# NTSB MIA95IA238: Boeing 737-400, N404KW, Fort Lauderdale, FL, September 26, 1995 - Type: NTSB incident investigation - Classification: Incident · Minor injuries · Incident investigation · Final report - Date: September 26, 1995, 16:48 local (20:48 UTC) - Place: Fort Lauderdale, FL - Coordinates: 26.089437, -80.150672 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.0894&lon=-80.1507&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 3 minor, 162 uninjured - Status: Completed, report December 4, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 37680 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA95IA238 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/37680/pdf - Page: https://openairdocs.org/ntsb/MIA95IA238 ## Probable cause INADEQUATE WRITTEN MAINTENANCE PROCEDURES ADDRESSING STEPS TO BE FOLLOWED IN THE EVENT OF A COMPONENT FAILURE DURING AN ENGINE WASH. THE EMERGENCY SLIDES FAILED TO DEPLOY DUE TO IMPROPER INSTALLATION BY COMPANY MAINTENANCE PERSONNEL. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, takeoff - initial climb - engine accessories,engine starter - failure,total - precautionary landing - performed, pilot in command - procedure inadequate, company maintenance personnel (cause) - engine accessories,engine starter - undetermined - air cond/heating/pressurization - fumes - Miscellaneous/other, emergency descent/landing - misc eqpt/furnishings,slides - disabled - maintenance,installation - improper, company maintenance personnel (cause) ## Analysis DURING INITIAL TAKEOFF CLIMB THE FLIGHT CREW ENCOUNTERED SMOKE IN THE COCKPIT AND PASSENGER COMPARTMENT. THE PILOT-IN-COMMAND DECLARED AN EMERGENCY, RETURNED TO THE DEPARTURE AIRPORT, AND COMMANDED AN EMERGENCY EVACUATION OF PASSENGERS AND FLIGHT CREW. TWO AFT EMERGENCY SLIDES DID NOT DEPLOY. EXAMINATION OF THE AIRPLANE REVEALED THE SMOKE/FUMES ENTERED THE AIRPLANE THROUGH THE AIR CONDITIONING SYSTEM AS A RESULT OF A WASH SOLUTION REMAINING IN THE LEFT ENGINE LONGER THAN REQUIRED DURING AN ENGINE WASH. WHILE THE ENGINE WAS BEING WASHED ON THE DAY BEFORE THE ACCIDENT, THE STARTER FAILED AND THE SOLUTION REMAINED IN THE ENGINE MORE THAN THE REQUIRED 20 MINUTES WHILE THE STARTER WAS BEING CHANGED. EXAMINATION OF THE AFT EMERGENCY SLIDES REVEALED THE INSTALLATION SAFETY PINS WERE STILL INSTALLED. ## Factual narrative On September 26, 1995, about 1648 eastern daylight time, a Boeing 737-400, N404KW, registered to International Lease, operated by Carnival Airlines, as a 14 CFR Part 121 scheduled domestic passenger flight, experienced smoke in the cockpit and passenger cabin area on initial takeoff climb from Fort Lauderdale-Hollywood International Airport. Visual meteorological conditions prevailed and an IFR flight plan was filed. The pilot- in-command declared an emergency and landed at the Fort Lauderdale-Hollywood Airport. An emergency evacuation was conducted down the forward emergency slides. The two rear emergency slides did not deploy. The airline transport pilot-in-command, first officer, 4 cabin attendants and 156 passengers were not injured. Three passengers reported minor injuries. The flight was originating at the time of the incident. Carnival Airlines Director of Quality Control, stated the airplane had an engine wash on September 25, 1995. During the engine wash on the No. 1 engine the starter failed. The wash solution remained in the engine longer than the required 20 minutes; waiting for the starter to be changed. Carnival Airlines engine wash procedures do not address component failure procedures during an engine wash. The fumes entered the cockpit and cabin area through the airplane air conditioning system. Review of the airplane records indicate the emergency slides were installed in Coopesa, Costa Rica on May 18, 1995, during a "C" phase inspection. Visual inspection of the emergency evacuation slides by Carnival Airlines maintenance personnel after the incident revealed the installation safety pins were still installed. ## Aircraft - Registration: N404KW (not matched to a registry record) - Reported make and model: BOEING 737-400 - Category: Airplane - Serial number: 25371 - Airframe hours: 9579 - Engines: GE CFM56-3C-1 23500 lbs thrust turbo fan - Damage: No damage - Flight: Part 121 - Operator: Carnival Airlines - Registered owner: International Lease - Airworthiness certificate: Standard, Transport - Last inspection: AAIP, September 18, 1995, 20 hours before - Departed: FLL - Destination: ISP, ISLIP, NY - Flight plan: IFR - Airport: FLL, Ft. Lauderdale-Hollywood, runway 9, 9,001 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; airline transport, commercial; airplane ratings: single-engine land, single-engine sea, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 12,000 total, 550 in this make and model, 11,000 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 10 knots - Visibility: 12 statute miles - Lowest ceiling: none - Temperature: 88 °F, dew point 75 °F - Altimeter: 29.00 inHg - Observed at: FLL ## 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 19950926033959I](https://openairdocs.org/incident/19950926033959I), Sep 26, 1995: Boeing 7374Q8, Ft Lauderdale, FL. Smoke in aircraft on climbout. Oxygen masks deployed. Returned. Evacuated. Smoke from engine wash. Slides saftied. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.