MIA03FA130

The airplane was pushed back from the gate and the left engine was started with no discrepancies reported. During the starting of the right engine, numerous passengers saw torching aft of the tailpipe. A commotion ensued which drew the attention of the three of the four flight attendants who reported seeing an orange glow either inside or outside the airplane. The captain later reported there were no abnormal engine indications in the cockpit, but he then secured the right engine. The captain secured the left engine after simultaneously noticing passengers on the ramp and illumination of entry door lights. A flight attendant reported a male passenger (who was bigger than her) approached her at door 2L and attempted to open the door by partially rotating the 2L door handle. The door did not open completely but was 'cracked.' The flight attendant eventually opened the door fully and locked it against the fuselage. The male passenger exited immediately, followed by several other passengers. She then opened the 2R door and passengers exited it as well. Passengers also evacuated the airplane via the 3L and 3R doors, which a flight attendant opened. Readout of the flight data recorder revealed that at the time the fuel cutoff switch for the right engine was recorded to be in the "run" position, the recorded fuel flow was 1,696 PPH. Within approximately 2 seconds of the right engine fuel cutoff switch being in the "run" position, the fuel flow was recorded to be 3,136 PPH. The maximum recorded fuel flow of 6,272 PPH occurred 2 seconds before the fuel cutoff switch was recorded to be in the "cutoff" position, or 24 seconds after the fuel cutoff switch was in the "run" position. In contrast, within 4 seconds of the left engine fuel cutoff switch being in the "run" position for engine start, the recorded fuel flow was 544 PPH. Further review of the previous eight engine starts revealed the left and right fuel flows were nearly matched, with no recorded fuel flow value greater than 580 PPH within the first 4 seconds after the fuel cutoff switch was recorded to be in the "run" position. The flight crews are trained that during hot starts, the fuel flow almost immediately exceeds 700PPH. The engine start procedures checklist indicates the engine start is to be aborted if abnormally high or fluctuation fuel flow is noted.

History of flight

On June 23, 2003, about 0710 eastern daylight time, a Boeing 757-232, N633DL, registered to Wilmington Trust Company, operated by Delta Air Lines, Inc., as flight 1036, experienced a passenger-initiated evacuation of the airplane while pushed away from the gate and stopped on the ramp at the Tampa International Airport, Tampa, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed for the 14 CFR Part 121 scheduled, domestic, passenger flight from Tampa International Airport, to Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia. The airplane was not damaged and there were no injuries to the captain, first officer, three flight attendants, or 139 passengers (one of whom was a company flight attendant occupying a coach passenger seat). One flight attendant and 26 passengers sustained minor injuries, and three passengers sustained serious injuries as a result of the evacuation. The airplane had pushed back from the gate approximately 3 minutes earlier.

The flight data recorder indicates the No. 1 engine was started first following pushback; no abnormalities associated with the engine start were reported by the flightcrew. The captain reported that the tow tug was released from the airplane, and the right engine start sequence commenced. At 0709:07, the cockpit voice recorder (CVR) recorded the first officer to state "fuels on" followed two seconds later by, "... light off." The fuel cutoff switch was placed to the run position at 25 percent N2, and at 0709:14, the CVR recorded the first officer to state, "N1." The flight data recorder readout revealed that the N1 rotation speed increased to a maximum of 12 percent. The captain reported that during the No. 2 engine start, as it was spooling up, we felt a buffet that would be consistent with jet wash from another aircraft. The captain reported that he observed the ground crew walking back to the terminal and when they were about 100 feet away, he noticed that one of the ground crew members holding her hands to her mouth. At 0709:42, the CVR recorded the first officer to state "something wrong with the engine." At the same time the CVR recorded the captain to state "he's pointing at the engine. Something's wrong with the engine." The captain further reported that although there were no abnormal engine indications in the cockpit, he secured the No. 2 engine. At 0710:03, (determined by CVR transcript), the flight attendant assigned to Door 1R (determined in post accident interviews) advised the flightcrew, "we have fire in the back." The captain respond "okay, how's it look" followed by a comment from the first officer indicating, "where a fire in the back?" The flight attendant reported the fire was in the galley area, followed by a report of another flight attendant (later determined to be the On Board Leader) putting on the personal breathing equipment (PBE) and getting the Halon fire extinguisher.

The captain reported that about the time he was notified of the fire by door 1R flight attendant, he noticed that some passengers were on the ramp and the "emergency door and entry door lights were illuminated." He then secured the No. 1 engine, and instructed the first officer to contact ground control and request the dispatch of emergency equipment. The ground controller advised the flightcrew that they had already dispatched emergency equipment due to the fact that they had observed what occurred. At 0710:40, the CVR recorded the captain to ask the door 1R flight attendant, "... do you see the fire cause we shut it down the engine's...." The flight attendant responded, "OK, they opened the door", followed by "they're out", to which the captain commented "they're out." At 0710:52, the CVR recorded the captain to state "...okay, we got an evacuation checklist." The first officer responded "... ATC, parking brakes, handle", to which the captain responded "set." The CVR transcript further indicates that at 0711:04, the first officer stated "engine and APU fire switches." Approximately 1 second later the door 1R flight attendant advised the flightcrew that they were still trying to figure out what was occurring in the cabin. The captain responded by stating "looks like people are already off the airplane", to which she reported "I know I know what do you want us to do cause", to which the captain reported "just stand by for right now. I mean there's, is there no fir is there any fire?" The flight attendant reported "it looks like the fire's extinguished" to which the captain reported "OK." The CVR records the captain to ask the Tampa International Airport ATCT ground controller if the airport fire rescue equipment was responding. The CVR transcript continues and at 0711:48, the captain advised the door 1R flight attendant to walk in the cabin to make sure there was no fire. At 0711: 58, the captain stated "no indication, no EGT, everything was normal." At 0712:28, a flight attendant on interphone reported "oh, the ladies they started ** hollering fire, fire, everybody came to the mid doors, and one of the man he pulled the slide bar, pulled both the slides and I let people out, and ** doors** and everybody evacuated from the back." At 0713:00, the captain stated, "so a passenger just unilaterally pulled...." At 0713:16, the CVR transcript records the first public announcement from the captain indicating "ladies and gentlemen for the rest of you on board the airplane..." with the rest of the announcement being unintelligible.

The captain further reported that he did not pull the fire bottle handles for the engines because a "fire marshal" who had boarded the aircraft informed him there was no fire. A request was made with Delta operations for stairs to be brought out to de-plane the remaining passengers. The first officer's written statement was nearly identical to the statement prepared by the captain; he offered no new information. According to the FAA inspector-in-charge, the flightcrew informed him they did not experience any indications or discrepancies during the No. 2 engine start.

All but one flight attendant (On-Board Leader) reported seeing an orange glow during the right engine start. The flight attendant who was occupying a seat in coach reported seeing "an orange glow, like flames flickering at the windows." One of the flight attendants reported to NTSB she couldn't tell if the orange glow was inside or outside. A flight attendant who was securing the galley area near the 2L door reported to NTSB hearing a noise from the "wing area" that sounded like passengers screaming. She stood up from her kneeling position and noted passengers standing directly in front of her. She could not see the wings because people were standing but did report seeing an "orange glow" in the cabin. She reported passengers were trying to reach the door which she was blocking with her body and a male passenger who was wearing a "burgundy shirt and tan pants" yelled, "fire, [expletive], fire." He was bigger than her and reached over, grabbed the door handle and rotated it. The handle did not rotate fully and the door, "only was cracked." The male passenger then lifted her up and "put" her against the forward galley counter. She had a scratch on her back but was not disabled and felt no pain. She grabbed the door handle and opened the door fully and locked it against the fuselage. The slide/raft inflated normally, and was going initially to the left but straightened out quickly. The male passenger went down the slide immediately. She attempted to keep other passengers from exiting because the engines were running but they did not obey her. She then opened the 2R door, and passengers evacuated via it as well. The flight attendant assigned to door 3L reported that after assessing the outside conditions, she opened it first, followed by door 3R.

One of the 67 passenge