MIA92IA020

NTSB incident investigation · Boeing 727-31 · Gulf Of Mexico · November 2, 1991

Incident · No injuriesIncident investigationFinal report
Date
November 2, 1991, 10:17 local (15:17 UTC)
Place
Gulf Of Mexico
Injuries
118 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N839TWBoeing 727-31
Weather
Visual (VMC) · Day
Status
Completed · report May 3, 1993
Report
Approved by Office Director
Case key
33001

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

On this page

Probable cause

The overfilling of the forward lavatory during servicing and the failure to replace the fill/rinse line cap after servicing by the ground service personnel which resulted in the lavatory venting fluid through the fill/rinse line during flight and the subsequent ice formation and ingestion of ice into number three engine.

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.

Loss of engine power(total) - mech failure/malfCruise - normal
Water and waste system - failure,partial
Maintenance,service of aircraft/equipment - improperGround personnelCause
ComplacencyGround personnelCause
Water and waste system - missing
Water and waste system - siphoning
Water and waste system - ice
Engine assembly - foreign object damage

Analysis

Ground personnel serviced forward lavatory just before flight. Flight attendant stated fluid was visible in upper toilet area of forward lavatory after servicing indicating it had been overfilled. Enroute number 3 engine failed and was shutdown. Flight diverted to miami. On arrival a blue streak was found on the right side of the aircraft beginning at the forward lavatory service door and ending at the inlet to number 3 engine. The forward lavatory service door was found closed and the fill/rinse line cap was missing when the door was opened. The fill/rinse line check valve was found stuck open. When a cap was installed on the line no leakage occurred. The lavatory drain line did not leak. Number 3 engine had sustained fan damage due to ingestion of soft matter.

Aircraft

Registration
N839TW
Reported as
Boeing 727-31
Category
Airplane
Serial number
18904
Engine
P&W JT8D, 14,000 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 121
Operator
Private Jet Expeditions
Registered owner
Tran World Airlines
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · January 2, 2000
Departed
EWR · Newark, NJ
Destination
MMUN · Cancun, OF
Flight plan
IFR

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
37
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
8,700 total · 4,200 in this make and model · 6,800 as pilot in command · 150 in the last 90 days · 45 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
30 statute miles
Lowest ceiling
None
Temperature
-65 °F
Altimeter
29.00 inHg