Casualties unknown

1983-01-24: Boeing 767-231 (N602TW) — San Diego, CA

San Diego, CA, US

On January 24, 1983, a Boeing 767-231 (registration N602TW) was involved in an aviation accident near San Diego, CA. Investigators recorded the probable cause as: The integrator locking pin was not fully seated, allowing the latch shaft to move aft and release the door latches. This summary draws on records from the U.S. National Transportation Safety Board (NTSB) historical archive; 5 related events involving the same aircraft type or operator are linked below.

Sourcesthe U.S. National Transportation Safety Board (NTSB) historical archivePrimary reportUpdated 1781061362Data APIEditorial standards
Aircraft registered N602TW
Aircraft registered N602TW. Photo: Aero Icarus from Zürich, Switzerland / CC BY-SA 2.0, via Wikimedia Commons

During descent at 12,000 ft, the left overwing evacuation slide separated near San Diego. Investigation found the integrator locking pin was not fully seated due to ambiguous installation procedures, prompting a design change.

Incident

While descending through 12,000 feet approximately 40 miles east of San Diego, California, the left overwing evacuation slide annunciator light illuminated. The slide separated from the aircraft about 7 miles east of the airport. No flight control problems were noted.

Investigation Findings

Examination determined that the evacuation slide system integrity was satisfactory, and the slide squib and actuator had not been activated. Evidence indicated that the integrator locking pin had not been fully seated, which allowed the latch shaft to move aft, causing the door latches to release. A modification performed on January 22, 1983, had involved changing the latch attach screws, a procedure that required unlatching the lock pin. Ambiguities were found in the installation procedure for the off-wing slide; the instructions failed to describe the mode of operation with respect to the turning directions of the latch-unlatch levers. This incident was the fourth in-flight overwing slide deployment.

Corrective Actions

In response to this incident, Boeing initiated a design change of the integrator mechanism. As an interim measure, compliance with Service Bulletin 767-25-5 was required by February 15, 1983.

Probable cause

The integrator locking pin was not fully seated, allowing the latch shaft to move aft and release the door latches. The installation procedure for the off-wing slide was ambiguous, failing to describe the mode of operation regarding turning directions of the latch-unlatch levers.

Investigation report by the U.S. National Transportation Safety Board (NTSB) historical archive. Original record: https://carol.ntsb.gov/event/20001214X42025. This page is a structured re-presentation; facts and quotes are in the National Transportation Safety Board (NTSB), United States.