ASN Wikibase Occurrence # 358227
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| Date: | Tuesday 26 September 1995 |
| Time: | 16:48 LT |
| Type: |  Boeing 737-4Q8 |
| Owner/operator: | Carnival Airlines |
| Registration: | N404KW |
| MSN: | 25371/2195 |
| Year of manufacture: | 1992 |
| Total airframe hrs: | 9579 hours |
| Engine model: | GE CFM56-3C-1 |
| Fatalities: | Fatalities: 0 / Occupants: 165 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Fort Lauderdale, FL -
 United States of America
|
| Phase: | Initial climb |
| Nature: | Unknown |
| Departure airport: | (KFLL) |
| Islip, NY (KISP) | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
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.
Probable Cause: 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.
Accident investigation:
 |
|
Sources:
NTSB MIA95IA238
Location
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 14-Mar-2024 11:15 | ASN Update Bot | Added |
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