UPS 747 Dubai Final Report
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This is a fascinating thread. I am very impressed by the standard of the report, and how little the thread has deviated.
Whilst things like not allowing self-oxidising materials in bulk on planes makes sense, I noted one posting that raised my eyebrows - that freighters don't have cabin doors to separate them from the hold. I had never considered this before, and wonder what the reason (or at least the justification) is. To me, the default would seem to be to keep the crew isolated from the cargo unless there is a particular reason for them to go back. I'd even go so far as to say that the crew compartment should be separately pressurised.
So, what am I missing?
Whilst things like not allowing self-oxidising materials in bulk on planes makes sense, I noted one posting that raised my eyebrows - that freighters don't have cabin doors to separate them from the hold. I had never considered this before, and wonder what the reason (or at least the justification) is. To me, the default would seem to be to keep the crew isolated from the cargo unless there is a particular reason for them to go back. I'd even go so far as to say that the crew compartment should be separately pressurised.
So, what am I missing?
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747 Cargo Space Isolation
that freighters don't have cabin doors to separate them from the hold.
The report resulted in an impressive number of recommendations: I leave you to decide how many were actually implemented:
http://lessonslearned.faa.gov/SA295/SAAIB_report.pdf
Last edited by Pinkman; 9th Aug 2013 at 20:59.
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Thanks, Pinkman. I'll have a look at that. Sorry to hear about your friend - it can't be easy for you or him to be reading this now.
Last edited by peakcrew; 9th Aug 2013 at 21:39.
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The Captains blood sample was positive for ethylalcohol with a concentration of (11 mg/dl). ????
The [FAA Civil Aerospace Medical Institute] laboratory performed an independent analysis of the specimens sent by the FAA to the institute. The CAMI specimen analysis indicates the presence of ethanol in samples from the captain and first officer; however, their report states that the ethanol reported in these cases are from post-mortem ethanol formation and not from the ingestion of ethanol.
...their report states that the ethanol reported in these cases are from post-mortem ethanol formation and not from the ingestion of ethanol.
Ethanol analysis is one of the most common tests performed on forensic specimens. The presence of ethanol in aircraft accident victims constitutes an important part of both aircraft accident investigations and litigation. Using modern analytical techniques, there is little doubt as to the quantitative amount of ethanol present in a postmortem specimen. The origin of the ethanol detected, however, is an important variable that must be considered when interpreting ethanol results in postmortem specimens.
Many species of bacteria, yeast and fungi produce ethanol and other volatile organic compounds as a byproduct of their metabolism. Candida albicans has been identified as the microbe most often responsible for postmortem production of ethanol in humans. This species of yeast is commonly found in humans in vivo. However, microbes not normally found in vivo, such as the Mucor species of mold, are commonly found in decaying organic matter and soil; they may be introduced from the environment if the circumstances surrounding death are violent, as is often seen in aviation accidents. After death, endogenous and/or exogenous microbes begin rapidly consuming glucose and other nutrients present in the body and produce ethanol and/or other organic volatiles as metabolic byproducts. Under optimal conditions, substantial concentrations of ethanol may be formed within hours of death.
I noted one posting that raised my eyebrows - that freighters don't have cabin doors to separate them from the hold. I had never considered this before, and wonder what the reason (or at least the justification) is. To me, the default would seem to be to keep the crew isolated from the cargo unless there is a particular reason for them to go back.
In the case of the 747-400F, there is a door between the upper deck and the main deck (fire resistant), and another door between the flight deck and the rest of the upper deck. Per the AFM and a placard on the main deck/upper deck door, it must be closed for takeoff and landing, and in-flight except when main deck access is required (e.g. care and feeding of live cargo). The flight deck door may be left open in-flight (given there was no one else on the aircraft it wouldn't surprise me if they left it open to provide easier access to the galley and lav), but the upper deck door was almost certainly closed.
I've only skimmed the report, but it sounds like the cargo fire was almost directly under the upper deck, and it's intensity quickly compromised the smoke/fire barrier between the main deck and upper deck. The smoke problem in the flight deck was then compounded by the miss-fortune of having Pack 1 drop (for those who may not know - standard procedure on a 747F for main deck fire is to depressurize the airplane to rob the fire of oxygen, while the flight crew uses supplemental oxygen, then use Pack 1 to supply air to the upper deck to keep it at a higher pressure to prevent smoke entering).
Unless someone is proposing that the main deck be lined with several tons of steel fire barriers (and the usable payload be reduced to ping pong balls and down pillows), the only way to have prevented an event of this type is to ban significant quantities of self oxidizing cargo.
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I don't know the current FARs, but back in the day FAA allowed nets of a certain strength instead of a bulkhead/door behind the cockpit on freighters, the theory being that the net would provide a limited degree of protection from shifting cargo in a rapid deceleration or impact situation.
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Thanks, tdracer and Etud_lAvia: there seems to be a difference of opinion here 
Since there is no effective way to protect an aircraft from a fire in self-oxidising materials, it seems to be insane to allow bulk transport by air. I'd go so far as to ban their carriage in the hold at all, even in luggage. An individual laptop (or smartphone) battery could cause enough damage to seriously compromise a flight because they have tremendous energy density.
Since there is no effective way to protect an aircraft from a fire in self-oxidising materials, it seems to be insane to allow bulk transport by air. I'd go so far as to ban their carriage in the hold at all, even in luggage. An individual laptop (or smartphone) battery could cause enough damage to seriously compromise a flight because they have tremendous energy density.
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I have finally started reading the entire report in detail. With the smoke so bad, the F/O was basically blind when it came to tuning radios and seeing the flight instruments. It appears that he could get his face close enough to the MCP to be able to see at least some of it as even near the end, he was able to arm the approach.
Unlike some planes, the 747 pilot sits quite far away from the instrument panel which is usually at arms length with a glareshield that sticks out quite far and sort of blocks you from being able to press your face against the flight instrument display. It would be near impossible to get your face close enough to the instrument displays to see anything while still seated. This explains why he kept asking for his present altitude, heading and speed. Being unable to change radios he had to stay on a different frequency from ATC and relay information.
That he was able to actually get toward and fly over the Dubai airport seem amazing for someone with less than 100 hours on type. I notice that he did fly the 757/767 so that probably help in terms of some familiarity with MCP controls and possibly radios.
Doing most stuff would have to be in the blind with possible exception of some or most MCP knob movement. These knobs are each shaped differently for speed, heading, and altitude so that they can be recognized by feel while flying. I know the feel of the heading select knob and the Altitude knob and the speed knob as they are quite different. But it would still be extremely difficult to correctly manipulate the controls properly when certain square buttons need to be pushed and displays on the MCP for selected speed, altitude and heading need to be read. I think if the MCP alone can be read in its entirety, with practice someone could work out an autoland without being able to see the flight instruments or a ditching could be attempted by descending to 200 feet over the water capturing the altitude and then configuring and descending at 100 fpm into the water. Just remember to set the local altimeter setting on both sides(once again near impossible for the left side) so maybe selecting transponder #2 might work).
As I read the report, I become convinced that if put all of a sudden in the same position without previous real thought or practice and planning, most of us likely would have crashed as well trying to do this in the blind whether ditching or trying an approach. Perhaps a good amount of experience would have made it possible but when you can't even see what you are selecting, it would be extremely time consuming to figure it all out.
As the report states, "The aircraft was not equipped with an alternative viewing system to allow the pilot(s) to view the instruments and panels in the smoke filled environment." I have actually been in the demonstration booth at an NBAA convention for the EVAS smoke vision system as seen in the link below. It really works in an environment where you cannot see a think a few inches from your face. See link below for a demo(start at 1:20) but the video only shows for a couple of seconds the actual difference this system makes.
As I was thinking about this this morning, something occurred to me as I was looking right at a potential desperate solution to be able to find something to be able to make things barely visible again.
It was my large clear plastic water bottle. Dump out the water(and depending on the bottle, you may be able to barely see what you are selecting as you need to look at various radio frequencies, a section of the PFD flight instrument display, or the radio panel. No guarantees but it is worth a try and might actually work.
Unlike some planes, the 747 pilot sits quite far away from the instrument panel which is usually at arms length with a glareshield that sticks out quite far and sort of blocks you from being able to press your face against the flight instrument display. It would be near impossible to get your face close enough to the instrument displays to see anything while still seated. This explains why he kept asking for his present altitude, heading and speed. Being unable to change radios he had to stay on a different frequency from ATC and relay information.
That he was able to actually get toward and fly over the Dubai airport seem amazing for someone with less than 100 hours on type. I notice that he did fly the 757/767 so that probably help in terms of some familiarity with MCP controls and possibly radios.
Doing most stuff would have to be in the blind with possible exception of some or most MCP knob movement. These knobs are each shaped differently for speed, heading, and altitude so that they can be recognized by feel while flying. I know the feel of the heading select knob and the Altitude knob and the speed knob as they are quite different. But it would still be extremely difficult to correctly manipulate the controls properly when certain square buttons need to be pushed and displays on the MCP for selected speed, altitude and heading need to be read. I think if the MCP alone can be read in its entirety, with practice someone could work out an autoland without being able to see the flight instruments or a ditching could be attempted by descending to 200 feet over the water capturing the altitude and then configuring and descending at 100 fpm into the water. Just remember to set the local altimeter setting on both sides(once again near impossible for the left side) so maybe selecting transponder #2 might work).
As I read the report, I become convinced that if put all of a sudden in the same position without previous real thought or practice and planning, most of us likely would have crashed as well trying to do this in the blind whether ditching or trying an approach. Perhaps a good amount of experience would have made it possible but when you can't even see what you are selecting, it would be extremely time consuming to figure it all out.
As the report states, "The aircraft was not equipped with an alternative viewing system to allow the pilot(s) to view the instruments and panels in the smoke filled environment." I have actually been in the demonstration booth at an NBAA convention for the EVAS smoke vision system as seen in the link below. It really works in an environment where you cannot see a think a few inches from your face. See link below for a demo(start at 1:20) but the video only shows for a couple of seconds the actual difference this system makes.
As I was thinking about this this morning, something occurred to me as I was looking right at a potential desperate solution to be able to find something to be able to make things barely visible again.
It was my large clear plastic water bottle. Dump out the water(and depending on the bottle, you may be able to barely see what you are selecting as you need to look at various radio frequencies, a section of the PFD flight instrument display, or the radio panel. No guarantees but it is worth a try and might actually work.
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make things barely visible again.
You will have to decide the water bottle trick prior to losing visibility or decide to carry an empty water bottle.
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It's surprising how the press hasn't discussed this accident while covering the increasing shift of air freight into the bellies of passenger airplanes.
If this had happened in 2015, the fire could have started on an Emirates or Delta flight......
Boeing Cargo Planes Lose to Boeing Passenger Planes - Businessweek
If this had happened in 2015, the fire could have started on an Emirates or Delta flight......
Boeing Cargo Planes Lose to Boeing Passenger Planes - Businessweek
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RE ESCAPE MODULES
'
Yep - good theory but NOT easy to do. How many know that then B1 bomber was initially designed and flown with a crew escape module. And it was tested on a supersonic sled, air dropped, etc> I wuz working For Rockwell at the time on that program. And very much involved in the manufacturing- assembly area as part of tooling. The total complexity involved re quick auto disconnect of all controls, the deployment of multiple parachutes, the provisions for landing on hard ground or in the water- upright and being aerodynamically stable plus altitude- oxygen provisions, etc even where cost was NOT an issue cannot be simply described.
And despite best attempts and extensive quality control issues- it was a failure. One test pilot was killed during initial testing when things went barf and the parachutes did not properly deploy
https://en.wikipedia.org/wiki/Rockwell_B-1_Lancer
I doubt any civilian large commerical aircraft could afford the cost..
The whole cockpit flies up and away from the unrecoverable aircraft.
And despite best attempts and extensive quality control issues- it was a failure. One test pilot was killed during initial testing when things went barf and the parachutes did not properly deploy
https://en.wikipedia.org/wiki/Rockwell_B-1_Lancer
Rockwell's design featured a number of features common to 1960s U.S. designs. Among these was the use of a "crew capsule" that ejected as a unit during emergencies, which was introduced to improve survivability in the case of an ejection at high speed.
- On 29 August 1984, B-1A (AF Ser. No. 74-0159) stalled and crashed while performing minimum control speed tests at low altitude. The crew used the escape capsule to leave the bomber, but the parachutes deployed improperly, causing the capsule to hit nose down. The impact killed the B-1's pilot, Rockwell test pilot Doug Benefield, and seriously injured two other crew members.[157][158]
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Good point. So it could work depending on how you went about it. Just a desperation idea. You might be able to see the MCP or radio frequency through water in the bottle. Worth a try anyways.
Most of the reputable Airlines banned Lithium Ion Batteries in April this year unless they are held within the device that they operate.sounds like the Industry is slowly waking up.
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If anyone needs evidence of badly packaged,and consigned,non declared dangerous goods,out of Hong Kong,PM me...I had a smoking cargo of after market lithium laptop batteries,packed together,20 in a box,no correct separators,removed from my 777,before departure,2 years ago.
The said cargo,20 boxes,arrived on an Airbus,from Hong Kong,transiting on my flight, to Montivideo.....
Holly Sxxt...
Fortunately,very alert loaders noticed fine smoke as they closed the cargo doors...potentially the worst incident in my 44 years of aviation.
The said cargo,20 boxes,arrived on an Airbus,from Hong Kong,transiting on my flight, to Montivideo.....
Holly Sxxt...
Fortunately,very alert loaders noticed fine smoke as they closed the cargo doors...potentially the worst incident in my 44 years of aviation.
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fatigue?
Er. the FAA has done nothing? 14 CFR Part 117 seems to be something. Perhaps not well read in Purley, but had a decent impact in FAA land.