Individually Owned: 150,657
Corporate Owned: 137,281
Ft. Lauderdale-Hollywood Airport
Aircraft Accident/Incident Report
Fort Lauderdale, Florida 33315
Tuesady, September 26, 1995 16:48 EDT
NTSB Narrative Summary Released at Completion of Accident
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.
NTSB Probable Cause Narrative
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.
Event Information
| Type of Event | Incident |
| Event Date | 9/26/1995 |
| Event Day of the Week | Tuesday |
| Time of Event | 1648 |
| Event Time Zone | Eastern Daylight Time |
| Event City | FORT LAUDERDALE |
| Event State | FLORIDA |
| Event Country | -- |
| Zipcode of the event site | 33315 |
| Event Date Year | 1995 |
| Event Date Month | 9 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | FT. LAUDERDALE-HOLLYWOOD |
| Event Location Nearest Airport ID | FLL |
| Indicates whether the acc/inc occurred off or on an airport | On Airport |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | 10 |
| Weather Briefing Completeness | Unknown |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1555 Eastern Daylight Time |
| Direction of event from weather observation facility (degrees) | 0 |
| Weather Observation Facility ID | FLL |
| Elevation of weather observation facility | 10 |
| Distance of event from weather observation facility (units?) | 0 |
| Time Zone of the weather observation | EDT |
| Lighting Conditions | Day |
| Lowest Ceiling Height | 0 |
| Lowest Non-Ceiling Height | 2500 |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 12 |
| Air Temperature at event time (in degrees celsius) | 31 |
| Dew Point at event time (in degress fahrenheit) | 24 |
| Wind Direction (degrees magnetic) | 150 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 10 |
| Wind Velocity Indicator | Unknown |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | 29 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | Minor |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | -- |
| Injury Total Minor | 3 |
| Injury Total None | 162 |
| Injury Total Serious | -- |
| Injury Total All | 3 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 5004 |
| NTSB Notification Source | -- |
| NTSB Notification Date | Sep 26 1995 12:00AM |
| NTSB Notification Time | 1755 |
| Fiche Number and/or location -used to find docket information | IMAGE |
| Date of most recent change to record | Dec 7 2000 4:36PM |
| User who most recently changed record | dbo |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N404KW |
| NTSB Number | MIA95IA238 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 121: Air Carrier |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | -- |
| Damage | None |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | BOEING |
| Aircraft Model | 737-400 |
| Aircraft Series Identifier | 737-400 |
| Aircraft Serial Number | 25371 |
| Certified Max Gross Weight | 150000 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 165 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | AAIP |
| Date of Last Inspection | Sep 18 1995 12:00AM |
| Airframe hours since last inspection | 20 |
| Airframe Hours | 9579 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | -- |
| Aircraft Owner Name | INTERNATIONAL LEASE |
| Aircraft Owner Street Address | 1999 AVE OF THE SOUTH |
| Aircraft Owner City | LOS ANGLES |
| Aircraft Owner State | CA |
| Aircraft Owner Country | |
| Aircraft Owner Zipcode | 90067 |
| Operator is an individual? | -- |
| Operator Name | CARNIVAL AIRLINES |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | 1815 GRIFFIN ROAD |
| Operator City | DANIA |
| Operator State | FL |
| Operator Country | |
| Operator Zip code | 33004 |
| Operator Code | RIVA |
| Owner has at least one certificate | Yes - certificate holder |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | Unknown |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | Scheduled |
| Indicates Domestic or International Flight | Domestic |
| Operator carrying Pax/Cargo/Mail | Passenger Only |
| Type of Flying (Per_Bus / Primary) | Unknown |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | Yes |
| Departure Airport Code | FLL |
| Departure City | |
| Departure State | |
| Departure Country | |
| Departure Time | 0 |
| Departure Time Zone | |
| Destination Same as Local Flt | -- |
| Destination Airport Code | ISP |
| Destination City | ISLIP |
| Destination State | NY |
| Destination Country | |
| Specific Phase of Flight | Takeoff |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jan 2 2001 10:30AM |
| User who most recently changed record | dbo |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 9 |
| Runway Length | 9001 |
| Runway Width | 150 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |