N633DL

HISTORY OF FLIGHT

On June 23, 2003, about 0710 eastern daylight time, a Boeing 757-232, N633DL, registered to Wilmington Trust Company, operated by Delta Air Lines, Inc., as flight 1036, experienced a passenger-initiated evacuation of the airplane while pushed away from the gate and stopped on the ramp at the Tampa International Airport, Tampa, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed for the 14 CFR Part 121 scheduled, domestic, passenger flight from Tampa International Airport, to Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia. The airplane was not damaged and there were no injuries to the captain, first officer, three flight attendants, or 139 passengers (one of whom was a company flight attendant occupying a coach passenger seat). One flight attendant and 26 passengers sustained minor injuries, and three passengers sustained serious injuries as a result of the evacuation. The airplane had pushed back from the gate approximately 3 minutes earlier.

The flight data recorder indicates the No. 1 engine was started first following pushback; no abnormalities associated with the engine start were reported by the flightcrew. The captain reported that the tow tug was released from the airplane, and the right engine start sequence commenced. At 0709:07, the cockpit voice recorder (CVR) recorded the first officer to state "fuels on" followed two seconds later by, "... light off." The fuel cutoff switch was placed to the run position at 25 percent N2, and at 0709:14, the CVR recorded the first officer to state, "N1." The flight data recorder readout revealed that the N1 rotation speed increased to a maximum of 12 percent. The captain reported that during the No. 2 engine start, as it was spooling up, we felt a buffet that would be consistent with jet wash from another aircraft. The captain reported that he observed the ground crew walking back to the terminal and when they were about 100 feet away, he noticed that one of the ground crew members holding her hands to her mouth. At 0709:42, the CVR recorded the first officer to state "something wrong with the engine." At the same time the CVR recorded the captain to state "he's pointing at the engine. Something's wrong with the engine." The captain further reported that although there were no abnormal engine indications in the cockpit, he secured the No. 2 engine. At 0710:03, (determined by CVR transcript), the flight attendant assigned to Door 1R (determined in post accident interviews) advised the flightcrew, "we have fire in the back." The captain respond "okay, how's it look" followed by a comment from the first officer indicating, "where a fire in the back?" The flight attendant reported the fire was in the galley area, followed by a report of another flight attendant (later determined to be the On Board Leader) putting on the personal breathing equipment (PBE) and getting the Halon fire extinguisher.

The captain reported that about the time he was notified of the fire by door 1R flight attendant, he noticed that some passengers were on the ramp and the "emergency door and entry door lights were illuminated." He then secured the No. 1 engine, and instructed the first officer to contact ground control and request the dispatch of emergency equipment. The ground controller advised the flightcrew that they had already dispatched emergency equipment due to the fact that they had observed what occurred. At 0710:40, the CVR recorded the captain to ask the door 1R flight attendant, "... do you see the fire cause we shut it down the engine's...." The flight attendant responded, "OK, they opened the door", followed by "they're out", to which the captain commented "they're out." At 0710:52, the CVR recorded the captain to state "...okay, we got an evacuation checklist." The first officer responded "... ATC, parking brakes, handle", to which the captain responded "set." The CVR transcript further indicates that at 0711:04, the first officer stated "engine and APU fire switches." Approximately 1 second later the door 1R flight attendant advised the flightcrew that they were still trying to figure out what was occurring in the cabin. The captain responded by stating "looks like people are already off the airplane", to which she reported "I know I know what do you want us to do cause", to which the captain reported "just stand by for right now. I mean there's, is there no fir is there any fire?" The flight attendant reported "it looks like the fire's extinguished" to which the captain reported "OK." The CVR records the captain to ask the Tampa International Airport ATCT ground controller if the airport fire rescue equipment was responding. The CVR transcript continues and at 0711:48, the captain advised the door 1R flight attendant to walk in the cabin to make sure there was no fire. At 0711: 58, the captain stated "no indication, no EGT, everything was normal." At 0712:28, a flight attendant on interphone reported "oh, the ladies they started ** hollering fire, fire, everybody came to the mid doors, and one of the man he pulled the slide bar, pulled both the slides and I let people out, and ** doors** and everybody evacuated from the back." At 0713:00, the captain stated, "so a passenger just unilaterally pulled...." At 0713:16, the CVR transcript records the first public announcement from the captain indicating "ladies and gentlemen for the rest of you on board the airplane..." with the rest of the announcement being unintelligible.

The captain further reported that he did not pull the fire bottle handles for the engines because a "fire marshal" who had boarded the aircraft informed him there was no fire. A request was made with Delta operations for stairs to be brought out to de-plane the remaining passengers. The first officer's written statement was nearly identical to the statement prepared by the captain; he offered no new information. According to the FAA inspector-in-charge, the flightcrew informed him they did not experience any indications or discrepancies during the No. 2 engine start.

All but one flight attendant (On-Board Leader) reported seeing an orange glow during the right engine start. The flight attendant who was occupying a seat in coach reported seeing "an orange glow, like flames flickering at the windows." One of the flight attendants reported to NTSB she couldn't tell if the orange glow was inside or outside. A flight attendant who was securing the galley area near the 2L door reported to NTSB hearing a noise from the "wing area" that sounded like passengers screaming. She stood up from her kneeling position and noted passengers standing directly in front of her. She could not see the wings because people were standing but did report seeing an "orange glow" in the cabin. She reported passengers were trying to reach the door which she was blocking with her body and a male passenger who was wearing a "burgundy shirt and tan pants" yelled, "fire, [expletive], fire." He was bigger than her and reached over, grabbed the door handle and rotated it. The handle did not rotate fully and the door, "only was cracked." The male passenger then lifted her up and "put" her against the forward galley counter. She had a scratch on her back but was not disabled and felt no pain. She grabbed the door handle and opened the door fully and locked it against the fuselage. The slide/raft inflated normally, and was going initially to the left but straightened out quickly. The male passenger went down the slide immediately. She attempted to keep other passengers from exiting because the engines were running but they did not obey her. She then opened the 2R door, and passengers evacuated via it as well. The flight attendant assigned to door 3L reported that after assessing the outside conditions, she opened it first, followed by door 3R.

One of the 67 passengers who returned the NTSB questionnaire reported he was seated either in seat 21A or 22A, and he assisted the flight attendant. He reported he was the first out of the forward galley door and stayed at the bottom to assist other passengers. With respect to the question that asked "what proportion of your evacuation was spent on:" he reported 25 percent was spent opening the exit. The individual also reported that passengers over the wings had opened all four exits at that point, and someone in the back yelled there was a fire, so we kinda shrugged and decided it would be best to exit. He also reported that at the time they evacuated, 20 people were already out of the airplane via other exits. Another passenger who returned the questionnaire and was seated in 21B reported there was no flight attendant in my bulkhead galley, she was at the rear of the aircraft. With respect to the question that asked whether his physical size assisted me a in evacuation he responded "agree", and added a comment, "75 inches, 200 pounds, I took charge of my section!" He reported in writing that because there was no flight attendant in the mid-galley, "... it was up to me to assist others off the plane."

AIRCRAFT INFORMATION

The airplane was manufactured by Boeing in 1987, as a model 757-232, and was assigned serial number 23614. It was equipped with two Pratt and Whitney 2037 turbofan engines. The interior configuration consisted of 24 first-class seats, and 159 coach class seats. The airplane was also equipped with three "Type I" exits on each side of the aircraft, as well as two "Type III" exits over each wing. The airplane was last inspected in accordance with the continuous airworthiness inspection program on June 2, 2003, and had accumulated 22.6 hours since the inspection at the time of the accident. The airframe total time at the time the accident was 52,381.9 hours.

Review of aircraft discrepancies that go back 30 days prior to the accident revealed door 2L had been written up...