Aircraft Accident/Incident Report

Dfw, Texas
Thursday, September 25, 2003 6:50 CDT

NTSB Narrative Summary Released at Completion of Accident

The airliner experienced fumes and smoke in the cabin after powering back from the gate. The airplane was about 200 feet from the jetway when the captain initiated an emergency evacuation. The airplane was not damaged, and 8 of the 89 passengers sustained minor injuries during the evacuation. During the emergency evacuation, the tailcone slide deployed but did not automatically inflate. An off-duty flight attendant reported that she attempted to manually inflate the slide but that she could not locate the red manual inflation handle on the slide's girt. She observed a small metal ring near where the red manual inflation handle should have been located and tried unsuccessfully to inflate the slide numerous times by pulling on that ring. The off-duty flight attendant then blocked the tailcone exit and directed passengers to other exits. The investigation revealed an improperly rigged cable assembly due to improper maintenance of the tailcone evacuation system by the airline. Additionally, other slides were found with similar problems. The slide manufacturer, Air Cruisers, had issued a service bulletin (SB) to address the problem. On May 10, 2004, the Safety Board issued two recommendations (A-04-42 and -43) to the FAA to expeditiously issue an airworthiness directive to require operators to implement the SB on an accelerated schedule and not wait for the slides' next regularly scheduled maintenance interval, and to require operators that are operating airplanes with the affected slides inflation cables that have been improperly modified to include a manual inflation cable handle with a key ring, to reinstall new, unmodified inflation cables at the next scheduled maintenance opportunity.

NTSB Probable Cause Narrative

The improper maintenance of the tailcone evacuation system, which prevented the evacuation slide from inflating during an evacuation due to smoke/fumes in the cabin.

Event Information

Type of Event Incident
Event Date 9/25/2003
Event Day of the Week Thursday
Time of Event 650
Event Time Zone Central Daylight Time
Event City DFW
Event State TEXAS
Event Country --
Zipcode of the event site --
Event Date Year 2003
Event Date Month 9
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude --
Event Location Longitude --
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport --
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source --
Time of the weather observation
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID --
Elevation of weather observation facility --
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation --
Lighting Conditions --
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling --
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) --
Air Temperature at event time (in degrees celsius) --
Dew Point at event time (in degress fahrenheit) --
Wind Direction (degrees magnetic) --
Variable Wind Indicator --
Wind Speed (knots) --
Wind Velocity Indicator --
Wind Gust Indicator --
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) --
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Minor
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor 8
Injury Total None 86
Injury Total Serious --
Injury Total All 8
Investigating Agency NTSB
NTSB Docket Number (internal use) 23004
NTSB Notification Source H. Casanova - SCRA
NTSB Notification Date Sep 25 2003 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Jan 30 2008 4:08PM
User who most recently changed record NTSB\johb
Basic weather conditions --
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N462AA
NTSB Number DCA03IA058
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 121: Air Carrier
Type of Flight Plan filed --
Flight plan Was Activated? No
Damage None
Aircraft Fire --
Aircraft Explosion --
Aircraft Manufacturer's Full Name McDonnell Douglas
Aircraft Model MD-80
Aircraft Series Identifier --
Aircraft Serial Number --
Certified Max Gross Weight --
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft --
Number of Engines --
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection --
Date of Last Inspection --
Airframe hours since last inspection --
Airframe Hours --
ELT Installed --
ELT Activated --
ELT Aided Location of Event Site --
ELT Type --
Aircraft Owner Name --
Aircraft Owner Street Address --
Aircraft Owner City --
Aircraft Owner State --
Aircraft Owner Country --
Aircraft Owner Zipcode --
Operator is an individual? --
Operator Name AMERICAN AIRLINES INC
Operator Same as Owner? --
Operator Is Doing Business As --
Operator Address Same as Owner? --
Operator Street Address --
Operator City --
Operator State --
Operator Country --
Operator Zip code --
Operator Code AALA
Owner has at least one certificate --
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
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) --
Second Pilot on Board --
Departure Point Same as Event No
Departure Airport Code --
Departure City --
Departure State --
Departure Country --
Departure Time --
Departure Time Zone --
Destination Same as Local Flt --
Destination Airport Code --
Destination City --
Destination State --
Destination Country --
Specific Phase of Flight Taxi
Report sent to ICAO? No
Evacuation occurred Yes
Date of most recent change to record Nov 14 2003 10:38AM
User who most recently changed record MARN
Since inspection or accident --
Event Location Runway Number and Location --
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --