Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Anchorage, Alaska 99502
Thursday, April 28, 2005 5:30 AKD
NTSB Narrative Summary Released at Completion of Accident
The flight crew was conducting an international passenger flight under Title 14, CFR Part 121, when they smelled and saw smoke in the cockpit. The pilot declared an emergency, and diverted to the nearest airport, where the airplane landed without incident. According to the flight crew, just prior to the smell and smoke, there was a crew change that required the cockpit security door to be opened and closed. An examination of the security door by maintenance personnel and the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) revealed an excess length of wiring, which provides power to the electrically locking security door, was laying atop the door's metal-encased, unshielded, locking solenoid inside the doorframe. Several of the wires were encased in a plastic anti-chafe mesh. A portion of the mesh was melted, and had the smell of burnt plastic. During a discussion with the IIC, a mechanic said he had seen similar doors overheat when the door and frame were misaligned, prohibiting full extension of the locking bolt. The cockpit door was modified in accordance with Supplemental Type Certificate (STC) ST01391LA, which meets the FAA's requirements for a reinforced cockpit door. The door uses a "demand access" electrically operated door latching solenoid. The door manufacturer issued an addendum to the airplane manufacturer's maintenance manual. The addendum includes removal, installation, and system tests of the striker/solenoid unit. The installation section does not specifically address the issue of securing excess wiring located above the striker/solenoid within the doorframe. The installation instructions do contain a "caution," referencing the need for the security bolt to engage fully. Failure of the bolt to fully engage will cause the solenoid to remain energized and overheat. Construction of the striker/solenoid assembly is such that the metal-encased electrical coil of the unshielded solenoid is the upper-most portion of the assembly within the doorframe. The installation includes a warning light that illuminates if the solenoid does not shut off. The crew did not report seeing the warning light in-flight, and the light and locking mechanism functioned properly during subsequent tests on the ground; it was not tested in-flight. The conversion of the door was completed on March 21, 2003. Prior to the incident, the new security door had been in service about 16,416 flight hours, and 1170 cycles. FAA Advisory Circular (AC) 65-15A, Chapter 11, covers practices and procedures for the installation and maintenance of aircraft electrical wiring. The AC notes that practices and procedures outlined in this section are general recommendations, and are not intended to replace the manufacturer's instructions. Chapter 11, page 441, Slack in Wiring Bundles, states: "Single wires or wire bundles should not be installed with excessive slack." Page 442, Routing and Installations, states: "All wires and wire groups should be routed and installed to protect them from: (2) high temperatures."
NTSB Probable Cause Narrative
The inadequate installation of the cockpit security door locking device, which resulted in smoke in the cockpit during normal cruise, and a precautionary landing. A factor associated with the incident was the manufacturer's insufficiently defined installation instructions.
Event Information
| Type of Event | Incident |
| Event Date | 4/28/2005 |
| Event Day of the Week | Thursday |
| Time of Event | 530 |
| Event Time Zone | -- |
| Event City | Anchorage |
| Event State | ALASKA |
| Event Country | -- |
| Zipcode of the event site | 99502 |
| Event Date Year | 2005 |
| Event Date Month | 4 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 611028N |
| Event Location Longitude | 1495947W |
| Event Location Airport | -- |
| Event Location Nearest Airport ID | -- |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | -- |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Pilot |
| 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 | Day |
| 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 | Unknown |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | -- |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | None |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 201 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 19784 |
| NTSB Notification Source | FAA Anchorage, ROC |
| NTSB Notification Date | Apr 28 2005 12:00AM |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | Jun 28 2006 1:30PM |
| User who most recently changed record | NTSB\JOHB |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | Anchorage FSDO-03 |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N277WA |
| NTSB Number | ANC05IA064 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 121: Air Carrier |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | Yes |
| Damage | Minor |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | McDonnell Douglas |
| Aircraft Model | MD-11 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 48743 |
| Certified Max Gross Weight | 602000 |
| 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 | 298 |
| Number of Engines | 3 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Continuous Airworthiness |
| Date of Last Inspection | -- |
| Airframe hours since last inspection | -- |
| Airframe Hours | -- |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | MDFC-Knoxville Company |
| Aircraft Owner Street Address | 500 Naches Avenue |
| Aircraft Owner City | Renton |
| Aircraft Owner State | WA |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 98055 |
| Operator is an individual? | No |
| Operator Name | WORLD AIRWAYS INC |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | 101 World Drive |
| Operator City | Peachtree City |
| Operator State | GA |
| Operator Country | USA |
| Operator Zip code | 30269 |
| Operator Code | WRLA |
| 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 | Non-scheduled |
| Indicates Domestic or International Flight | International |
| Operator carrying Pax/Cargo/Mail | Passenger Only |
| Type of Flying (Per_Bus / Primary) | -- |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | -- |
| Departure City | Osan Air Base |
| Departure State | UN |
| Departure Country | USA |
| Departure Time | 755 |
| Departure Time Zone | UTC |
| Destination Same as Local Flt | -- |
| Destination Airport Code | KSEA |
| Destination City | Seattle |
| Destination State | WA |
| Destination Country | USA |
| Specific Phase of Flight | Cruise - normal |
| Report sent to ICAO? | Yes |
| Evacuation occurred | No |
| Date of most recent change to record | Apr 5 2006 1:17PM |
| User who most recently changed record | STAM |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | NA |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |