N404KW

Unknown
Minor

BOEING 737-400 S/N: 25371

Accident Details

Date
Tuesday, September 26, 1995
NTSB Number
MIA95IA238
Location
FORT LAUDERDALE, FL
Event ID
20001207X04543
Coordinates
26.089437, -80.150672
Aircraft Damage
Unknown
Highest Injury
Minor
Fatalities
0
Serious Injuries
0
Minor Injuries
3
Uninjured
162
Total Aboard
165

Probable Cause and Findings

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.

Aircraft Information

Registration
N404KW
Make
BOEING
Serial Number
25371
Engine Type
Turbo-jet
Model / ICAO
737-400 B734
Aircraft Type
Fixed Wing Multi Engine
No. of Engines
2

Analysis

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.

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# MIA95IA238