SEA06IA105

NTSB incident investigation · Boeing 757-222 · Portland, OR · May 17, 2006

Incident · No injuriesIncident investigationFinal report
Date
May 17, 2006, 09:08 local (16:08 UTC)
Place
Portland, OR
Injuries
189 uninjured
Damage
No damage
Phase of flight
Takeoff
Aircraft
N506UABoeing 757-222
Weather
Visual (VMC) · Day
Status
Completed · report March 26, 2007
Report
Approved by Office Director
Parties
United Airlines, FAA FSDO
Case key
63741

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 inadvertent deployment of the off-wing escape slide due to the inadequate latching of the slide compartment door following access by maintenance personnel.

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.

Miscellaneous/otherTakeoff
Misc eqpt/furnishings,slides - unlatchedCause
Maintenance,alignment - inaccurateCompany maintenance personnelCause

Analysis

Post landing examination of the airplane by personnel from United Airlines and the Federal Aviation Administration revealed that the left off-wing escape slide had deployed, without inflating, and was observed hanging from the aircraft's fuselage. Further examination by United maintenance personnel revealed that the slide carrier tray assembly had rotated out to the open position. The off-wing slide compartment, door and operating latch mechanism were inspected by United maintenance personnel and no discrepancies were noted. Additional examination of the off-wing escape slide assembly by personnel from Boeing engineering revealed no evidence of mechanical malfunction with the system. Maintenance records indicated that on May 15, 2006, (four flights before the slide deployment) the off-wing escape slide pack was replaced in accordance with routine scheduled maintenance intervals for the assembly. The maintenance was completed, and inspected, by United Airlines personnel at a maintenance facility in Chicago, Illinois. A post incident Maintenance Investigation report submitted to the NTSB by United Airlines indicated that the inadvertent deployment of the off-wing slide assembly was the result of the carrier tray not being locked in the stowed position.

Factual narrative

On May 17, 2006, about 0908 Pacific daylight time, a Boeing 757-222 (B-757), N506UA, owned and operated by United Airlines, returned for landing shortly after takeoff from the Portland International Airport, Portland, Oregon, subsequent to an engine indication and crew alerting system (EICAS) advisory message indicating the left off-wing escape slide door was open. The flight was being conducted under Title 14, CFR Part 121, as a scheduled domestic passenger flight, operated by United Airlines, Inc., as Flight 364. There were no injuries to the two pilots, five flight attendants, or the 182 passengers aboard. Visual meteorological conditions prevailed, and an instrument rules flight plan had been filed for the flight to Denver, Colorado.

Personnel from United Airlines reported that while climbing through 900 feet mean sea level (msl), the flight crew received a left off-wing escape slide door EICAS message and elected to return to the airport. The crew reported that there were no adverse control problems and the airplane landed at the departure airport without further incident.

Post landing examination of the airplane by personnel from United Airlines and the Federal Aviation Administration revealed that the left off-wing escape slide had deployed, without inflating, and was observed hanging from the aircraft's fuselage. Further examination by United maintenance personnel revealed that the slide carrier tray assembly had rotated out, to the open position. The off-wing slide compartment, door and operating latch mechanism were inspected by United maintenance personnel and no discrepancies were noted. Additional examination of the off-wing escape slide assembly by personnel from Boeing engineering revealed no evidence of mechanical malfunction with the system.

Maintenance records indicated that on May 15, 2006, (four flights before the slide deployment) the off-wing escape slide pack was replaced in accordance with routine scheduled maintenance intervals for the assembly. The maintenance was completed, and inspected, by United Airlines personnel at a maintenance facility in Chicago, Illinois.

A post incident Maintenance Investigation report submitted to the NTSB by United Airlines indicated that the inadvertent deployment of the off-wing slide assembly was the result of the carrier tray not being locked in the stowed position.

Aircraft

Registration
N506UA
Reported as
Boeing 757-222
Category
Airplane
Serial number
24627
Airframe hours
52,976
Engines
Pratt & Whitney PW2037, 37,500 lbs thrust, turbo fanPratt & Whitney PW2037, 37,500 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Registered owner
United Air Lines Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · June 1, 2005
Departed
PDX · Portland, OR
Destination
DEN · Denver, CO
Flight plan
IFR
Airport
PDX · Portland Intl, runway 28R, 8,000 × 150 ft, asphalt

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
46
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
December 1, 2005
Seat
Left
Flight hours
16,500 total · 6,000 in this make and model · 180 in the last 90 days · 68 in the last 30 days · 4 in the last 24 hours
Role
Co-pilot
Age
48
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right
Flight hours
10,000 total · 3,500 in this make and model · 241 in the last 90 days · 86 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 48 °F
Altimeter
30.04 inHg
Observed at
KPDX, 1 nm away