SEA98IA027

NTSB incident investigation · Boeing 737-522 · Eugene, OR · December 26, 1997

Incident · No injuriesIncident investigationFinal report
Date
December 25, 1997, 23:19 local (Dec 26, 1997, 07:19 UTC)
Place
Eugene, OR
Injuries
105 uninjured
Damage
No damage
Phase of flight
Standing
Aircraft
N918UABoeing 737-522
Weather
Visual (VMC) · Night/dark
Status
Completed · report November 10, 1998
Report
Approved by Office Director
Case key
42721

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

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Probable cause

A checklist procedure was not followed. The initiation of an evacuation was a factor.

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/otherStanding - engine(s) operating
Checklist - not followedPilot in commandCause
Evacuation - initiatedPilot in commandFactor

Analysis

After the airplane had taxied to and stopped at the gate, the jetway was positioned to the 1 left door. While the passengers were beginning to deplane, the captain positioned the fuel levers to the 'cutoff' position. Ground power had not yet been connected and the airplane went dark. The captain then repositioned the fuel levers to the 'idle' position. Immediately following this action, ground personnel noticed smoke coming from the number two engine and notified the flight crew of a fire. The captain ordered an evacuation and began the checklist procedures. When the flight crew reached the position of the fuel levers step in the checklist, the captain noticed that the fuel levers were in the 'idle' position. The captain then positioned the fuel levers to the 'cutoff' position. The smoke began to dissipate from the engine and the all clear signal was given by the ground crew. After the smoke dissipated, the captain cancelled the evacuation. Approximately 20 passengers had deplaned via the 2 right slide to the ground. Another 10 to 20 passenger went out the over wing exit. Maintenance personnel inspected the engine and reported that there was no indication of an actual fire, and suspected that when the fuel lever was positioned to the 'idle' position, the fuel valve opened and jet fuel was injected into the hot decelerating engine.

Factual narrative

On December 25, 1997, at 2319 Pacific standard time, a Boeing 737-522, N918UA, flight number 318, registered to and operated by United Airlines as a 14 CFR Part 121 scheduled passenger transport, was standing at the gate at the Eugene, Oregon, Airport and in the process of deplaning passengers when the Captain ordered an emergency evacuation after ground personnel reported a fire in the number 2 engine. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan had been filed for the flight. The airplane was not damaged. The two airline transport rated pilots, three flight attendants, and 100 passengers were not injured. The flight had originated from San Francisco, California, about one hour and 30 minutes before the incident.

United Airlines personnel reported that the flight crew was told to expect ground power to be hooked to the airplane at the gate. The aircraft was taxied to the gate and the jetway was positioned to the 1 left door.

While the passengers were beginning to deplane, the captain positioned the fuel levers to "cutoff" to shutdown both engines. The ground power had not yet been connected and the airplane went dark. The captain then positioned both fuel levers back to the "idle" position. Immediately following this action, ground crew noticed smoke and notified the flight crew of a fire in the number two engine. The captain immediately initiated an evacuation by using the PA system. The flight crew then performed the checklist procedures and when they got to the position of the fuel levers step in the list, the captain noticed that the fuel levers were in the "idle" position. The captain then positioned the fuel levers to the "cutoff" position. The smoke began to dissipate from the engine and the all clear signal was given by the ground crew.

After the smoke dissipated, the captain cancelled the evacuation. Approximately 20 passengers had deplaned via the 2-right slide to the ground. Another 10 to 20 passengers went out the over wing exit. When the evacuation was cancelled, the passengers that had not reached the ground, came back inside the cabin and exited via the 1-left door. The slide at 2-left did not deploy as the door had not been re-armed. The flight attendant reported that the event was over before the door could be closed and the slide re-armed.

Mechanics inspected the engine and reported that there was no indication of an actual fire and suspected that when the fuel lever was positioned to the "idle" position, the fuel valve opened and jet fuel was injected into the decelerating hot engine.

Aircraft

Registration
N918UA
Reported as
Boeing 737-522
Category
Airplane
Serial number
25385
Airframe hours
18,287
Engine
Cfm 56-3, 20,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Registered owner
United Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · November 30, 1997 · 228 hours before
Departed
SFO · San Francisco, CA
Flight plan
IFR
Airport
EUG · Mahlon Sweet Field

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
32
Certificates
Commercial, Flight instructor, Airline transport, Flight engineer
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
6,300 total · 853 in this make and model · 118 in the last 90 days · 42 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
350° at 4 knots
Visibility
6 statute miles
Lowest ceiling
400 ft overcast
Temperature
36 °F, dew point 34 °F
Altimeter
30.00 inHg
Observed at
225