined (cause)
  - maintenance - inadequate, company maintenance personnel (contributing factor)
  - insufficient standards/requirements,aircraft, company/operator mgmt (contributing factor)
  - emergency procedure - inadequate, company/operator management
  - emergency lights - not possible
  - evacuation - delayed, copilot/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](https://openairdocs.org/deregistered/N530DA-1995-08-14), registration cancelled 1995-08-14, S/N 21813 (OpenAirDocs)
- Reported make and model: BOEING 727-232
- Registry model: [Boeing 727-232](https://openairdocs.org/model/boeing-727-232) (registry code 1384082) (OpenAirDocs)
- Category: Airplane
- Serial number: 21813
- Airframe hours: 30173
- Engines: P&W JT8D-15A 15500 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 45; 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 (OpenAirDocs).

- [Accident 19891014066559A](https://openairdocs.org/incident/19891014066559A), Oct 14, 1989: Boeing 727232, Salt Lake City, UT, Destroyed. Leaky cabin oxygen system written up several times but ignored, finally exploded and burned during loading at gate.

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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