Individually Owned: 150,657
Corporate Owned: 137,281
Oakland Intl Airport
Aircraft Accident/Incident Report
Oakland, California 94614
Friday, March 17, 1989 12:00 PST
NTSB Narrative Summary Released at Completion of Accident
THE CREW WAS NOT AWARE AN APU FIRE HAD OCCURRED AT THE GATE PRIOR TO STARTING THE MAIN ENGINES. AFTER DEPARTURE THE AIRPLANE EXPERIENCED SEVERE VIBRATIONS; AN EMERGENCY WAS DECLARED, AND THE FLIGHT LANDED WITHOUT INCIDENT. ABOUT 1/2 OF THE UNDERSIDE OF THE ELEVATOR & TRIM TAB WERE SEVERELY FIRE DAMAGED. THE TAIL CONE WAS CHARRED & BLISTERED OVER A 3 FT BY 3 FT AREA. FOUR GROUND SERVICE PERSONNEL HANDLED THE AIRCRAFT DURING PUSHBACK. THE APU COMBUSTOR CAP DRAIN LINE WAS FOUND CLOGGED WITH SEVERAL PIECES OF ROOM TEMPERATURE VULCANIZING (RTV) MATERIAL (POTTING COMPOUND) USED IN THE APU BUILDUP PROCESS. THE APU MANUFACTURER'S OVERHAUL MANUAL CAUTIONS OPERATORS TO USE RTV SPARINGLY, AND TO REMOVE ANY EXCESS PRIOR TO INSTALLING EXHAUST PIPE SHIMS TO PREVENT PLUGGED FUEL DRAIN FITTINGS AND TORCHING STARTS. IN ADDITION, THE ATOMIZER ASSEMBLY SHOWED STREAKING IN THE PRIMARY ORIFICES, AND EXAMINATION OF THE OIL PUMP REVEALED SLOW SEQUENCING (IGNITION AND FUEL INITIATION).
NTSB Probable Cause Narrative
IGNITION OF PUDDLED FUEL FROM A BLOCKED COMBUSTOR DRAIN LINE, AND A SLOW START DURING WHICH FUEL WAS MISTED AND BLOWN OUT THE TAIL PIPE. AN EXISTING TAILWIND AT THE GATE ALLOWED THE FUEL TO WET THE TAIL SURFACES AND BE IGNITED DURING THE APU START. THE OPERATOR CONFIRMED USING RTV MATERIAL IN THE APU BUILDUP PROCESS AT THEIR FACILITY.
Event Information
| Type of Event | Accident |
| Event Date | 3/17/1989 |
| Event Day of the Week | Friday |
| Time of Event | 1200 |
| Event Time Zone | Pacific Standard Time |
| Event City | OAKLAND |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 94614 |
| Event Date Year | 1989 |
| Event Date Month | 3 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | OAKLAND INTL |
| Event Location Nearest Airport ID | OAK |
| Indicates whether the acc/inc occurred off or on an airport | On Airport |
| Distance from airport in statute miles | 0 |
| Degrees magnetic from airport | 0 |
| Airport Elevation | -- |
| Weather Briefing Completeness | Not pertinent |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1145 Pacific Standard Time |
| Direction of event from weather observation facility (degrees) | 270 |
| Weather Observation Facility ID | OAK |
| Elevation of weather observation facility | 10 |
| Distance of event from weather observation facility (units?) | 5 |
| Time Zone of the weather observation | PST |
| Lighting Conditions | Day |
| Lowest Ceiling Height | 20000 |
| Lowest Non-Ceiling Height | 2500 |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | Broken |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 20 |
| Air Temperature at event time (in degrees celsius) | 14 |
| Dew Point at event time (in degress fahrenheit) | 6 |
| Wind Direction (degrees magnetic) | 160 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 7 |
| Wind Velocity Indicator | Unknown |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | -- |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | None |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 69 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 2036 |
| NTSB Notification Source | -- |
| NTSB Notification Date | Mar 17 1989 12:00AM |
| NTSB Notification Time | 1615 |
| Fiche Number and/or location -used to find docket information | 41269 |
| Date of most recent change to record | Dec 18 2002 11:28AM |
| User who most recently changed record | NTSB\GIUV |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N12318 |
| NTSB Number | DCA89MA034 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 121: Air Carrier |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | -- |
| Damage | Substantial |
| Aircraft Fire | Ground |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | BOEING |
| Aircraft Model | 737-300 |
| Aircraft Series Identifier | 737-300 |
| Aircraft Serial Number | 318 |
| Certified Max Gross Weight | 135000 |
| 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 | 149 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Continuous Airworthiness |
| Date of Last Inspection | -- |
| Airframe hours since last inspection | -- |
| Airframe Hours | 10633 |
| ELT Installed | Unknown |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | -- |
| Aircraft Owner Name | CONTINENTAL AIRLINES INC. |
| Aircraft Owner Street Address | 2929 ALLEN PARKWAY |
| Aircraft Owner City | HOUSTON |
| Aircraft Owner State | TX |
| Aircraft Owner Country | |
| Aircraft Owner Zipcode | 77019 |
| Operator is an individual? | -- |
| Operator Name | |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | |
| Operator City | |
| Operator State | |
| Operator Country | |
| Operator Zip code | |
| Operator Code | CALA |
| 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 | |
| Departure City | |
| Departure State | |
| Departure Country | |
| Departure Time | 0 |
| Departure Time Zone | |
| Destination Same as Local Flt | -- |
| Destination Airport Code | DEN |
| Destination City | DENVER |
| Destination State | CO |
| Destination Country | |
| Specific Phase of Flight | Standing |
| 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 | 0 |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |