NTSB Identification: MIA95IA238.
The docket is stored in the Docket Management System (DMS). Please contact Records Management Division
Scheduled 14 CFR operation of CARNIVAL AIRLINES
Incident occurred Tuesday, September 26, 1995 in FORT LAUDERDALE, FL
Probable Cause Approval Date: 12/04/1995
Aircraft: BOEING 737-400, registration: N404KW
Injuries: 3 Minor,162 Uninjured.

NTSB investigators used data provided by various sources and may not have traveled in support of this investigation to prepare this aircraft incident report.

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.

The National Transportation Safety Board determines the probable cause(s) of this incident to be:

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.

Full narrative available

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