LAX03IA137

NTSB incident investigation · Airbus Industrie A300F4-605R · Oakland, CA · April 10, 2003

Incident · No injuriesIncident investigationFinal report
Date
April 10, 2003, 13:50 local (20:50 UTC)
Place
Oakland, CA
Injuries
2 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N676FEAirbus Industrie A300F4-605R
Weather
Visual (VMC) · Day
Status
Completed · report December 28, 2004
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20030410004379I
Case key
56867

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

the failure of the 1R evacuation slide to inflate because the transport-locking pin had not been removed from the regulator during the slide's installation on the 1R door. The cause of the cabin/cockpit smoke was contamination of the air conditioning packs.

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.

Miscellaneous/otherClimb
Air cond/heating/pressurization - contamination,other than waterCause
Air cond/heating/pressurization - smokeCause
Airframe/component/system failure/malfunctionStanding - engine(s) not operating
Maintenance,installation - improperCompany maintenance personnelCause
Misc eqpt/furnishings,slides - not operatingCause

Analysis

During climb out, the fight crew declared an emergency due to smoke in the cockpit and returned to the departure airport for a normal landing, after which the emergency evacuation slides failed to inflate. The flight crew said that they smelled an acrid smoke followed immediately by the illumination of the MAIN DECK CARGO FIRE light and the audio tone (bell). They conducted the emergency procedures, declared an emergency, and turned back for landing. On the downwind leg the MAIN DECK CARGO FIRE light went out; however, on final approach, the MID 2 LOOPS A and B illuminated. After landing the flight crew attempted to evacuate via the 1R emergency slide; however, it did not inflate. The first officer said that he was able to open the door, and that they made several unsuccessful attempts to manually inflate the slide without success. Post incident examination found that the slides' inflation bottle was fully pressurized. Two maintenance personnel noted that the transport-locking pin was with the slide when it was removed from the airplane. The slide was disassembled for inspection at the manufacturer's facility. No discrepancies were found that would have prevented the slide from inflating. Damage was found to the slide's girt bar in the area of the manual inflation handle that was consistent with the transport-locking pin being installed in the inflation bottle's regulator at the time of the slide's deployment. The cause of the smoke was determined to be oil or other fluid contamination of the air-condition packs.

Factual narrative

On April 10, 2003, at 1350 Pacific daylight time, an Airbus A300F4-605R, N676FE, declared an emergency due to smoke in the cockpit during the takeoff climb out from the Metropolitan Oakland International Airport (OAK), Oakland, California. Federal Express (FedEx) operated the nonscheduled domestic cargo airplane under the provisions of 14 CFR Part 121. The airplane was not damaged. The two airline transport certificated pilots were not injured. Visual meteorological conditions prevailed for the cross-country flight, and an instrument flight rules (IFR) flight plan had been filed. The flight departed Oakland at 1330, with a scheduled destination of Denver International Airport (DEN), Denver, Colorado.

In the captain's written statement he indicated that during climb out he and the first officer smelled an acrid smoke followed immediately by the illumination of the MAIN DECK CARGO FIRE light, as well as the audio tone (bell). They conducted the emergency procedures, declared an emergency, and turned back to land at Oakland. While on the downwind leg, the MAIN DECK CARGO FIRE light went out. However, on final, the MID 2 LOOPS A and B illuminated.

The captain stated that after landing, the flight crew accomplished the GROUND EMERGENCY EVACUATION procedures. He indicated that the 1R door slide did not inflate automatically or manually.

In the first officer's written statement he indicated that during the evacuation he opened the 1R door. The door opened and the evacuation slide partially deployed; however, it did not inflate. The captain made several unsuccessful attempts to inflate the slide with the manual inflation handle. The first officer further stated that he and maintenance personnel checked the door during the preflight at Oakland.

FedEx attributed the smoke to oil and another fluid, possibly glycol, contaminating the air-conditioning packs. Maintenance personnel found the number 1 and 2 water coalescer separator bags covered in a dark fluid. They replaced the APU load compressor, along with the two water coalescer separator bags. They completed a ground run of the airplane with no discrepancies noted.

According to a maintenance person who arrived with a pay mover to move the airplane back to the FedEx facility, when he arrived on-scene he saw that the emergency slide had been deployed and was hanging against the fuselage from its girt bar, and was deflated. He went inside the airplane and a crewmember pointed, with a flashlight, where smoke had been. He observed a "white smoke low to the floor three quarters down the fuselage, smoke was minimal and motionless, [he] did not observe any smell of smoke."

FedEx employees took several pictures of the incident slide after it had been removed from the airplane and placed into a maintenance vehicle. The pictures indicated that the slide's inflation bottle was still fully pressurized and that internal components from the inflation bottle's regulator had been removed. A Safety Board investigator interviewed numerous maintenance employees who had contact with the slide. Two of the employees recalled seeing the transport-locking pin (with a red streamer) with the incident slide on the back of the maintenance truck.

The incident slide was torn down at the manufacturer's facility, and they noted no discrepancies that would have prevented the slide's inflation during the evacuation. According to the manufacturer, damage to the slide's girt in the area of the manual inflation handle was consistent with the transport locking pin being installed in the inflation bottle's regulator at the time of the slide's deployment.

Aircraft

Registration
N676FE
Reported as
Airbus Industrie A300F4-605R
Category
Airplane
Serial number
790
Airframe hours
5
Engines
General Electric CF6-80C2A5F, 61,000 lbs thrust, turbo fanGeneral Electric CF6-80C2A5F, 61,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Federal Express Corporation
Registered owner
State Street Bank and Trust Co. of CT TSTE
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · April 10, 2003 · 7,267 hours before
Departed
OAK · Oakland, CA
Destination
DEN · Denver, CO
Flight plan
IFR
Airport
OAK · Metropolitian Oakland INTL, runway 29, 10,000 × 150 ft, asphalt

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
56
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
September 6, 2002
Seat
Left
Flight hours
3,346 total · 1,693 in this make and model · 3,288 as pilot in command · 107 in the last 90 days · 36 in the last 30 days · 3 in the last 24 hours
Role
Co-pilot
Age
52
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
4,680 total · 2,675 in this make and model · 142 in the last 90 days · 41 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 15 knots
Visibility
10 statute miles
Lowest ceiling
5,500 ft overcast
Temperature
63 °F, dew point 48 °F
Altimeter
30.05 inHg
Observed at
OAK

FAA reports on this event · 1

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