Chicago Midway International Airport
Aircraft Accident/Incident Report

St. Louis, Missouri 63134
Monday, July 7, 2008 8:45 CDT

NTSB Narrative Summary Released at Completion of Accident

The incident occurred during a charter flight for a political candidate, his staff, news reporters, and United States Secret Service (USSS) personnel. According to postincident flight crew statements, during the initial climb, the MD-81 airplane’s pitch increased without a corresponding flight control input and exceeded normal limits before the captain was able to regain control. Although the flight crew was able to regain airplane control, a significant restriction in pitch control still remained. Consequently, the flight crew elected to land instead of continuing to the intended destination. Normal pitch control pressures returned during descent, and no further flight control restrictions or anomalies were encountered during the remainder of the flight. Postincident inspection of the airplane indicated that the tailcone evacuation slide had inflated inside the tail area of the airplane as the airplane lifted off. The pitch control restriction was caused by the inflated slide and a subsequently damaged walkway railing that impinged on a set of elevator cables in the tailcone. The investigation further revealed that the slide cover had not been secured to the floor fittings on the walkway before the flight. It could not be determined why the slide’s cover was not secured. In normal circumstances, the cover is secured by the mechanic who installs it and should remain secured until it is removed from the airplane. The airplane’s tailcone is attached to the aft end of the fuselage and can be jettisoned, either from inside or outside the airplane, to provide an opening for an emergency exit. In an evacuation, when the aft bulkhead door is opened, an integrated door mechanism jettisons the tailcone, thus initiating the evacuation slide deployment. The tailcone falls away from the aft fuselage, and an attached lanyard pulls open the evacuation slide cover. This, in turn, rotates the slide pack aft, and a second lanyard triggers the inflation cylinder to inflate the slide. Results of calculations performed using flight data recorder data indicated that, during the incident flight’s takeoff rotation and initial climb, there were inertial loads of sufficient magnitude and duration to allow an unsecured slide cover to rotate open and initiate slide inflation. Postincident testing showed that the slide pack could not have rotated enough to activate its inflation cylinder if the slide container had been properly secured. Further, a properly secured slide cover would have contained the slide if the inflation cylinder had improperly discharged. Postincident testing of the inflation cylinder did not reveal any anomalies that would have resulted in an unintentional discharge of the cylinder for other reasons. The tailcone evacuation slide’s last service check before the incident flight was performed by the airline on June 5, 2008, and no anomalies were noted. That check was a general visual examination of numerous items throughout the cabin, which included inspection of the forward tie-down straps that secure the slide cover to the floor fittings. There would be no reason for the mechanic to touch the straps during this inspection. In addition, on June 20, 2008, the tailcone slide’s inflation bottle pressure was inspected; this inspection did not specifically call for looking at the straps. A review of flights since that service check indicated that the airplane had experienced load magnitudes that were similar to the incident flight; however, the duration of the inertial loads experienced was not long enough to result in slide inflation. Since the last service check, the incident airplane had flown three flight legs with the presidential candidate aboard. Because a presidential candidate was aboard the airplane, the USSS performed security sweeps of the aircraft before flight. Following the incident, an internal USSS investigation revealed that no USSS personnel or USSS support personnel interfered with or altered the aircraft’s hardware or systems related to the tailcone evacuation slide. Shortly after the July 2008 incident, the airline released a maintenance alert bulletin describing the incident and initial findings from the investigation. The airline also released a revision to the service check work card which added specific language calling for airline maintenance personnel to examine the tie-down straps to verify their proper installation and security during reoccurring service checks. Only two previous incidents of inadvertent tailcone evacuation slide inflation in MD-80 series airplanes have been reported (one to the Federal Aviation Administration’s Service Difficulty Reporting system and one to Boeing, which holds the MD-80 type certificate); the causes of each of these inflations could not be definitively determined. No actions were taken.

NTSB Probable Cause Narrative

The inadvertent partial inflation of the evacuation slide within the tailcone during takeoff and subsequent binding of the elevator control cables. The partial inflation resulted from the tailcone evacuation slide cover failing to be secured to the floor fittings on the walkway for undetermined reasons.

Event Information

Type of Event Incident
Event Date 7/7/2008
Event Day of the Week Monday
Time of Event 845
Event Time Zone Central Daylight Time
Event City St. Louis
Event State MISSOURI
Event Country --
Zipcode of the event site 63134
Event Date Year 2008
Event Date Month 7
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 384455N
Event Location Longitude 0902212W
Event Location Airport Chicago Midway International
Event Location Nearest Airport ID KMDW
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 620
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 851 Central Daylight Time
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID KMDW
Elevation of weather observation facility 620
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation CDT
Lighting Conditions Day
Lowest Ceiling Height 15000
Lowest Non-Ceiling Height 8500
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 26
Dew Point at event time (in degress fahrenheit) 21
Wind Direction (degrees magnetic) 230
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 10
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) 15
Altimeter Setting at event time (in. Hg) 29.95
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 51
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 25699
NTSB Notification Source Midwest Airlines
NTSB Notification Date Jul 7 2008 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Sep 21 2009 10:22AM
User who most recently changed record lema
Basic weather conditions Visual Meteorological Cond
FAA District Office Federal Aviation Administration, AAI-100

Aircraft Involved

Aircraft #1

Aircraft Registration Number N804ME
NTSB Number CHI08IA182
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-81
Aircraft Series Identifier --
Aircraft Serial Number 48030
Certified Max Gross Weight 140000
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 2
Cabin Crew Seats 5
Passenger Seats 82
Total number of seats on the aircraft 89
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Jun 5 2008 12:00AM
Airframe hours since last inspection --
Airframe Hours 46844
ELT Installed No
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name Midwest Airlines, Inc.
Aircraft Owner Street Address 6744 South Howell Avenue
Aircraft Owner City Oak Creek
Aircraft Owner State WI
Aircraft Owner Country USA
Aircraft Owner Zipcode 53154-1474
Operator is an individual? No
Operator Name Midwest Airlines, Inc.
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address 6744 South Howell Avenue
Operator City Oak Creek
Operator State WI
Operator Country USA
Operator Zip code 53154-1474
Operator Code MWEA
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
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 Domestic
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 KMDW
Departure City Chicago
Departure State IL
Departure Country USA
Departure Time 845
Departure Time Zone CDT
Destination Same as Local Flt --
Destination Airport Code KCLT
Destination City Charlotte
Destination State NC
Destination Country USA
Specific Phase of Flight Takeoff - initial climb
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record May 14 2009 11:35AM
User who most recently changed record foxt
Since inspection or accident Time of Accident
Event Location Runway Number and Location 31C
Runway Length 6522
Runway Width 150
Sight Seeing flight No
Air Medical Flight No
Medical Flight --