MIA01FA029

After takeoff from Miami, the flight experienced a pressurization system malfunction, which the captain identified as the airplane depressurizing. The flight attendants and passengers complained of pain in their ears at that time. The flight crew placed the pressurization system into manual control, turned off the autopilot and autothrottle systems, and began a descent to return to Miami. During the return to Miami, several lavatory smoke alarms activated and the captain call light illuminated in the cabin; however, no evidence of fire or smoke was found. The flight crew did not complete the checklists for manual pressurization control and emergency landing during the return to Miami, both of which called for the airplane to be depressurized prior to landing. After landing and stopping on a taxiway, the captain also noticed an aft baggage compartment fire loop light illuminated, prompting him to evacuate the airplane. After the captain ordered the evacuation, the flight attendants attempted to open the doors. The doors would not open. The flight attendant/purser at the L1 (front left passenger) door continued to attempt to open the door, and the door explosively opened, ejecting the flight attendant/purser from the airplane to the ground, causing fatal injuries. The remainder of the doors opened and the airplane was evacuated. The emergency evacuation checklist did not call for the flight crew to check for depressurization of the airplane prior to commanding an evacuation. Post-accident examination of the airplane revealed that insulation blankets, which had been manufactured and replaced by the airplane operator's maintenance personnel, had not been properly secured per the airplane manufacturer's data. The blanket had migrated over to, and partially blocked, the forward and aft pressurization outflow valves, leading to the pressurization system malfunction. The forward outflow valve was found 3/8-open and the aft outflow valve was found fully closed. The lavatory smoke alarms were found to activate when subjected to abnormal pressure. There were no FAA technical standards for the lavatory smoke detectors. A sensor in the aft cargo compartment was found out of tolerance and also activated when subjected to abnormal pressure. The cabin doors were found to have no means for relieving pressure prior to opening the doors. The cabin altimeter in the cockpit did not have a mechanical stop in the negative direction, and under excessive pressure conditions, allowed the needle to move past the negative range into the high positive range. The aircraft manufacturer stated that when the pressurization system is in the manual mode, the outflow valves do not automatically open during landing and that a person cannot open a door if the airplane is pressurized above approximately 1.5 psi differential. As result of this investigation, the Safety Board previously issued 18 safety recommendations to the FAA.

History of flight

On November 20, 2000, about 1222 eastern standard time, an Airbus Industrie A300B4-605R, N14056, registered to Wilmington Trust Company, and operated by American Airlines, Inc., as flight 1291, a Title 14 CFR Part 121 scheduled international passenger flight, from Miami, Florida, to Port Au Prince, Haiti, had a flight attendant receive fatal injuries during an emergency evacuation after the flight returned to Miami. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The aircraft received minor damage and the airline transport-rated pilot, first officer, 5 flight attendants, 3 other crewmembers, and 100 passengers were not injured. One flight attendant received fatal injuries, 3 passengers received serious injuries, and 1 flight attendant and 18 passengers received minor injuries. The flight originated from Miami, Florida, the same day, about 1149.

According to American Airlines, Inc. records, the captain reported for the accident flight at 1010 and the first officer reported at 1020. The flight crew received departure paperwork for the flight that included airplane information, weight and balance information, NOTAMS and weather information. Flight 1291 departed the gate at 1120 and was airborne at 1149. The first officer was the pilot flying.

At 1156, during the climb to flight level 230, at about 16,000 feet above mean sea level (msl), the captain stated to the copilot that the airplane was depressurizing and for him to get the airplane down. The first officer disconnected the autopilot and began a descent. The flight crew notified Miami Air Route Traffic Control Center of a pressurization problem and requested a descent to 10,000 feet. Miami Center cleared flight 1291 to descend to 10,000 feet. The captain switched to manual pressurization control. At about 1159, after leveling at 10,000 feet, the flight crew advised the controller that they were unable to control pressurization and requested a clearance to return to Miami. The controller assigned a heading of 115 degrees and instructed the flight crew to contact Miami Approach Control.

At about 1214, after being cleared to land by the Miami Air Traffic Control Tower, the captain declared an emergency, requested fire equipment to stand-by and stated to the tower controller: "we are getting some warnings of a fire, although there is no evidence of a fire at this time." Flight 1291 landed in Miami at about 1218. Total flight time for this abbreviated flight segment was 29 minutes.

Shortly after landing, the airplane stopped on the taxiway and the flight crew requested fire personnel to inspect the exterior of the airplane for any visible evidence of fire. At about 1220, after being cleared to taxi to the ramp, a flight attendant called the captain on the intercom and reported a smell of smoke in the middle lavatory. She said it smelled like rubber burning. Immediately following this communication, the captain stated that he noticed that one of the cargo compartment fire detection loop lights was illuminated. He informed the ground controller, "we have a fire and we are going to evacuate right here."

The flight attendants experienced difficulty opening the cabin doors when the emergency evacuation was initiated. The captain was notified of this difficulty. While the captain was evaluating the problem, he said he heard a "whoosh" sound and then the cabin doors opened, emergency slides deployed and passengers evacuated the airplane.

At the captain's command to evacuate, the purser went to the L1 door and tried to open it, using one hand. The door would not open. The purser went back to the cockpit to tell the flight crew. The purser then came out of the cockpit and tried to open the door using both hands. He also heard someone from the back of the airplane state that the doors were not opening. Also, the number three and number four flight attendants stated their doors would not open. He was watching the purser out of the corner of his eye when all of a sudden there was an explosion. He was being pulled toward the L1 door and hit the corner of the lavatory and the L1 jump seat. He fell to the floor and blacked out momentarily. When he awoke the L1 door was open and the purser was on the ground about 60 feet from the airplane.

Personnel information

The captain held an Airline Transport Pilot certificate last issued on May 2, 1996, with airplane multiengine land, and instrument airplane ratings. He also held type ratings in the Airbus A-300B4-605R/A-310, Boeing 757 and 767, and Lockheed 300. At the time of the accident, the captain held an Federal Aviation Administration (FAA) first class medical certificate dated June 15, 2000. American Airlines hired the captain on February 8, 1985. A review of FAA records found no accident, incident or enforcement action. The captain last received a proficiency check in the Airbus A-300B4-605R on October 24, 2000.

The first officer held an FAA Airline Transport Pilot certificate last issued on June 22, 1999, with airplane single engine land, airplane multiengine land, rotorcraft helicopter, and instrument airplane and helicopter ratings. He also held type ratings in the A-300B4-605R/A-310 and the Lockheed L-382. At the time of the accident, the first officer held an FAA first class medical certificate dated, May 31, 2000, with no restrictions. American Airlines hired the first officer on June 29, 1998. A review of FAA records found no accident, incident or enforcement action. The first officer last received a proficiency check in the Airbus A-300B4-605R on June 13, 2000.

Aircraft information

The airplane was an Airbus Industrie A-300B4-605R, serial number 463, U.S. registration N14056, manufactured in 1988. The airplane was equipped with two General Electric CF6-80C2A5 engines, which are rated at 61,500 pounds of takeoff thrust each. At the time of the accident, the airplane had accumulated 34,346 total flight hours.

Logbook records show the airplane was last inspected on September 28, 2000, 345 flight hours before the accident, when the airplane received a "B" check in accordance with the American Airlines continuous airworthiness program. On November 9, 2000, the aft pressurization outflow valve was changed.

Weight and balance

The following information was obtained from the flight departure paperwork:

Basic Operating Weight 206669 lbs.

Passenger Weight 21780 lbs.

Baggage Weight 11177 lbs.

Zero Fuel Weight 239626 lbs.

Maximum Zero Fuel Weight Allowed 288800 lbs.

Fuel 55600 lbs.

Ramp Weight 296626 lbs.

Maximum Ramp Weight Allowed 380500 lbs.

Taxi Fuel Burn 1400 lbs.

Actual Takeoff Weight 295226 lbs.

Maximum Takeoff Weight Allowed 323800 lbs.

Estimated Fuel Burn to PAP 18965 lbs.

Estimated Landing Weight 267000 lbs.

Maximum Landing Weight Allowed 308600 lbs.

Takeoff center of gravity (CG) was 26.1 percent of the mean aerodynamic chord (MAC) and was within the approved limits of the airplane.

Meteorological information

The Miami International Airport 1238 surface weather observation was winds from 330 degrees at 8 knots, visibility 10 statute miles, clouds scattered at 2,500 feet above ground level, temperature 83 degrees F, dew point temperature 70 degrees F, altimeter setting 30.09 inches Hg. Visual meteorological conditions prevailed at the time.

Flight recorders

The cockpit voice recorder (CVR) was a Fairchild model A-100A s/n 50909. The CVR was brought to the audio laboratory of the National Transportation Safety Board (NTSB) on November 21, 2000. The CVR Group convened on November 29, 2000. A transcript was prepared of the entire 30:59-minute recording.

The solid state flight data recorder (FDR), Fairchild model FA2100 (serial number 00857), was removed from the aircraft and sent to the National Transportation Safety Board's laboratory in Washin