# NTSB LAX83IA080: Boeing 767-231, N602TW, San Diego, CA, January 24, 1983

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: January 23, 1983, 20:44 local (Jan 24, 1983, 04:44 UTC)
- Place: San Diego, CA
- Location: 32.7895° N, 117.1718° W: Placed by OpenAirDocs from NTSB’s distance and direction from SAN DIEGO INTL (SAN), within about a mile (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=32.7895&lon=-117.1718&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 159 uninjured
- Status: Completed
- Report: Approved by Office Director
- NTSB case key (mKey): 23581
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX83IA080
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/23581/pdf
- Page: https://openairdocs.org/ntsb/LAX83IA080

## Analysis

WHILE DESCENDING THRU 12,000 FT APRX 40 MI EAST OF SAN DIEGO, CA, THE LEFT OVERWING EVACUATION SLDE ANNUNCIATOR LIGHT ILLUMINATED. THE SLIDE SEPARATED FROM THE ACFT APRX 7 MI EAST OF THE ARPT. NO FLT CONTROL PROBLEMS WERE NOTED. INTEGRITY OF THE SYS WAS FOUND TO BE SATISFACTORY. THE EVACUATION SLIDE SQUIB & ACTUATOR HAD NOT BEEN ACTIVATED. THERE WERE INDICATIONS THAT THE INTEGRATOR LOCKING PIN HAD NOT BEEN FULLY SEATED, WHICH ALLOWED THE LATCH SHAFT TO MOVE AFT, THUS ALLOWING THE DOOR LATCHES TO RELEASE. DURING A MODIFICATION ON 1/22/83, THE LATCH ATTACH SCREWS HAD BEEN CHANGED. THIS MODIFICATION REQUIRED UNLATCHING THE LOCK PIN. AMBIGUITIES WERE FOUND IN THE INSTALLATION PROCEDURE FOR THE OFF- WING SLIDE; THE INSTRUCTIONS FAILED TO DESCRIBE THE MODE OF OPERATON WITH RESPECT TO TURNING DIRECTIONS OF THE LATCH- UNLATCH LEVERS. THIS WAS THE 4TH IN-FLT OVERWING SLIDE DEPLOYMENT. AS A RESULT OF THIS INCIDENT, BOEING BEGAN A DESIGN CHANGE OF THE INTEGRATOR MECHANISM. IN THE INTERIM, COMPLIANCE WITH SB 767-25-5 WAS REQUIRED BY 2/15/83.

## Sequence of events

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

- Airframe/component/system failure/malfunction, descent - normal
  - misc eqpt/furnishings,slides - deployed inadvertently (cause)
  - condition(s)/step(s) insufficiently defined, manufacturer (contributing factor)

## Aircraft

- Registration: [N602TW](https://openairdocs.org/deregistered/N602TW-2003-04-02), registration cancelled 2003-04-02, S/N 22565, built 1982 (OpenAirDocs)
- Reported make and model: BOEING 767-231
- Registry model: [Boeing 767-231](https://openairdocs.org/model/boeing-767-231) (registry code 1385131) (OpenAirDocs)
- Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs)
- Category: Airplane
- Serial number: 22565
- Airframe hours: 394
- Engines: P&W JT9D-7R4D turbo fan
- Damage: Minor damage
- Flight: Part 121
- Registered owner: Trans World Airlines
- Airworthiness certificate: Standard, Normal
- Last inspection: Continuous airworthiness, January 2, 1983, 0 hours before
- Departed: STL, ST.LOUIS, MO
- Flight plan: IFR
- Airport: SAN, Lindberg

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 48; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, unknown; seat: left; flight hours: 8,228 total, 127 in this make and model

## Weather

- Conditions: Visual (VMC), Night/bright
- Wind: calm
- Visibility: 50 statute miles
- Lowest ceiling: none

## 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 19830123006589I](https://openairdocs.org/incident/19830123006589I), Jan 23, 1983: Boeing 767231, San Diego, CA. On approach left over-wing escape slide fell from aircraft. Recovered by police. Found slide doors opened.

## Other investigations on N602TW (1)

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

- [NTSB NYC92IA129](https://openairdocs.org/ntsb/NYC92IA129), Jun 28, 1992: Boeing 767-231ER (N602TW), Jamica, NY, incident, minor damage. Probable cause: THE FAILURE OF THE FIFTH STAGE LOW PRESSURE TURBINE VANES DUE TO FATIGUE.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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