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Date: | Friday 17 March 1989 |
Time: | 14:00 LT |
Type: | Boeing 737-3T0 |
Owner/operator: | Continental Airlines |
Registration: | N12318 |
MSN: | 23369/1188 |
Total airframe hrs: | 10633 hours |
Engine model: | GE CFM-56-3 |
Fatalities: | Fatalities: 0 / Occupants: 69 |
Aircraft damage: | Substantial |
Category: | Accident |
Location: | Oakland, CA -
United States of America
|
Phase: | Standing |
Nature: | Passenger - Scheduled |
Departure airport: | |
Destination airport: | Denver International Airport, CO (KDEN) |
Investigating agency: | NTSB |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative: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).
Probable Cause: 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.
Accident investigation:
|
| |
Investigating agency: | NTSB |
Report number: | DCA89MA034 |
Status: | Investigation completed |
Duration: | 3 years and 3 months |
Download report: | Final report |
|
Sources:
NTSB DCA89MA034
History of this aircraft
Other occurrences involving this aircraft Revision history:
Date/time | Contributor | Updates |
24-Mar-2024 10:32 |
ASN Update Bot |
Added |
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